The Injured Eye - Practical Management Guidelines and Referral Criteria For The Rural Doctor

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CPD Article

The injured eye – practical management


guidelines and referral criteria for the
rural doctor
Naidu K, MBChB, FCOphth(SA)
Dept of Ophthalmology
Nelson R Mandela School of Medicine
University of KwaZulu-Natal

Correspondence to: Kavitha Naidu, e-mail: kavi1910@yahoo.com

Abstract

Ocular trauma encompasses a wide spectrum of mechanisms and presentations, affecting the orbit, globe of the eye, optic
nerve and adnexae. The causative injuries range from the relatively superficial to those that threaten sight. The rural doctor
plays a vital role in the initial management of patients with ocular trauma and his/her decisions and treatment can influence the
patient’s final visual outcome. This article serves to classify ocular trauma and to provide management guidelines for treating
minor trauma and initiating proper care for injuries that require referral to specialist ophthalmologists.

SA Fam Pract 2006;48(7): 39-45

Box 1: Ten common terms asso- INTRODUCTION occur predominantly in males and
ciated with eye injuries: Ocular trauma is an extensive topic. illiterates.1
The rural doctor requires a basic Traditional healers may form part
classification for correct manage- of the referral process. They should
1. Afferent pupillary defect ment and to ensure the collection be educated to promote simple
2. Chemosis of accurate clinical data for cases preventative measures, such as the
3. Hyphaema requiring referral. Of importance are use of protective eyewear. The rural
4. Uveal prolapse the mechanisms of the ocular injury, doctor should establish an amicable
5. Traumatic cataract which are illustrated in Table I. relationship with the traditional healer
6. Vitreous haemorrhage Socio-economic factors play a and advise him or her on those
7. Endophthalmitis major role in the spectrum of injuries emergencies requiring referral.
8. Proptosis sustained by a specific population.
9. Blowout fracture In rural areas, the injuries tend to be GENERAL GUIDELINES
10. Diplopia related to agricultural labour, alcohol When confronted with ocular trauma,
abuse and concomitant assault, and the practitioner should firstly take a

Table I. Mechanisms of eye injuries

1. Mechanical: a. Foreign bodies on the superficial eye and adnexae


b. Contusion injuries, i.e. injuries with a blunt object
c. Penetrating injuries, i.e. injuries with a sharp object
2. Chemical
3. Thermal
4. Combination injuries, e.g. firework injuries, which may
include thermal, chemical and contusive or penetrating injuries

Table II. Important features in the history


1. Mode of injury, i.e.
- Exact causative mechanism

- Accidental or assault
2. Time to presentation
- Delayed presentation of penetrating eye injuries increases the risk of endophthalmitis.
3. Concurrent injuries elsewhere on the body.
4. Medical, past ocular and family history

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CPD Article

Table III. Specific ocular examination

a. Visual acuity with a Snellen chart


b. Assessment and documentation of the injury with proper reference to the anatomical structures.
Note - appearance of the orbital rims, eyes and adnexae, i.e. presence of proptosis, enophthalmos or
displacement of the globes.
c. Examination of the upper and lower lids and lid margins for lacerations.
d. Examination of the globes by gently opening the eye-
Note the - conjunctiva
- sclera
- cornea
- anterior chamber
- iris
- pupil
Look for abrasions, lacerations, foreign bodies or debris, iris tears, pupil irregularity.
e. Pupillary responses – exclude an afferent pathway defect, which indicates severe injury.
f. Direct ophthalmoscopy

- then, on closer examination, to assess the optic nerve and macula and to exclude a vitreous
haemorrhage or retinal detachment.
g. Confrontational visual fields.
h. Assessment of ocular motility in all directions.

