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Home , Eye injury, Globe rupture

ASSESSMENT Assessing an patient

Dorothy Mutie Don’ts Initial assessment Consultant Ophthalmologist: Jaramogi • Do not assume that a visual acuity of The ABCDE approach to the evaluation Oginga Odinga Teaching and Referral 6/6 excludes serious eye complications. and treatment of patients with potentially Hospital, Kisumu, Kenya. life-threatening should be Email: [email protected] • Do not delay irrigation in chemical injuries. followed: Nyawira Mwangi • Do not delay referral. Principal Lecturer: • Airway with cervical spine protection • Do not manage eye injuries in a patient • Breathing and ventilation Programmes, Kenya Medical Training who is not stabilised: life-threatening College, Nairobi, Kenya. • Circulation Email: [email protected] conditions must be addressed first. • Disability (using Glasgow Coma Scale • Do not touch or otherwise manipulate and pupillary assessment) Eye injuries are common, occurring either an eye with rupture or perforating injury. • Exposure and Environment control. as isolated injuries or as part of head or • Do not prescribe topical anaesthetic. facial injuries. • Do not pull out a protruding foreign Patients with serious non-ocular injuries Health workers at primary level or in a body. or unstable vital signs should be managed trauma department should have a good • Do not use traditional eye medicines. in a trauma facility. Following stabilisation knowledge of the presentation and the specific assessment of ocular injuries Mechanical injuries involving the eyeball management of ocular injuries. Health can proceed. can be classified using the Birmingham workers must be able to skillfully handle Eye Trauma Terminology System (BETTS), injuries to ocular structures in a way that History which applies only to mechanical eye aims to restore vision and prevent further In the following eye injuries, the health injuries. Chemical and thermal injuries are loss of vision. worker needs to get a quick description of dealt with separately. BETTS is a practical This article discusses the practical what happened, institute immediate guide to classifying eye injuries. It ensures steps that should be taken at first contact measures and obtain a detailed history that all the health workers involved in the with the patient and highlights the level of later. care of the same patient have a consistent urgency of referral. understanding of the type of injury. 1 Suspected chemical injury: immediate First things first Further, it helps to ensure that there is irrigation as described below. uniformity, which enables comparison of 2 Active bleeding: arrest bleeding and Your first priority is to manage the anxiety data in future audits and research (see pad the eye. and of the person with an article on page 43). 3 Severe pain, especially in children: (see article on page 50). Pain has been give analgesia to enhance patient suggested as a factor in development of What you need comfort. post-traumatic stress disorders (PTSD).1 For the patient with an eye injury: Essential (the basics) For all other eye injury patients, a detailed history should be taken, including: • Reassure them of your intention to do • Visual acuity chart your very best. • Age and occupation • Torch • Let children stay with their caregiver as • Presenting symptoms. Which eye is much as possible. • Cotton buds affected? Is it both ? Is there • Even when the injury looks very bad, • Lid speculum (double vision)? avoid giving that indication at the • Eye shield (plastic/metallic) • Source and mechanism of injury. beginning, either by what you say to • Local anaesthetic drops Chemical and thermal injuries need to be patients, what you say to other staff • Antiseptic, e.g. iodine solution identified and treated immediately. Blunt objects (such as closed fists or blocks of members, or through your facial • Tetanus toxoid expressions. wood) are more likely to cause rupture of • Analgesics • Treat patients with courtesy, even if the the eyeball, whereas sharp objects (such cause of their injury is as the result of • Irrigating fluid as knives) are likely to cause lacerations. a fight. • Topical anaesthetic drops Inert intraocular foreign bodies (such as • Give oral analgesics as needed. • Gloves for examination glass, stone or plastic) cause less reaction than metals (copper, aluminium, Dos lead, iron). Plant material (wood or Additional (in an ideal scenario) • Use a moist sterile dressing to cover the vegetable matter) are poorly tolerated. eye (with a shield for additional • Slit lamp If an intra-ocular foreign body (IOFB) is protection). • Tonometer suspected, obtain information on its composition: organic (plant matter) or • Prevent secondary injuries, particularly • Magnifying loupe infections, through aseptic techniques inorganic (metal), magnetic or not, and • Direct ophthalmoscope and appropriate use of antibiotics. any possible chemical property, such as • Assess both eyes, even if the injury is • Eye pads acidic or alkaline. unilateral. • Fluorescein strips • Time of the injury. This helps to • Document all the findings and • Litmus paper determine the treatment strategy, as a procedures. • Cyclopegic drops quiet eye with a sealed 1-week-old corneal laceration may be managed • Monitor visual outcome. • Topical and systemic antibiotics • Plan for rehabilitation of the patient. conservatively, whereas an acute injury

