History and exam
Key diagnostic factors
common
hyphaema
Blood in the anterior chamber of the eye indicates that the eye has suffered a significant injury and structures within the anterior and posterior segments are likely to be damaged.
A full ocular assessment is mandatory and particular attention should be made to the intra-ocular pressure, structures within the drainage angle, clarity and stability of the lens, the posterior pole, and the peripheral retina.
ecchymosis
May follow blunt trauma to the eye.
severe eye pain
Indicative of eye trauma.
blurred vision
May follow eye trauma or open globe injury.
corneal abrasions
May be caused by fingernails, animal claws, pieces of paper or cardboard, make-up applicators, hand tools, or a foreign body lodged under the eyelid.
corneal oedema
Slit-lamp examination may show oedema following blunt trauma to the eye.[34]
Examine corneal lacerations carefully and perform a Seidel test if unsure whether the laceration is full or partial thickness.
sub-conjunctival haemorrhages
Can occur following trauma. Can also occur following a sudden increase in venous pressure, as occurs with coughing, sneezing, straining, or vomiting.
Sub-conjunctival haemorrhages usually do not require treatment. However, a large haemorrhage, especially if associated with other ocular findings, may be a sign of an open globe injury. They are often present with conjunctival lacerations.
If they are recurrent, systemic problems, such as an underlying bleeding disorder, should be ruled out.[35]
corneal and conjunctival lacerations
Should raise the suspicion for injury of deeper structures and the presence of an open globe injury or intra-ocular foreign body.
Patients may present with mild pain, red eye, a foreign-body sensation, and usually a history of trauma.
Perform careful slit-lamp examination to evaluate if there are any lacerations in the underlying sclera.
Slit-lamp examination shows fluorescein staining of the conjunctiva.
Sub-conjunctival haemorrhages are often present with conjunctival lacerations.
punctate epithelial erosions
In the presence of a conjunctival foreign body located under the upper eyelid, slit-lamp examination may show vertically oriented linear abrasions on the cornea.
uncommon
loss of sight
May occur in serious eye injury.
Other diagnostic factors
common
excessive lacrimation
Sometimes follows trauma to the eye.
conjunctival chemosis
Oedema of the conjunctiva may follow injury.
conjunctival hyperaemia
Dilated conjunctival vessels.
May follow blunt trauma or chemical burn.
corneal epithelial defect/abrasion
May follow a chemical burn or mechanical trauma.
uncommon
open globe injury
When globe injury is suspected, stop the examination, cover the affected eye with a protective shield, and do not apply pressure. Refer the patient for complete evaluation and repair by an eye surgeon in the operating room.[30][31]
Signs of open globe injury include conjunctival haemorrhage and lacerations, a shallow or flat anterior chamber with iris-cornea touch, a peaked pupil, an iris defect, low intra-ocular pressure, a defect in the anterior capsule of the lens or trauma cataract, and vitreous or retinal haemorrhage.[45] Diagnostic signs include exposed uveal tissue, a positive Seidel test, or an intra-ocular foreign body seen on slit-lamp exam, dilated exam, or radiographic imaging. Associated ophthalmic injuries include eyelid lacerations and orbital fractures.
eyelid burns
May follow a chemical burn.
photophobia
May follow eye trauma.
diplopia
Sometimes follows blunt trauma to the eye.
May be a sign of a serious injury.
miosis
Constriction of the pupil is associated with traumatic iritis and anterior chamber inflammation.
corneal stromal clouding
May follow a chemical burn.
iridodialysis
Separation of the iris root from its attachment at the ciliary body may follow a blunt trauma. It presents as a black slit at the limbus and deforms the pupil.
A large dialysis can cause photophobia and monocular diplopia.
conjunctival foreign body
Foreign bodies in the conjunctiva may cause pain, discomfort, tearing, and a foreign-body sensation. Slit-lamp examination may show punctate epithelial erosions or linear vertical corneal abrasions. If linear abrasions are seen, perform eyelid eversion with careful examination of the tarsal conjunctiva to search for a foreign body.[33]
Dilated fundus examination can be performed to examine the vitreous and retina for possible foreign bodies.
corneal foreign body
Foreign bodies in the cornea may be metallic, glass, or organic. They present with conjunctival injection, tearing, and foreign-body sensation. Slit-lamp examination should show the offending particle. The depth of corneal involvement and possible penetration in the anterior chamber should be determined.[33]
In cases of suspected anterior segment intra-ocular foreign bodies, gonioscopic examination may be performed to assess any intra-ocular foreign body in the angle.
Descemet's membrane tears
Slit-lamp examination may show tears to this membrane following blunt trauma to the eye.[34]
corneoscleral lacerations
May be present in severe cases of blunt trauma to the eye. They are typically located at the limbus, under the rectus muscles, or at the site of prior surgical wounds.
Full-thickness corneal lacerations can be differentiated from partial-thickness lacerations using slit-lamp examination and Seidel test. An asymmetrically lower intra-ocular pressure compared with the other eye, and a shallow anterior chamber, may be seen with full-thickness lacerations.
persistent headache
May occur in serious eye injury.
loss of consciousness
May occur in serious eye injury.
blood or clear fluid from ears or nose
May occur in serious eye injury.
inability to move eye(s)
May occur in serious eye injury.
Risk factors
strong
age 18-45 years
Nearly one half of all reported eye injuries occur in people between the ages of 18-45 years.
male sex
no protective eyewear
The majority of all eye injuries can be prevented by using protective eyewear. For example, most eye-related work injuries occur in patients not wearing eye protection.
workplace injuries
Approximately 20% of all ocular injuries occur at work, with construction being the leading occupation associated with eye injuries.[1]
The most common blunt objects reported were rocks and lumber; the most common sharp objects were sticks, knives, scissors, screwdrivers, and nails.[1]
Chemical injuries may involve acids, alkalis, fuels, solvents, lime, and wet or dry cement powder. Proper protective techniques, such as safety glasses, are essential to prevent severe eye injuries.
falls
Falls are an important cause of eye trauma in the US (approximately 33.8 encounters per 100,000 population), especially in women, older people, and children.[9]
Of 87,991,036 fall encounters presenting to emergency departments in the US from 2006 to 2015, 952,781 encounters had eye trauma as a primary or secondary diagnosis.[9]
fireworks
exposure to ultraviolet light
Excessive exposure to ultraviolet light can cause flash burns to the cornea (e.g., from sungazing, the reflection of the sun on snow and ice at high elevation, or exposure within tanning booths).
weak
previous eye surgery
alcohol-based hand sanitisers
Alcohol-based hand sanitiser dispensers may pose a risk to young children because of the height at which they are wall-mounted, and the frequent lack of immediate access to eye-wash facilities.[28]
Experience during the COVID-19 pandemic indicates the need to keep alcohol-based hand sanitisers away from young children.
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