comprehensive history of the events dispensed to the patient, however,


leading to, and timeline surrounding, as they can lead to over-usage and
the injury (see Table II). Secondly, on result in corneal epithelial loss and
examination of the patient, an ocular significantly interfere with corneal
assessment as outlined in Table immunity.2
III should be performed after the Deeply embedded foreign bodies
general examination. require removal under the illumination
of a slit lamp. If there is a suspicion
MECHANICAL INJURIES that the foreign body penetrated
a. Foreign bodies on the eye the eye, the patient will require an
Protective eyewear is essential when X-ray of the orbit and referral to an
working with any heavy machinery or ophthalmologist.
power tools, and when hammering, Grinding or welding injuries that
chiselling or knocking, especially result in a small piece of metal
metal on metal. on the eye often have a rust ring,
Most small superficial foreign which is difficult to remove without
bodies can be removed with a magnification. These patients
cotton-tipped applicator after instil- sometimes complain of ‘arc eye’,
lation of topical anaesthetic drops, which presents as painful, injected
which are available in a single usage eyes as a result of welding for long Subtarsal foreign bodies can
preparation. These drops assist in periods without protective eyewear. also be removed under topical
examining a patient with a painful, The treatment of arc eye is given in anaesthetic drops. The upper
tearing eye. They should never be Table IV. lid must be everted gently with a
cotton-tipped applicator by placing
Table IV. Treatment of arc eye
pressure on the tarsal plate while the
patient looks down. The foreign body
1. Topical anaesthetic drops
can then be seen and removed with
2. Double eye padding
the applicator.
3. Analgesia orally
Insects on the eye may require
surgical removal under general
anaesthetic with the use of a
Table V: Signs of a blowout fracture microscope. Bee and wasp
stings to the cornea cause a toxic
1. Periocular ecchymosis and oedema inflammatory reaction in the eye
2. Subcutaneous emphysema
and require analgesia, specialist
3. Enophthalmos (eye appears smaller)
assessment and surgical treatment,
4. Infraorbital numbness
5. Limitation of eye movement especially in upward or lateral gaze
depending on the severity of the
6. Eye deviated – appears squint reaction and whether the stinger is
amenable to removal.3

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CPD Article

b. Non-penetrating/contusion in- of the bones forming the orbit. The A corneal abrasion can be
juries floor of the orbit and the medial wall recognised by instilling fluorescein
Lid abrasions and minor haematomas are involved most commonly and, drops onto the eye. This dye stains
without any concurrent globe injury being extremely thin, they fracture the damaged epithelial cells and
or drop in vision may be managed as a pressure wave extends across thus outlines the abraded area (see
conservatively with analgesia and the orbit. This potentially spares the Figure 3). The treatment of corneal
cold compresses. Any direct impact eyeball from rupturing.2 The patient abrasions is set out in Table VI.
to the globe or the orbit requires will complain of deterioration in Patching of the abraded eye is felt to
referral to a specialist. vision, numbness of the cheek, be counterproductive to healing, as
An orbital blow-out fracture is side of the nose and upper lip, and it reduces the oxygen supply to the
caused by a sudden increase in diplopia (double vision). The signs cornea. It also increases the corneal
the orbital pressure as a result of a of a blowout fracture are listed in temperature and the micro-organism
striking object that is greater than Table V, and the injury is illustrated replication rate, leading to infection.2
5 cm in diameter, such as a fist or in Figure 1. Affected patients should Figure 4. Vitreous haemorrhage
tennis ball.4 This results in fractures be referred for a CT scan of the orbits
Figure 1: A patient with a blowout to decide whether surgical orbital
fracture of the left orbit, showing repair is required.
enophthalmos and restrictive strabismus
of the left eye.

Hyphaema, blood in the anterior


chamber of the eye, is a common
presentation of contusive eye injuries
(35% of closed globe trauma).2 Most
Proptosis of the eye after a contu- patients are younger than 20 years
sive injury (see illustration in Figure 2) old and the male to female ratio is 3:
implies a subperiosteal or retrobulbar 1.2 Hyphaema is easily recognised
haematoma, especially if there is as a level of blood in the anterior
subconjunctival haemorrhage and chamber, obscuring the iris and
chemosis with taughtness of the eye- sometimes the pupil.
lids. The pupillary reactions must be Figure 5. Retinal detachment
documented, and the patient should
be referred for an orbital CT scan
Figure 2: Lid swelling and chemosis
after a contusive eye injury and drainage of the haematoma.
Lid swelling and extensive sub-
conjunctival haemorrhage with
swelling, giving the appearance of
a ‘jelly roll’ of conjunctiva, should
alert the practitioner to a severe
ocular injury with probable posterior
globe rupture. An additional clue is
a deepened anterior chamber of the
eye and poor visual acuity, with an
afferent pupillary defect.4

