What is the initial workup and management for a blunt eye injury?

Initial Workup and Management of Blunt Eye Injury

The initial workup for blunt eye trauma should include visual acuity testing, pupillary examination, slit lamp or penlight examination of the anterior segment, and direct fundoscopic examination to identify potentially vision-threatening injuries that require urgent ophthalmologic consultation. 1, 2, 3

Primary Assessment

1. Visual acuity assessment:

   • Document baseline visual acuity in both eyes
   • Use Snellen chart or near card if available
   • If unavailable, assess ability to count fingers, detect hand motion, or perceive light

2. External examination:

   • Inspect for periorbital ecchymosis, edema, lacerations
   • Assess for orbital rim fractures by palpation
   • Evaluate for proptosis or enophthalmos
   • Check extraocular movements (limitation may indicate muscle entrapment or cranial nerve injury)

3. Pupillary examination:

   • Check pupil size, shape, and reactivity
   • Assess for relative afferent pupillary defect (RAPD), which suggests optic nerve damage

4. Anterior segment evaluation:

   • Examine for hyphema (blood in anterior chamber)
   • Look for lens dislocation
   • Assess corneal clarity and integrity
   • Check intraocular pressure if equipment available (tonometer)

5. Posterior segment assessment:

   • Perform dilated fundoscopic examination if no contraindications
   • Look for vitreous hemorrhage, retinal tears/detachment, choroidal rupture
   • Evaluate optic disc for edema or pallor

Critical Findings Requiring Immediate Ophthalmology Consultation

• Decreased visual acuity
• Hyphema (blood in anterior chamber)
• Irregular pupil shape (iris injury)
• Lens dislocation
• Elevated intraocular pressure
• Vitreous hemorrhage
• Retinal tears or detachment
• Choroidal rupture
• Globe rupture or laceration

Management Principles

1. Protect the eye:

   • Apply rigid eye shield (not pressure patch) if globe rupture suspected 3
   • Avoid applying pressure to the eye
   • Position patient with head elevated to reduce intraocular pressure

2. Pain management:

   • Oral analgesics as appropriate
   • Avoid topical anesthetics for pain control (can delay healing)

3. Prevent complications:

   • Antiemetics to prevent vomiting (increases intraocular pressure)
   • Avoid activities that increase intraocular pressure

4. Imaging considerations:

   • CT scan without contrast for suspected orbital fractures or intraocular foreign bodies
   • Ultrasound may be useful for posterior segment evaluation when direct visualization is not possible

Special Considerations

• Patients with symptomatic floaters and flashing lights require immediate dilated fundoscopic examination to evaluate for retinal tears or detachment 3
• Even seemingly minor blunt trauma can cause severe damage to angle structures, lens, macula, and peripheral retina 1
• Always examine both eyes thoroughly, as the contralateral eye may have sustained less obvious but significant injury 1
• Early treatment of retinal tears and elevated intraocular pressure can prevent severe vision loss 1

Follow-up

• All patients with significant blunt eye trauma should have ophthalmology follow-up within 24 hours
• Patients should be instructed to return immediately for worsening pain, decreased vision, new floaters/flashes, or increasing redness

Remember that potentially severe injuries may not be immediately apparent due to vitreous hemorrhage or may be located in the angle or far periphery of the retina, necessitating comprehensive evaluation by an ophthalmologist 1, 4.