46 COMMUNITY EYE HEALTH JOURNAL | VOLUME 28 ISSUE 91 | 2015 requires surgical intervention. Figure 1. Instilling topical anaesthetic Figure 2: Proptosis (right eye). • Place of injury. Where did the injury when the cannot be opened occur? • Events surrounding the injury. Was the injury accidental or non-accidental Michelle Lin and was protective gear (e.g. protective Jeffrey T Finer eyewear or seat belts) in use, where appropriate? • Any steps taken to manage the injury prior to presentation at health facility. These include irrigation, use of any medication, and removal of foreign body at home. • Previous ocular history. This includes the vision before the injury, use of contact lenses, previous trauma or surgery, and current medication. Figure 3. Traumatic Figure 4: Everting the upper using • Current and previous medical (right eye). a cotton bud. history. Existing conditions such as diabetes mellitus, hypertension, bleeding disorders and allergies need

to be identified. Sang Lee Pak The examination NOTE: If you suspect an open injury, stop. You can make it worse by examining it, causing increased prolapse of ocular contents. Refer the patient to theatre for examination under anaesthesia.

The patient may be examined in an JJ, 2014, www.cecentral.com Source: Yunker upright position if it is possible to do so. If it is difficult to open the eyes, lying down may make it easier. Children should generally sit on their parents’ Figure 5: Sub-conjunctival haemorrhage. Figure 6. Hyphaema. laps or lie down if retraction of the lids may be required. If the patient has difficulty opening the eyes, topical anaesthetic drops helps to reduce the pain and allows for exami- nation. Ask the patient to tilt their head backwards or to lie down. Instil a few Courtesy of Mpekethu Mingaine drops on the medial canthus area of the Courtesy of Mpekethu Mingaine affected eye (i.e. nearest the nose) and ask the patient to blink briefly. This will allow some of the anaesthetic to seep into the eye and provide relief (Figure 1). Retracting eyelids aids in observation of the rest of the structures and in irrigation. Use lid retractors or a lid speculum. If these • Visual fields. May be assessed by • Examining the upper and lower are not available, use bent paper clips. confrontation method. fornix. Ask the patient to look up as you Step 1: Visual examination • Adnexae. Lid defects (, lacerations) pull the lower eyelid to expose the lower • Inspection. Record the location, size should be noted. Canaliculi injury fornix. The upper fornix and tarsal and appearance of obvious injuries such should be suspected in medial eyelid are observed better if the lid as lacerations, swelling (contusions) or injuries. is double everted using a Desmarres lid foreign bodies (FB). Note any proptosis • Eyeball. If the lids of both eyes can retractor. A cotton bud may be used to (Figure 2) or enophthalmos (Figure 3). open, assess whether both eyeballs are evert the lid (Figure 4) but the upper • Visual acuity. Record the visual acuity of the same size. A smaller eye could fornix will be difficult to visualise. Look for each eye (presenting vision, and mean a blow-out fracture; or the larger out for foreign bodies and lacerations. vision with pinhole). eye could mean bleeding behind the • Conjunctiva. Note any sub-conjunctival • Orbital wall. Should be palpated for eyeball or . haemorrhage (Figure 5) and its furthest crepitus or bony deformity. extent. This is important for follow up as • Ocular motility. Should be assessed in Step 2: Using a source of light well as to rule out hidden scleral lacerations. the cardinal directions of gaze (vertical For the next steps, use a source of light. • and . These may have up-down, horizontal right to left, Where there is a slit lamp, use it, provided full length or lamellar lacerations, with diagonal left to right and right to left) that the patient is comfortable. Continues overleaf ➤