Table VI. Treatment of corneal abrasions

1. Chloramphenicol ointment
2. Analgesia
3. Eye pad
4. Referral to rule out intraocular damage

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The blood may organise into a Table VII. Sequelae of contusive eye Figure 6. Large corneal laceration.
clot in the anterior chamber or be injuries
comprised of dispersed circulating
red blood cells, making the details of ANTERIOR SEGMENT
the iris and pupil appear unclear.
Orbits – Orbital rim/blowout fracture
A full hyphaema, often called an
Retrobulbar haemorrhage
‘eight-ball’ hyphaema, sometimes Lids – Periorbital haematoma
occurs, giving the appearance of Traumatic ptosis
a dark red to brown-black cornea, Lid abrasion
with no view of the anterior chamber. Lid rupture
This is associated with an elevated Conjunctiva – Haemorrhage
intraocular pressure and severe eye Chemosis
pain. All patients with a hyphaema Sclera – Anterior or posterior rupture
need referral for bed rest, topical Cornea – Abrasion
Rupture Figure 7. Scleral laceration with uveal
steroid therapy, control of intraocular and vitreous prolapse.
Anterior chamber – Hyphaema
pressure and surgical anterior
Uveitis
chamber washout if necessary.
Iris – Sphincter rupture
Angle – Angle recession
Other injuries that require referral Ciliary body – Ciliary body shutdown
are: Pupil – Traumatic mydriasis
- A mid-dilated pupil, indicating a Lens – Cataract
traumatic mydriasis Subluxation/dislocation
- Irregularities in the iris appearance, Rupture
indicating iris sphincter or root
tears POSTERIOR SEGMENT
- Opacification of the lens – a
Vitreous – Haemorrhage
cataract forms
Retina – Retinal swelling/oedema/
- Rupture or dislocation of the lens
haemorrhages
In patients with clear media, Retinal tears
examination with the direct Macular hole
ophthalmoscope may exclude Retinal detachment Other features of a corneal, scleral
posterior segment haemorrhage Choroid – Haemorrhage or corneoscleral laceration include:
or injury (see Table VII). However, Choroidal rupture • Hyphaema,
any non-penetrating eye injury Optic nerve – Optic neuropathy • A shallow or flat anterior chamber
associated with deterioration in Optic nerve avulsion of the eye
visual acuity, or where the impact Globe – Total rupture • Iris and lens damage, with a
on the eye was significant, should distorted pupil
be referred. • A ruptured cataract

c. Penetrating/perforating injuries cold compresses, antibiotics and Ocular lacerations are managed by
Lacerations analgesia. covering the eye with an eye pad,
Lid lacerations not involving the Subconjunctival haemorrhages administering a topical antibiotic
lid margin should be sutured. are self-limiting and only require the and controlling the patient’s pain
However, those with tarsal plate, patient to be reassured. with oral analgesics. The patient
levator or lacrimal puncta and Ocular lacerations with uveal needs to be referred to the nearest
canalicular damage need specialist prolapse present as a brown ophthalmologist for surgical repair
repair. Associated haematomas knuckle of protruding tissue. (See as soon as possible. If a delay in
of the lids may be treated with figures 6 and 7). specialist care is anticipated, a

Table VIII. Epidemiology of intraocular foreign bodies2,5

Incidence: 18-41%
Age: Range 3-79 years
Average 29-38 years
Sex: Males 92-100%
Cause: Hammering steel or brick: 60-80%
Power or machine tool accident: 18-25%
Weapon related: 19%

