Evaluation: history and physical exam

Initial assessment and treatment should focus on the ABCs of trauma resuscitation, and any life-threatening injuries should be addressed first, as with any trauma patient [6,7]. Eye injuries can be distracting, and it is important not to divert attention from other sources of serious injury early in the trauma survey process. It is also critical to recognize that associated facial trauma and swelling may affect airway patency, and this should be secured before further examination of the orbit if needed.

After initial stabilization and primary survey, attention can be focused on the ocular injury and a thorough evaluation should be performed. In the case of known or suspected chemical contact to the face and eye, immediate irrigation with normal saline or clean water should be performed during this evaluation process

The key components in the evaluation of traumatic eye injuries are a thorough history and careful eye examination. The history focuses on key points surrounding the event and should note the type of injury, the time of onset, and any specific symptoms reported by the patient [6]. Mechanism of injury is also recorded and may include blunt or penetrating trauma and thermal or chemical burns to the eye or periorbital areas of the face. Other important points include the patient’s visual acuity before the injury, if known, the presence or absence of contact lenses, any past medical history of eye disorders, and any history of ophthalmological surgical or medical treatment [7].

The physical examination of the eye begins with evaluation of visual acuity, establishing a baseline level of function and providing functional assessment of possible damage to the eye [7,8]. In the field, this can be performed using a hand-held Snellen chart to document the smallest objects or letters identifiable at a specific distance from the eye. Visual acuity is recorded for each eye individually and then using both eyes simultaneously [7]. If no chart is available, a newspaper or other source of small print is useful to estimate visual acuity. Patients who normally wear prescription glasses for reading should perform this with those same glasses if available, but those who use contact lenses should not have those replaced for this examination. If the patient’s glasses are unavailable, it is possible to use a piece of paper with a small pin-sized hole through which the patient can view the chart and complete the examination [6,7]. This “pin-hole test” corrects for the refractive error of the patient’s eyes and should allow completion of the examination. For those who cannot read the Snellen chart due to injury or underlying ocular disease, other options include assessing the patient’s ability to count fingers, detect hand motions, or perceive the presence or movement of light [6]. The method of testing and patient performance should be documented for each eye.