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Home , Corneal abrasion, Eye injury, Globe rupture

CPD Article

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

Correspondence to: Kavitha Naidu, e-mail: [email protected] Abstract

Ocular trauma encompasses a wide spectrum of mechanisms and presentations, affecting the , of the eye, and adnexae. The causative 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 , doctor should establish an amicable 5. Traumatic 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. 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. 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

SA Fam Pract 2006:48(7) 39 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, and adnexae, i.e. presence of proptosis, 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 - - - - anterior chamber - - Look for abrasions, lacerations, foreign bodies or debris, iris , 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 . 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 . If there is a suspicion MECHANICAL INJURIES that the 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 depending on the severity of the 5. Limitation of eye movement especially in upward or lateral gaze reaction and whether the stinger is 6. Eye deviated – appears squint amenable to removal.3

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b. Non-penetrating/contusion in- of the bones forming the orbit. The A 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 to decide whether surgical orbital Figure 1: A patient with a blowout fracture of the left orbit, showing repair is required. enophthalmos and restrictive 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 and drainage of the haematoma. after a contusive 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 . 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 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 . 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. pressure and surgical anterior Anterior chamber – Hyphaema chamber washout if necessary. Iris – Sphincter rupture Angle – Angle recession Other injuries that require referral – Ciliary body shutdown are: Pupil – Traumatic - A mid-dilated pupil, indicating a – Cataract traumatic mydriasis Subluxation/dislocation - Irregularities in the iris appearance, Rupture indicating iris sphincter or root tears POSTERIOR SEGMENT - Opacification of the lens – a cataract forms Vitreous – Haemorrhage – 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 – Haemorrhage or corneoscleral laceration include: or injury (see Table VII). However, Choroidal rupture • Hyphaema, any non-penetrating eye injury Optic nerve – • 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, 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 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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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 ‘’ 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 and socket, as opposed to a sharp Figure 9. Foreign body from Figure 8 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- of a retained bullet or pellet frag- suring 6 mm. 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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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 School of Medicine, University of work injury to the face and eyes. 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 to open globe injuries for the non- 1. Nirmalan PK, Katz J, et al. Ocular trauma ophthalmologist. in a rural south Indian population: the Aravind Comprehensive Eye Survey. Ophthalmology 2004;111(9):1778-81. 2. CHEMICAL EYE INJURIES 2. Kuhn F, Pieramici DJ. Ocular trauma Chemical injuries are commonly - principles and practice. Thieme Medical Publishers; 2002. caused by household detergents, 3. Kirk RW, Andrew JW, et al. External disinfectants, solvents, cosmetics, 4. COMBINATION EYE INJURIES disease and cornea. Basic and Clinical drain cleaners, ammonia and bleach. These injuries vary depending on Science Course. American Academy of Ophthalmology; 1998. p. 361-2. Agriculturally related chemicals, the cause. They usually occur as 4. Kanski JJ. Clinical ophthalmology such as fertilisers and pesticides, a result of a firework injury, a motor – a systematic approach. Butterworth- and industrial chemicals, such as vehicle accident or an explosive or Heinemann. 2003. 5. Visser L. Common eye emergencies caustic solutions and solvents, can . The patient requires a and procedures – lecture notes for cause complete ocular destruction.8 thorough examination at a slit lamp general practitioners; 2005. Early treatment is crucial and and sometimes under anaesthesia, 6. Narsing AR, Blackman HJ, et al. Intraocular inflammation and uveitis. referral is urgent. The immediate and therefore will need immediate Basic and Clinical Science Course. management, after establishing specialist referral. The eye should American Academy of Ophthalmology; the causative chemical or irritant, be kept covered with a light dressing 1998. p. 128-9. 7. Kirk RW, Andrew JW, et al. External is to irrigate the eye with copious and analgesia must be administered disease and cornea. Basic and Clinical amounts of normal saline or sterile orally. It is very important for the Science Course. American Academy of referring doctor to exclude injuries Ophthalmology; 1998. p. 357-9. water. Topical anaesthetic drops 8. Sceufele TA, Blomquist PH. Spectrum should be used to diminish eye pain elsewhere on the body before of ocular trauma at an urban county and an eye pad should be applied consulting the ophthalmologist. Hospital. Tex Med 2004;100(12):60-3. 9. 15. Viestenz A, Kuchle M. Blunt ocular before referral. Concentrated acid trauma. Part I: blunt anterior segment or alkaline burns must be referred SUMMARY trauma. Ophthalmologe 2004;101(12): as a matter of urgency. Alkalis in Ocular trauma requires a fully 1239-57. 10. 16. Viestenz A, Kuchle M. Blunt ocular particular tend to penetrate the functional referral pattern for the rural trauma. Part II: Blunt posterior segment eye and continue causing further doctor. One should establish open trauma. Ophthalmologe 2005;102(1): damage. communication lines with the nearest 89-99.

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