9 | Ocular Emergencies & Trauma
9.2 Evaluation of Ocular Trauma
| History |
|---|
| Age, occupation |
| Brief history of accident |
| Specific symptoms |
| Prior condition of eyes |
| Past medical history |
| Medications, allergies |
| Physical Examination |
|---|
| Inspection |
| Visual acuity |
| Extraocular muscle motility |
| Pupils |
| Anterior segment |
| Posterior segment |
| Visual fields |
| Intraocular pressure (IOP) |
Inspection
- Inspect the eyelids
- Always be conscious of possible injury to multiple tissues
- Be extremely gentle
- Do not put pressure on a traumatized eye
- In you suspect a globe rupture at any point of the examination
- STOP
- Protect the eye
- Call ophthalmology
- NPO, Ancef IV
- Make sure tetanus is up to date
- CT orbits STAT
Visual Acuity
- Check each eye individually
- Using a pinhole will improve visual acuity in patients with a refractive error
- Glasses may have broken during the traumatic event
Extraocular Muscle Motility
- Orbital floor fracture
- May impair vertical gaze in the affected eye
- Nerve palsies
- Trauma is the most common cause of cranial nerve palsies under the age of 45 years
- Indication for neuroimaging
| CN 3 Palsy | Down & out eye Note pupils | Unlikely with minor head trauma If present may indicate previously occult pathology |
| CN 4 Palsy | Displaced up | Often bilateral when secondary to trauma |
| CN 6 Palsy | Turned in |
Pupils
- The swinging flashlight test assesses for a relative afferent pupillary defect (RAPD)
- An RAPD indicates an abnormality or lesion involving the afferent visual system, usually the optic nerve or retina
- Cataracts never cause an RAPD
| RAPD Present |
|---|
| Retinal detachment, extensive |
Optic nerve damage
|
| RAPD Absent with diminished vision |
|---|
| Hyphema |
| Cataract |
| Vitreous hemorrhage |
Anterior Segment
- Examine ideally with the slit lamp
- Inspect
- Conjunctiva
- Cornea
- Anterior chamber
- Iris
- Lens
Corneal foreign body (FB). Clinical photograph of the anterior segment showing a FB on the surface of the cornea with an area of surrounding epithelial defect.
Foreign body (FB) under the upper eyelid. Linear staining/epithelial defects on the cornea as seen in the illustration on the left are suggestive of a FB under the upper eyelid in the clinical photograph on the right (arrow). The upper eyelid should be everted and examined thoroughly.
- Topical anesthetic (Tetracaine, Alcaine) can be useful in the examination of a patient with ocular pain or photophobia
- Regular usage of topical anesthetic can result in delayed healing and corneal toxicity. Do not use except to examine patients!
Posterior Segment
A proper examination of the posterior segment requires dilation. All dilating drops have red topped bottles.
| Dilating Drops | Duration of Action | |
|---|---|---|
| Sympathomimetic | Phenylephrine (Neosynephrine) | 3 – 5 hours |
| Anticholinergic | Tropicamide (Mydriacyl) | 4 – 6 hours |
| Anticholinergic | Cyclopentolate (Cyclogyl) | 24 – 48 hours |
| Anticholinergic | Homatropine | 3 – 5 days |
| Anticholinergic | Atropine | 10 – 14 days |
- Examine
- Vitreous
- Optic disc
- Retinal vessels
- Macula
- Peripheral retina
If the posterior segment is not visible despite a clear anterior chamber, then dilate the pupil. Consider:
- Cataract
- Vitreous hemorrhage
- Retinal detachment
Visual Fields
- Confrontation visual fields
- Gross test of visual fields
- Test 4 quadrants in each eye separately
Intraocular Pressure (IOP)
IOP can be measured with the following devices:
- Goldman applanation tonometry
- Gold standard
- Tonopen ©
- User friendly
- Available in most emergency rooms
- Sciotz tonometry
- Mostly historical
OMIT IOP MEASUREMENT IF ANY SUSPICION OF GLOBE RUPTURE.
Table of Contents
- Classification of Trauma of the Eye & Ocular Adnexa
- Evaluation of Ocular Trauma
- Trauma of the Eyelids, Orbit & Adnexa
- Trauma of the Eye
- Open Globe Injury