Working up the traumatic eye

2 Aug

RAGING HYPOTHETICAL:

Your next patient presents after a minor MVC, complaining of eye pain. He looks like this:

 

What to do?!

 

Exam:

visual acuity, also be sure to ask about diplopia, which should make you think about entrapment, traumatic cranial nerve palsy, or lens dislocation if monocular

extraocular movement, if abnormal, this may suggest retrobulbar hemorrhage

palpate the orbital bones

eyelids – lacerations? Do they involve the margin or cannicular structures? This will involve a more complicated repair, most likely needing our consultant’s assistance

conjunctiva for hemorrhages

cornea and sclera lacerations should make you suspect a globe rupture

pupil shape, peaked or teardrop suggest globe rupture

fundoscopy

if the anterior chamber is intact, it is ok to check the pressure of both eyes. If you see an obvious open globe, do not check pressures. If there is an open posterior globe, the pressure will be falsely low.

 

Additional Testing

CT is best to assess injury and to rule out superior orbital fracture

Ultrasound has been shown NOT to affect ocular pressure as long as a clear dressing (tegaderm) is applied

(*see this blog post for the how to: https://dailyem.wordpress.com/2013/07/08/ultrasound-for-globe-rupture-diagnosis/)

 

Treatment

Globe rupture: protect the eye with a hard shield, expedient ophthalmologic consult

Retrobular hematoma: at risk for orbital compartment syndrome -> lateral canthotomy

Orbital blowout fracture: observation v. surgery

 

D/c Instructions

Neurosurgery referral if superior orbital fracture (so close to the CNS!)

Broad spectrum antibiotics to cover sinus flora

Nasal decongestion to constrict blood vessels

PO steroids to decreased inflammation

No nose blowing to prevent subcutaneous emphysema

Follow-up with ophthalmology

 

Submitted by K. Estes.

 

References: 1. Tintinalli’s Emergency Medicine:  7th Edition.; picture

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