Approach
Practitioners should recognise their limitations, and where necessary, seek further advice or refer the patient to an ophthalmologist, especially for presentations with significant eye injury, eye pain, or peri-ocular trauma.[30]
Treatment of ophthalmic trauma should be performed by an experienced physician. The patient should be made comfortable and the injured eye protected with a rigid shield or equivalent until transported to the specialist.
Conservative treatment for corneal abrasions will lead to healing within 48-72 hours. If there is no sign of improvement within this period, referral to a specialist is recommended.
Superficial injuries without a foreign body
Patients may present with superficial injuries only. However, these can vary in severity from a simple black eye that can be managed conservatively to chemical splashes that require urgent treatment.
Exposure to ultraviolet light
Following exposure, healing usually occurs within 24 hours with conservative treatment (i.e., observation, preservative-free artificial tears, topical antibiotic ointment).
Chemical splashes
Should be treated with immediate eye irrigation, using isotonic saline or sterile water.[33][46] Irrigation for known chemical injury should proceed for at least 15 minutes before examination is attempted. To measure pH, cease irrigation, wait for 1 minute, then apply universal indicator (pH) paper to the fornix. Continue irrigation and pH checking in this way until the pH normalises (range: 7.0 to 7.5).[33]
Irrigation may take several hours. Obtain an ophthalmology consultation after irrigation.
Topical antibiotic drops and ointment should be used until the epithelium is healed, and topical corticosteroids may be used for 5-7 days.
Black eye (ecchymosis)
Treatment includes ice, analgesics (aspirin should be avoided because it can predispose to bleeding), rest, and possible protection of the injured area with an eye shield. Associated ocular injuries should be ruled out by an experienced physician or eye doctor.
Minor abrasions
For minor abrasions (i.e., small and superficial) or other irritations that affect only the surface of the eye (i.e., the conjunctiva or cornea), and when no foreign bodies are present, short-term treatment with a topical antibiotic is usually sufficient to ease discomfort while healing. Topical antibiotics may also be considered if there are concerns for infection. It is unclear, however, whether antibiotic prophylaxis can prevent eye infections in people with corneal abrasion.[47] Most patients should receive topical antibiotics for symptom relief (lubrication).
Contact lens-associated abrasions have a higher rate of Pseudomonas infection and require alternative antibiotics.
Eyelid lacerations
The wound should be cleaned with minimal debridement and simple lacerations sutured. Patients should be referred to a specialist when the margin of the eyelid is involved, the medial part of the eyelid is lacerated (which could signify involvement of the tear duct), or fat is prolapsed.
Hyphaema
Hyphaema often follows a blunt trauma. A protective eye shield should be placed over the traumatised eye until the hyphaema resolves to avoid further injury to the affected eye. Physical activity should be restricted and patients should be advised to elevate the head of the bed to allow the blood to settle.
Corticosteroids, cycloplegics, and non‐drug interventions (e.g., binocular patching, bed rest, or head elevation) are commonly recommended, but there is a lack of evidence to support their use in the management of traumatic hyphaema or traumatic iridocyclitis.[48][49]
Elevated intra-ocular pressure (IOP) is present in 40% of hyphaemas at presentation.[23] Nausea and vomiting can be a sign of increased IOP, and emesis itself can increase the IOP. Consider anti-emetics where appropriate.
Antifibronlytic agents (e.g., aminocaproic acid, tranexamic acid) may reduce and stabilise blood clots by preventing fibrinolysis.[48][50]
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However, these agents have significant adverse effects (e.g., increased risk of thrombosis, nausea, abdominal pain) and are not used routinely to treat hyphaema. One systematic review found no good evidence to support the use of antifibrinolytic agents in the management of traumatic hyphaema (other than reducing secondary haemorrhage rate).[48]
Most hyphaemas resolve spontaneously within 2-6 days of injury. Surgical treatment with an anterior chamber washout is indicated when the hyphaema is complicated by corneal blood staining, persistently elevated IOP despite optimal medical management, or when a view is necessary to treat retinal pathology. In patients with sickle-cell trait or disease, perform surgical intervention if the IOP exceeds 24 for more than 24 hours, given the risk of optic nerve damage.[51]
Offer frequent follow-up examinations to monitor for elevated IOP or re-bleeding, and advise patients to avoid the use of aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs). Patients with a bleeding tendency (e.g., haemophilia, thrombocytopenia) or those on anticoagulants, should receive appropriate treatment to restore clotting ability.
