Eye Injuries

Chapter 55 Eye Injuries



Martha W. Stevens, MD, MSCE



1 Define an ophthalmologic “emergency” and give two common examples


An ophthalmologic emergency is any injury that may lead to incremental vision loss without early recognition and prompt initiation of treatment. Two common examples are chemical burn and globe rupture. Both of these presentations warrant emergent (same-day) ophthalmologic consult after beginning initial treatment/stabilization.



2 What is the initial treatment/stabilization for globe rupture?


Stop the examination, place a rigid eye shield, and keep the patient calm to avoid increased pressure to the globe, which may cause further extrusion of vitreous or aqueous humor. Administer pain medications, tetanus, and IV antibiotic prophylaxis, if possible. Order an imaging study if a retained foreign body is suspected.



3 List the important aspects of the history in all patients with eye injuries




image Change in visual acuity


image Change in appearance of eyes


image Discomfort or pain (including photophobia)


image History of trauma, including details of the mechanism (blunt/sharp, significant impact, soil contamination, foreign-body risk) and tetanus immunization history


image Corrective lenses (contacts currently in place?)


image Medications


image Eye surgeries


image History of ocular problems


image Systemic disease (sickle cell, connective tissue, or rheumatologic disease; hypertension; diabetes; HIV infection)



4 What is included in the routine physical examination for all pediatric patients with eye injuries (except when temporarily deferred in absolute emergencies)?




image Visual acuity


image Extraocular muscles


image Pupillary reactions


image External examination (including lids and conjunctivae)


image Direct ophthalmoscopy/red reflex


image Other tests as indicated: visual field testing (confrontational), slit-lamp examination, intraocular pressure (palpation or tonometer). The last two tests usually are performed by an ophthalmologist for pediatric patients.



5 What are the common pitfalls in evaluating children with eye injuries?




image Failure to treat life-threatening injuries before the most obvious but less serious eye injury


image Failure to examine both eyes


image Failure to consider globe injury (after finding a more superficial injury)


Levin AV: Eye trauma. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Baltimore, Lippincott Williams & Wilkins, 2006, pp 1485–1496.



6 How do you test visual acuity in infants?


Check for pupillary reaction to light and fixation reflex. Infants should be able to fix on a high-contrast object held in their central vision, such as the caretaker’s or examiner’s face or a bright toy. By 2–3 months of age, they should be able to fix on and start to follow an object or light, and by about 6 months to fix and follow to all visual fields. Central, steady, maintained fixation is estimated to be equivalent to 20/40 vision, unsteady fixation equivalent to 20/100, and eccentric wandering gaze to < 20/400.



7 How do you test visual acuity in preschool and school-aged children?




image 2½–3½ years old: Allen object recognition (picture) chart


image 3½ and older: Picture chart, tumbling E chart, or Sheridan-Gardner visual acuity test


image School age: Snellen chart (letters in rows of diminishing size)



8 What pearls should be kept in mind for visual acuity testing in children?




image Have the child identify the objects on the chart up close before testing at a distance.


image Test one eye at a time, “bad” eye first.


image Use a card or the child’s palm to cover the other eye; children “peek” between fingers.


image Always test with corrective glasses if available.



9 For patients without their glasses or contact lenses, how can you differentiate between decreased acuity and baseline refractive error?


Pinhole testing—with a premade device, a card with a hole punched with an 18-gauge needle, or multiple pinholes in a rigid eye shield—corrects refractive errors to about 20/30.



10 How do you record decreased acuity in patients unable to visualize a chart?




image Ability to count fingers from a specified number of feet


image Ability to perceive hand motion


image Light perception (with or without directionality)



11 What are the causes of an irregularly shaped pupil?




image Ocular rupture/corneal or other globe perforation


image Prior ocular surgery


image Scarring from previous iritis



12 What are the causes and expected course of subconjunctival hemorrhage?


Subconjunctival hemorrhage, the localized rupture of small subconjunctival vessels, may be spontaneous or may be due to direct trauma or increased intrathoracic pressure (e.g., coughing, noseblowing, vomiting). It usually is benign and resolves in 2–3 weeks without treatment or sequelae. Very large hemorrhages or those that fully encircle the iris raise concern for an underlying injury, such as globe perforation, or a bleeding diathesis.

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Sep 1, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Eye Injuries

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