Ocular Injuries: New Strategies In Emergency Department Management (Trauma CME)

Table of Contents

 

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Etiology And Pathophysiology
6. Differential Diagnosis
7. Prehospital Care
8. Emergency Department Evaluation
   1. History
   2. Physical Examination
   3. The Multiply Injured Patient
   4. Proptosis And Retrobulbar Hemorrhage
9. Diagnostic Studies
10. Treatment
    1. Corneal Abrasion
       1. Patching
       2. Topical Nonsteroidal Anti-Inflammatory Drugs
       3. Topical Antibiotics
       4. Topical Cycloplegics
       5. Summary
11. Special Populations
    1. Pediatric Patients
    2. Patients With Sickle Cell Disease And Coagulopathies
12. Controversies And Cutting Edge
    1. Topical Anesthetics For Corneal Abrasion
    2. Hospital Admission For Traumatic Hyphema
    3. Oxygen Therapy For Ocular Burns
13. Disposition
    1. Corneal Abrasion
    2. Ocular Burn
    3. Traumatic Hyphema
    4. Other Injuries
14. Summary
15. Risk Management Pitfalls For Ocular Injuries
16. Time- And Cost-Effective Strategies
17. Case Conclusions
18. Clinical Pathway For Management Of Ocular Trauma
19. Clinical Pathway For Management Of Retrobulbar Hemorrhage
20. Tables and Figures
    1. Table 1. Ocular Trauma Diagnoses
    2. Table 2. Pertinent Historical Questions For Ocular Trauma Patients
    3. Table 3. Conditions Diagnosable By Ultrasound And Their Characteristic Findings
    4. Table 4. Trials Examining The Use Of Topical NSAIDs To Treat Corneal Abrasion Pain
    5. Table 5. The Roper-Hall Classification System
    6. Figure 1. Eye Anatomy
    7. Figure 2. A Schematic Of Grossly Visible Common Ocular Injuries
    8. Figure 3. Irregularly Shaped Pupil Secondary To Glove Ruptur
    9. Figure 4. Traumatic Hyphema
    10. Figure 5. Corneal Abrasion With Multiple Linear Abrasions
    11. Figure 6. Proptotic Eye Seconary To Retrobulbar Hemorrhage
    12. Figure 7. Computed Tomography Image Showing Glass Intraocular Foreign Body
    13. Figure 8. Normal Ocular Ultrasound
    14. Figure 9. Ocular Ultrasound Of Retrobulbar Hemorrhage
21. References

Abstract

Ocular injuries are common in the emergency department, and they are the most frequent cause of noncongenital monocular blindness in children and adults. This review provides evidence-based recommendations for the diagnosis, treatment, and disposition of patients with all types of ocular trauma, including pain management, the use of antibiotics, cycloplegics, steroids, antifibrinolytics, and patching. Bedside ocular ultrasound has profoundly expanded diagnostic capability, particularly for the multiply injured patient, and routine management and disposition of patients with corneal abrasions has evolved significantly as well. Diagnosis and management of patients with retrobulbar hemorrhage is discussed in detail, with resources for performing vision-saving lateral canthotomy. Systematic evaluation and management of ocular trauma patients will ensure these patients have the best chance for a favorable final visual outcome.

Case Presentations

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?

Introduction

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.

Critical Appraisal Of The Literature

Risk Management Pitfalls For Ocular Injuries

1. “I didn’t have time to do proper visual acuity testing.”
   Visual acuity is, essentially, a “vital sign” of the eye. Formal visual acuity testing with a Snellen chart or other device typically takes less than 2 minutes and is an essential component of the patient’s physical examination. If the patient is unable to complete this, then a rough estimate of the patient’s visual acuity should be obtained. Can the patient count fingers, see a hand waving, or read? There may be later medicolegal implications regarding visual acuity, particularly in cases of workers' compensation, so this must be documented.^7,18,26
2. “I thought I should examine the patient’s eye prior to irrigation.”
   The patient’s best chance of a favorable visual outcome following an ocular burn is immediate and copious irrigation. Even if other life-saving measures must be instituted simultaneously, irrigation should begin immediately. Whatever fluid is most readily available (normal saline, lactated Ringer’s, tap water) should be used.^6,11,12 Record the length of time of irrigation, the solution being used, the pH of the eye, and the times when the pH of the eye was tested.⁶³ Additionally, it is the responsibility of the emergency clinician to ensure that triage staff is aware of the time sensitivity of irrigation in these patients so that they are treated expeditiously.⁸⁶
3. “I didn’t realize I had to record so much specific information about the trauma.”
   It is extremely important from a medicolegal standpoint to record specific information regarding the trauma. If the patient presented with visual complaints without a clear history of trauma, it should be ascertained what they were doing at the time of onset of symptoms, as heavy lifting may be the “trauma” that precipitated the ocular injury (eg, retinal detachment). This is also very important for workers' compensation cases.²⁰ Ocular pain while hammering or performing some other metal-on-metal activity is also important to elicit, as it places the patient at risk for an intraocular foreign body.¹
4. “The patient had severe trauma with other life-threatening injuries, so I didn’t really examine his eyes.”
   The fact that a patient may have life-threatening injuries or a swollen face that precludes direct examination of the globe does not absolve the emergency clinician of the responsibility to evaluate for and treat vision-threatening injuries. CT of the orbit can be very helpful, particularly if the patient is already to receive a CT of the head. If the patient is not stable enough to leave the ED, bedside ultrasonography is a good way to evaluate for vision-threatening injuries.^32,33,36
5. “I already examined the eye once, why do I need to examine it again?”
   If the patient has any change in symptoms or if any procedure is performed on the eye (eg, corneal foreign body removal), the eye should be re-examined and these results should be recorded. Changes in the patient’s symptoms may indicate an evolving pathology that requires attention, and the eye should be re-examined to evaluate for this possibility.⁸⁷
6. “I thought that topical steroids were indicated!”
   Although topical steroids may be used to treat a myriad of ocular conditions, they can be potentially harmful to the eye and their effects need to be monitored closely.
7. “The patient’s eye injury occurred at work and I forgot to ask whether he was wearing any eye protection.”
   Whether the patient was wearing eye protection is particularly important, especially if the trauma occurred at work.⁷ The patient may ultimately require workers' compensation.
8. “My patient states that he cannot follow up with his ophthalmologist until next week. I thought that was soon enough.”
   This depends on the ocular injury sustained. However, generally, the patient will need much closer follow-up, often within 24 hours. The inability to follow up must be taken into consideration when formulating a treatment plan for a patient.
9. “I thought all corneal abrasions were the same.”
   It must be discerned whether the patient with corneal abrasion wears contact lenses. If contact lenses are worn, then the patient will need a topical antibiotic that has antipseudomonal properties, and the patient must be told not to wear contact lenses until the corneal abrasion has resolved.¹⁵
10. “The Seidel test was negative, so I didn’t think the patient had a globe rupture.”
    The Seidel test can be negative if the area of globe rupture or laceration is small and has sealed off. A high index of suspicion must be maintained, primarily based on the mechanism of injury.^3,18,27 Ultrasound and CT can aid in the diagnosis of a globe rupture.^32,33,36

Tables and Figures

References

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.

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