Ocular Injuries: Emergency Department Strategies - Trauma EXTRA Supplement (Trauma CME)

Table of Contents

 

About This Issue

While the majority of eye injuries seen in the ED are minor, a stepwise approach to the evaluation of patients with ocular trauma facilitates early identification of sight-threatening injuries. In this issue, you will learn:

Key historical questions and ocular examination strategies for ocular trauma patients

The utility of CT and bedside ultrasound in the evaluation of ocular injuries

When surgical decompression of retrobulbar hemorrhage is indicated in the ED

The basic steps for performing lateral canthotomy with inferior cantholysis

The current recommendations for treatment of traumatic hyphema, traumatic iritis, ocular chemical burns, and corneal abrasions

1. About This Issue
2. Abstract
3. Introduction
4. Etiology and Pathophysiology
5. Differential Diagnosis
6. Prehospital Care
7. Emergency Department Evaluation
   1. History
   2. Physical Examination
   3. The Multiply Injured Patient
   4. Proptosis and Retrobulbar Hemorrhage
8. Diagnostic Studies
   1. Laboratory Studies
   2. Computed Tomography
   3. Ultrasound
9. Treatment
   1. Retrobulbar Hemorrhage
   2. Open-Globe Injuries
   3. Traumatic Hyphema
      1. Patching
      2. Corticosteroids
      3. Antifibrinolytics
      4. Summary
   4. Traumatic Iritis
   5. Ocular Chemical Burns
   6. Retinal Detachment, Posterior Vitreous Detachment, Vitreous Hemorrhage, and Lens Dislocation
   7. Corneal Foreign Body
   8. Corneal Abrasion
10. Disposition
    1. Retrobulbar Hemorrhage
    2. Traumatic Hyphema
    3. Ocular Burn
    4. Other Injuries
11. Controversies and Cutting Edge
    1. Topical Anesthetics for Corneal Abrasion
    2. Lateral Canthotomy Training
    3. Hospital Admission for Traumatic Hyphema
    4. Oxygen Therapy for Ocular Burns
12. Summary
13. Time- and Cost-Effective Strategies
14. Risk Management Pitfalls in Emergency Department Management of Ocular Injuries
15. Clinical Pathway for Emergency Department Management of Ocular Trauma
16. Tables and Figures
17. 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. Systematic evaluation and management of ocular trauma patients will ensure these patients have the best chance for a favorable final visual outcome. This review provides evidence-based recommendations for the diagnosis, treatment, and disposition of patients with traumatic ocular injuries, including retrobulbar hemorrhage, traumatic hyphema, open globe injuries, ocular chemical burns, and corneal abrasions. The use of bedside ultrasound, antibiotics, cycloplegics, steroids, antifibrinolytics, and patching are also discussed.

Introduction

Ocular injuries can be anxiety-provoking for both the patient and the emergency clinician. Traumatic eye complaints account for 3% of all emergency department (ED) visits in the United States,¹ where eye injuries are the leading cause of monocular blindness nationwide.^1-3 Eye injuries are also the most common cause of noncongenital unilateral blindness in the United States 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. On the other hand, the multiply injured patient poses a particular clinical challenge because a proper eye examination may be difficult or impossible. This issue of Emergency Medicine Practice: Trauma EXTRA! reviews best-practice recommendations for the evaluation and treatment of ocular trauma patients based on the available evidence.

Clinical Pathway for Emergency Department Management of Ocular Trauma

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

15. * Logothetis HD, Leikin SM, Patrianakos T. Management of anterior segment trauma. Dis Mon. 2014;60(6):247-253. (Review) DOI: 10.1016/j.disamonth.2014.03.004

22. * Brandt MT, Haug RH. Traumatic hyphema: a comprehensive review. J Oral Maxillofac Surg. 2001;59(12):1462-1470. (Review) DOI: 10.1053/joms.2001.28284

27. * Perry M, Moutray T. Advanced Trauma Life Support (ATLS) and facial trauma: Can one size fit all? Part 4: ‘Can the patient see?’ Timely diagnosis, dilemmas and pitfalls in the multiply injured, poorly responsive/unresponsive patient. Int J Oral Maxillofac Surg. 2008;37(6):505-514. (Review) DOI: 10.1016/j.ijom.2007.11.004

36. * Roque PJ, Hatch N, Barr L, et al. Bedside ocular ultrasound. Crit Care Clin. 2014;30(2):227-241. (Overview) DOI: 10.1016/j.ccc.2013.10.007

43. * Woreta FA, Lindsley KB, Gharaibeh A, et al. Medical interventions for traumatic hyphema. Cochrane Database Syst Rev. 2023;3(3):CD005431. (Cochrane review; 23 studies, 2969 patients) DOI: 10.1002/14651858.CD005431.pub5

63. * Calder LA, Balasubramanian S, Fergusson D. Topical nonsteroidal anti-inflammatory drugs for corneal abrasions: meta-analysis of randomized trials. Acad Emerg Med. 2005;12(5):467-473. (Meta-analysis; 11 trials) DOI: 10.1197/j.aem.2004.10.026

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Keywords: ocular trauma, ocular injuries, eye trauma, eye injuries, open-globe injury, corneal abrasion, ocular chemical burn, traumatic hyphema, traumatic iritis, proptosis, retrobulbar hemorrhage, corneal foreign body, lateral canthotomy