COMMUNITY EYE HEALTH JOURNAL | VOLUME 28 ISSUE 91 | 2015 47 ASSESSMENT Continued MANAGEMENT

or without uveal prolapse (the Managing eye injuries popping out through the cornea). Corneal staining with fluorescein can reveal scratch marks from a hidden conjunctival FB. Dorothy Mutie Perforating injury • Anterior chamber. If there is blood in Consultant Ophthalmologist: Jaramogi Presents with haemorrhagic chemosis, the anterior chamber (hyphaema), Oginga Odinga Teaching and Referral Hospital, Kisumu, Kenya. shallow anterior chamber, hyphaema, estimate the level of the hyphaema Email: [email protected] irregular , poor view of the fundus while the patient is in an upright position and a positive Siedel’s test. (Figure 6). If matter (whitish material Nyawira Mwangi Principal Lecturer: Ophthalmology Treatment: Immediately protect the eye in the anterior chamber) is noted, refer Programmes, Kenya Medical Training with a plastic/metal shield. very urgently (within 1–2 hours). College, Nairobi, Kenya. Refer very urgently. • . Note the size and shape, and Email: [email protected] the direct and consensual light reaction, Intraocular foreign body (IOFB) as well as the relative afferent pupillary Based on what you found during the eye Should be suspected where there is defect (RAPD). examination (see page 46), classify the injury as a non-mechanical injury history of trauma from flying objects • Lens. In some instances, it may be (chemical or thermal injury), a non-globe (typically hitting metal with a hammer) possible to observe a cataractous lens injury (orbital or adnexal injury) or as a and no external FB is found and/or where without lens rupture. mechanical globe injury. an entrance wound is noted. • Intraocular pressure (IOP). This In the case of mechanical globe injuries, should also be assessed where there is Treatment it is important to classify the injury closed globe injury (no full thickness • Protect the eye with a hard eye shield according to the Birmingham Eye Trauma wound of the eyeball). Low pressure (e.g. a metal eye shield) to protect the Terminology System (BETTS) (page 43) may indicate occult or globe from external pressure. and write it down in the patient’s notes; this . High pressure can • Give systemic analgesics. will help to ensure that everyone involved be expected immediately after • Give tetanus toxoid. in caring for the patient will have a consistent contusion to the globe. • An orbital X-ray, ocular ultrasound or understanding of the type of injury. The CT scan is necessary. • Posterior segment. Pupils may be resulting uniformity of terminology also dilated for fundoscopy if intraocular helps with research, making it possible to Refer very urgently. pressure (IOP) is normal and there is no compare data and do audits of injuries ­– expanding hyphaema. which is essential for prevention. Mechanical globe injury: Reference 1 Phifera J, et al. Pain symptomatology and pain closed globe medication use in civilian PTSD. Pain 2011;152(10). Mechanical globe injury: These are all partial-thickness wounds open globe of the eyewall, i.e. the sclera and A note on referral Ruptured globe cornea. The existing referral system should This presents with lowered intra-ocular pressure or flat anterior chamber, bloody Contusion be used, ensuring that patients are chemosis and irregular pupil. Intra-ocular Patients can present with chemosis, referred to a secondary or tertiary contents may be visible outside the globe. hyphaema and irregular pupil following level facility that has doctors with the blunt injury. skills (and equipment) to handle eye Treatment: Immediately protect the eye injuries appropriately. with a plastic/metal shield and give Treatment: Immediately protect the eye Talk to patients about their injury tetanus toxoid. Refer very urgently. with a plastic/metal shield. Patients with and the reason for the referral (see hyphaema should be positioned with the article on page 50). Write down the Penetrating injury head raised 30–45 degrees. most important information if In this injury an entrance wound can be Refer urgently. possible. Check that the patient and identified on the globe. her or his accompanying person Treatment: Immediately protect the eye Lamellar laceration know where to go, and how urgently. with a plastic/metal shield, A partial thickness corneal or scleral Clean as much blood and debris as is Refer urgently. Do not instil medication laceration requires repair, unless it is possible from around the injured into the eye. already self-sealing. area, even if referring immediately. Figure 1. Penetrating corneal laceration, Treatment: Primary closure (repair of in wound, traumatic . In this article and the one following: laceration) using 10/0 nylon or silk. Pad the eye for 24 hours and give topical and • Refer immediately means the patient should be seen by an systemic antibiotics. appropriately qualified person If repair is not possible, refer very within minutes. urgently. • Refer very urgently means she or he should be seen within 1-2 hours Foreign body on the surface of • Refer urgently means the patient Courtesy Mingaine Mpekethu the eye should be seen within 24 hours. Wash any loose foreign bodies away by irrigating the eye. © The author/s and Community Eye Health Journal 2015. For a corneal foreign body (FB): This is an Open Access article distributed under the Creative Commons Attribution Non-Commercial License. • Anaesthetise the eye

48 COMMUNITY EYE HEALTH JOURNAL | VOLUME 28 ISSUE 91 | 2015