Your shift begins and you pick up your first chart: “eye irritation.” You talk to the patient and discover that she felt the sudden onset of left eye pain and irritation while she was applying her eye makeup this morning; she is worried she may have scratched her eye with her fingernail. You give the patient's eye a drop of topical anesthetic and perform a fluorescein examination, which reveals a single corneal abrasion. You plan to discharge the patient home with a prescription for a topical antibiotic and a topical cycloplegic. The patient asks if she can have the bottle of topical anesthetic because it was so helpful in relieving her pain. You wonder whether this is safe...
While you are considering this, you are called into the resuscitation area for a patient involved in a severe motor vehicle crash. The patient was apneic and was intubated by EMS. The right side of his face is extremely swollen and you are unable to examine his right eye, and he is unable to provide any information about the vision in his right eye. His eye seems mildly proptotic, and you wonder if you need to be concerned for a retrobulbar hemorrhage. Is there anything that can be done at the bedside to evaluate for this possibility? Should treatment for retrobulbar hemorrhage be initiated presumptively in this patient?
After your trauma patient is stabilized, you see your next patient: another eye complaint! This patient was at work when an unknown chemical splashed into his left eye. He immediately began irrigation, but he continues to complain of pain and decreased vision in the eye. You wonder if you should examine the eye first, or initiate irrigation of the eye immediately. If the patient feels better, does ophthalmology need to be consulted in the ED? What medications should you send home with this patient?
Ocular injuries can be anxiety-provoking for both the patient and the emergency clinician. Eye injuries are the leading cause of monocular blindness in the United States.1-3 They are the most common cause of noncongenital unilateral blindness in the pediatric population.4
Fortunately, most eye injuries are minor and the overwhelming majority are not associated with significant morbidity.5 Even most ocular burns tend to be mild and inconsequential in the long term.6 In patients with mild injury, pain management and prevention of secondary infection are the mainstays of treatment.
The polytrauma patient poses a particular clinical challenge because a proper eye examination may be difficult or impossible. This issue of Emergency Medicine Practice provides a systematic review of best-practice recommendations based on the available evidence.
The National Guideline Clearinghouse was also queried (www.guideline.gov), with 1 relevant article noted. Guidelines from the American Academy of Ophthalmology and from the American College of Emergency Physicians were queried; however, there were no relevant guidelines.
Generally speaking, the evidence related to ocular trauma is of intermediate quality. Trials were often underpowered and had significant selection bias, making the findings difficult to apply to the general population. Studies were also affected by poor patient follow-up. Several reasons account for these issues. Ocular trauma is relatively rare, making recruitment into a study and the ability to have an adequately powered study difficult. Poor follow-up was often an issue because the patient’s symptoms may have resolved, decreasing the likelihood of following up and completing the study; this was especially true in some studies of corneal abrasion treatment.
In other ocular disease states, no studies were identified (eg, in the treatment of iritis). Case reports have been published, but no quality research has otherwise been performed. It appears that the treatment of this entity is based on dogma and tradition.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the reference.
Anne M. Messman, MD
November 1, 2015
November 30, 2018
Upon completion of this article, participants should be able to:
Date of Original Release: November 1, 2015. Date of most recent review: October 10, 2015. Termination date: November 1, 2018.
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AAFP Accreditation: This Medical Journal activity, Emergency Medicine Practice, has been reviewed and is acceptable for up to 48 Prescribed credits by the American Academy of Family Physicians per year. AAFP accreditation begins July 31, 2014. Term of approval is for one year from this date. Each issue is approved for 4 Prescribed credits. Credit may be claimed for one year from the date of each issue. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
AOA Accreditation: Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2A or 2B credit hours per year.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits and 0.5 Pharmacology CME credits, subject to your state and institutional approval.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical presentations; and (3) describe the most common mediocolegal pitfalls for each topic covered.
Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration–approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
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