Corneal abrasions with possible superficial foreign body
A corneal abrasion involves the denuding of the most superficial cornea layer, the corneal epithelium. Initial treatment involves the removal of any retained foreign body.[33]
Remove any retained body using a saline flush, fine-tipped forceps or a blunt spatula, or a sterile saline-wetted cotton bud or disposable hypodermic needle.[52][53] Avoid aggressive attempts to remove deeply embedded foreign bodies.
Oral analgesics (e.g., ibuprofen, paracetamol) may be required for pain relief, but non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are preferred for patients with significant tissue swelling. Topical ophthalmic NSAIDs can cause melts (peripheral ulcerative keratitis) in the setting of epithelial defects, and offer no clear benefits over oral analgesia.[54]
Consider topical ophthalmic anaesthesia to provide initial symptom relief and aid initial examination only.[33] One Cochrane review concluded that it is uncertain whether topical anaesthetics effectively treat pain associated with corneal abrasions or improve corneal healing.[32] Repeated use of topical anaesthetics is probably toxic to the corneal epithelium and may impair healing (e.g., risks corneal melting, ring infiltrates, and infection).[55][56] Patients should not receive topical anaesthetics for use at home.[56]
Despite limited evidence to support their use, cycloplegics, corticosteroids, and bandage contact lenses are frequently used.[57]
Treat patients with a topical antibiotic to prevent infection and ease discomfort. Prescribe if there is substantial epithelial loss or contamination. Ointments are preferred because they function as lubricants and theoretically aid healing, but can blur vision (thus, consider a combination of eye drops for the day and ointments at night). Contact lens-associated abrasions have a higher rate of Pseudomonas infection and require alternative antibiotics. Provide ophthalmological follow-up within 24 to 48 hours.
Eye patching for simple abrasions offers no clear benefits for healing and risks causing monocular vision.
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See Corneal abrasions (Management approach) for further detail.
Open globe injuries
Treatment of severe ocular trauma should be performed by an experienced physician. Practitioners should recognise their limitations, and where necessary, seek further advice or refer the patient elsewhere.
A full-thickness defect in the integrity of the wall of the eye (sclera or cornea) is known as an open globe injury. As soon as the diagnosis of open globe injury is established, the examination should be stopped and the eye covered by a protective shield. Appropriate intravenous antibiotics should be given, the patient should be kept nil by mouth, and arrangements for surgical repair should be made as soon as possible. The complete evaluation should be performed by an eye surgeon.
Traumatic endophthalmitis, a severe eye infection following eye trauma, may be associated with poor outcome. Small self-sealing open globe injuries should be examined by an eye doctor to rule out any leak.
The iris may plug the wound, resulting in an irregular and peaked pupil. For perforating injuries, the entry site can be treated as a full-thickness laceration and closed accordingly. The posterior exit site may be left to heal by primary intention to avoid unnecessary eye manipulation and vitreous extrusion.
Tetanus prophylaxis should be established and, if required, a booster injection should be given.[58] Patients with nausea or vomiting will require anti-emetics to avoid increased pressure on the eye. Systemic analgesics such as morphine may be required for pain control.[59]
For those injuries that require surgery, prompt repair by an ophthalmologist (within 24 hours) is required to restore the integrity of the eye and prevent infection. Pars plana vitrectomy is indicated in cases where there is an intra-ocular foreign body injury in the vitreous or a traumatic retinal detachment.[60] Lensectomy may be required for traumatic cataract, or subluxated or dislocated lens.
The surgical technique for removal of foreign bodies depends on the location of the foreign body in the eye, as well as the size, shape, and composition.[61] Risk factors for the development of postoperative retinal detachment include scleral or corneo-scleral entry wound, the size of the foreign body, preoperative retinal detachment, and location of the intra-orbital foreign bodies.[62]
If the corneal wound is small and leaking but the anterior chamber remains formed, attempts to stop the leak with pharmacological aqueous-humour suppression (e.g., topical beta-blockers or carbonic anhydrase inhibitors), patching, or therapeutic contact lens might be considered. Cyanoacrylate tissue adhesive may be useful for wounds that fail to seal.[63][64][65]
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Intravitreal antibiotics should be considered at the time of surgical repair if wound contamination involving the vitreous is present. Attention should be paid to early signs of endophthalmitis and suture exposure and to the status of the retina.
Recurrent corneal erosions
Treat recurrent erosions acutely with topical antibiotics. Refer patients with multiple recurrences, large defects, or non-healing defects for ophthalmological follow-up. Recurrent or refractory cases usually require ophthalmology referral for surgical intervention.[66][67][68] After epithelial healing, patients may benefit from treatment with artificial tears, lubricating ointment, and/or topical hyperosmotic agents for weeks or months.[69] See Corneal abrasions (Management approach) for further detail.
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