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CPD Article

systemic oral antibiotic and tetanus protection. The epidemiology of seal spontaneously. Patients may
prophylaxis should be admini- intraocular foreign bodies is given not be aware that there is a foreign
stered.2 in Table VIII (also see illustrations in body in their eye, particularly if it
Figures 8 to 11). is small and composed of an inert
A disorganised eye occurs in substance. Their symptoms may be
Figure 8. Intraocular foreign body em-
severe injuries and is described bedded in the retina of a patient. minimal, aside from mild discomfort,
when the ocular anatomy is and they commonly complain of
totally distorted and there is a ‘floaters’ in the eye.6
complete loss of vision. All patients with suspected
intraocular foreign bodies need an
Gunshot injuries X-ray or CT scan of the orbits and
Gunshot injuries are regarded as then referral. Once the position and
perforating eye injuries, as they are size of the foreign body have been
caused by high-speed projectiles confirmed, the patient will probably
that pass through the eye. Bullets undergo a pars plana vitrectomy to
are blunt missiles travelling at a remove the foreign body surgically.
high velocity with large amounts
of kinetic energy. They cause Figure 11. CT scan of the patient
significant damage to the eyeball in Figure 8 showing a large metallic
Figure 9. Foreign body from Figure 8
and socket, as opposed to a sharp foreign body in the right eye.
removed from the eye.
piece of shrapnel, which may cause
a more well-defined laceration with
less intraocular damage. The bullet
sometimes grazes past the globe
without penetration. In comparison
to an open globe injury, these
injuries carry a low risk of orbital
infection due to the speed and heat
at which the impact occurs.
All these patients need a CT
scan to exclude brain and sinus
injury, assess the degree of orbital
damage and exclude the presence Figure 10. Metallic foreign body mea-
suring 6 mm.
of a retained bullet or pellet frag-
ments. Patients may develop a slow
extra or subdural haemorrhage with
raised intracranial pressure and Stab injuries to the orbit
deterioration in their Glasgow coma Stab injuries to the orbit require
scale. These patients obviously urgent referral, as they result
need neurosurgical intervention in severe orbital sepsis and
first before their eye problems are endophthalmitis in two to seven
addressed. per cent of cases if the globe is
penetrated or perforated. These
Foreign bodies patients require prophylactic
Intraocular foreign bodies are antibiotics and an orbital and brain
usually found in patients who give Due to the often small size of the CT scan to exclude an intracranial
a history of sudden projectile, pene- foreign body and the speed at which tract, orbital wall breach or sinus
trating ocular injuries, where the it enters the globe, the entry wound damage. Penetrating injuries to
patient was not wearing any ocular on the eye may be small and may the globe as a result of wood or

Table IX. Stepwise approach to open globe injuries for the non-ophthalmologist:7

1. Assume that all open globe injuries involve an intraocular foreign body.
2. Shield the eye with a light dressing.
3. Prescribe systemic medication for pain/anxiety/nausea as needed.
4. Refer the patient to the nearest ophthalmological institution. A personal discussion with the ophthalmologist is highly
advised.
5. Unless it is an injury with a high infective risk and/or a long delay in transportation is expected, there is no need to start
antibiotic therapy, although tetanus prophylaxis may be given.

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CPD Article

wire, especially copper, are also 3. THERMAL EYE INJURIES referral centre ophthalmologist to
high-risk injuries for intraocular and Eye injuries caused by a spark ensure uncompromising, quality
orbital sepsis and require immediate from a match or fire or by boiling patient care at all times. Education
referral. water can vary in severity. The on simple measures such as the
former usually will result in a corneal use of protective eyewear should
Sympathetic ophthalmitis abrasion and some debris in the not be underestimated and requires
Sympathetic ophthalmitis is a fornices of the eye. The latter may communication with employers.
rare, bilateral, sight-threatening, be mild or very severe, depending The role of the traditional healer in
autoimmune panuveitis that occurs on the circumstances surrounding education and referral of patients
after injury to one eye (the exciting the injury. Concurrent skin and should be considered. This article
eye), followed by a latent period and scalp burns are common and provides rural doctors with basic
then involvement of the uninjured require immediate attention. The guidelines in treating patients and
globe (the sympathising eye). This thermal burn to the eye is often a will hopefully improve primary
condition can occur as early as 10 corneal abrasion and sometimes healthcare and earlier referral.
days or as late as 50 years following is associated with a conjunctival
the injury. abrasion. The degree of lid ACKNOWLEDGEMENTS
In injured eyes where there is no involvement varies. All such injuries All photographs courtesy and
potential for vision, it is advisable to require specialist referral. copyright of the Department of
remove the eye within 10 to 14 days Ophthalmology, Nelson Mandela
Figure 13. Patient with a severe fire-
of the injury. This requires prompt work injury to the face and eyes. School of Medicine, University of
referral of all patients in this risk KwaZulu-Natal.
category. Improved and timeous
wound closure and early removal of See CPD Questionnaire, page 50
severely damaged eyes have signi-
ficantly reduced the incidence of P This article has been peer reviewed
sympathetic ophthalmitis (±0,4%).2
Table IX provides an approach REFERENCES
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SA Fam Pract 2006:48(7) 45

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