Primary care of eye injuries
The eye is an external organ and is unable to withstand an injury which may be considered a minor injury elsewhere in the body. The function of an eye requires it to be exposed which increases the possibility of injury. Trauma which may cause only a bruise or cut to an arm or leg may result in blindness of an eye.
Often it is considered that a penetrating injury is more important or urgent than a blunt injury. This is an unwise approach – all injuries must be dealt with promptly and thoroughly.
The smaller the area which sustains the injury and the more dense or sharp the offending object, the greater the risk of penetrating injury.
In blunt injury the cornea is pressed backwards into the anterior chamber and the iris onto the surface of the lens. Pigment may be deposited on the anterior lens face. The intraocular pressure can rise. The lens may be affected, e.g., a concussion cataract can occur or the lens may dislocate due to rupture of the zonule (see diagrams).
Categories of eye injuries
Contusion/blunt injury (Fig. 1): caused by blunt objects, e.g., black eye (bruising and swelling), sub-conjunctival haemorrhage, hyphaema, orbital fracture.
Perforation: corneal or scleral (Fig. 2): caused by sharp objects.
Foreign bodies: corneal, conjunctival, sub-tarsal and intraocular.
Burns: caused by acid, alkali, molten metal, flaming liquid, scorched debris (ash), radiation.
Other chemicals: petrol, oil, household detergents, traditional medicine, snake venom.
Irritating substances/effects: fumes from vapours, smoke.
The following are possible injuries which should be considered during initial and subsequent systematic eye examination:
- Orbital fracture
- Retrobulbar haemorrhage
- Lacrimal drainage system laceration
- Eyelid and conjunctival burns and lacerations
- Corneal abrasion, laceration and ultraviolet keratitis
- Globe rupture
- Muscle damage
- Lens damage: dislocation or traumatic cataract
- Secondary iritis
- Secondary glaucoma
- Extraocular and intraocular foreign bodies
- Vitreous haemorrhage
- Retinal haemorrhage or detachment
- Choroidal haemorrhage
- Choroidal rupture
- Sympathetic ophthalmitis
When examining an eye, following a history of accident, it is particularly important to do so in a careful and systematic way. This is to ensure that no structure is left unassessed and an injury left untreated. So often it is the untreated consequence or complications of eye injuries which are responsible for permanent damage. Prompt attention may make an enormous difference to the final outcome.
John Sandford-Smith, in his book “Eye diseases in hot climates”, asks three questions:
- What caused the injury? Most patients will explain what happened. Just occasionally, however, the patient is unaware of any injury, especially if a small, sharp fragment has penetrated the eye at high speed.
- When did the injury occur? In some areas, patients may arrive days or even weeks after the injury. This further complicates the treatment.
- Which parts of the eye are injured?
Basic equipment needed for initial assessment and treatment of an injured eye
- Snellen’s visual acuity chart
- Anaesthetic eye drops
- Cotton buds
- Torch (flashlight)
- Magnifying loupe
- Clean water
- Antibiotic ointment
- Lid speculum
- Fluorescein strips
- Eye pad
- Eye shield
- Adhesive tape
Guidelines for primary care management
Always examine an eye injury with gentle hands, avoiding any pressure on the eye.
Eyelid margin laceration
- Check for any other injury involving the eye
- Apply an eye pad and shield
N.B. Refer for surgical repair.
- Instill anaesthetic eye drops
- Remove the foreign body gently either using a cotton bud or by irrigation
- Apply antibiotic ointment and an eye pad
- Check after 24 hours
N.B. Refer if unable to remove the foreign body or if any complication develops. (An iron foreign body on the cornea may leave a small rust ring after removal. Generally this does not require any further treatment).
- Identify the corneal abrasion with fluorescein dye
- Apply antibiotic eye ointment
- Apply an eye pad for 24 hours
- Repeat the same procedure (2 and 3) if the abrasion has not healed completely after 24 hours
- Apply antibiotic eye ointment 3 times a day for 3 days
N.B. Refer if no improvement after 3 days.
- Do not apply any pressure on the eye
- Do not instill any medication unless there will be delay before specialist care
- Apply an eye shield very gently
N.B. This is always an emergency and must be referred immediately. If there will be delay before specialist care, instill an antibiotic and also give a systemic antibiotic.
Hyphaema (blood in the anterior chamber)
- Apply eye pads to both eyes (if the patient can tolerate double padding)
- Advise bed rest and supervise for 5 days
N.B. Refer if blood has not cleared after 3 days or immediately if the intraocular pressure rises so that the eye surgeon can release the blood surgically.
Blunt injury to an eye may also cause other injuries (see diagrams). Refer for specialist care if significant injury is seen or if the visual acuity is < 6/18. Rest is advised until the complication has resolved. A further examination after one month is advisable.
Burns: fire or chemical
- Immediately irrigate the injured eye with copious clean water. Continue for 10 to 15 minutes, or longer if necessary
- Apply antibiotic ointment and an eye pad
N.B. This is always an emergency situation and must be referred immediately after irrigation.
DO NOT DELAY REFERRAL OF THE PATIENT EVEN TO CHECK THE VISUAL ACUITY.
Points to remember
- Take an accurate history and convey it to any other health worker treating the patient
- Always attempt to check the visual acuity before treating and referring (except in the case of burns)
- Refer all patients with a visual acuity of worse than 6/18
- Always use gentle hands in examination
This article has kindly been reviewed by John Sandford-Smith FRCS FRCOphth, Consultant Ophthalmologist, Leicester Royal Infirmary, United Kingdom.