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
  • Contusive
  • Laceration
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.


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