Management of Central Eye Injury Following CPAP Explosion
Immediate referral to an ophthalmologist or emergency department is essential for any eye injury following a CPAP explosion, as this represents an urgent ophthalmic condition requiring prompt evaluation and treatment.
Initial Assessment and Management
Primary Survey
- Rule out globe rupture or penetrating injury
- Assess visual acuity (if possible)
- Examine pupils for reactivity and relative afferent pupillary defect
- Check intraocular pressure (if safe to do so)
- Perform confrontational visual field testing
Critical Immediate Actions
- Do not apply pressure to the eye
- Apply protective eye shield without pressure if globe rupture is suspected
- Do not instill any medications until globe integrity is confirmed
- Administer pain medication as needed
Diagnostic Evaluation
Imaging
- CT scan (preferred over MRI) to assess:
- Orbital fractures
- Foreign bodies
- Muscle entrapment
- Globe integrity
Specialized Testing (by ophthalmologist)
- Slit-lamp examination
- Dilated fundoscopic examination (if safe)
- Forced duction testing to assess extraocular muscle function
- Gonioscopy to evaluate angle structures
Treatment Algorithm Based on Specific Injuries
1. Retinal Artery Occlusion
If central retinal artery occlusion (CRAO) is diagnosed:
- Treat as a medical emergency with immediate referral to a stroke center 1
- Consider hyperbaric oxygen therapy (100% oxygen over 9 hours) which has shown efficacy in small randomized trials 1
- Evaluate for concurrent cerebrovascular accident (present in up to 24% of cases) 1
2. Angle Closure
If angle closure is identified:
- Perform laser peripheral iridotomy to eliminate pupillary block 1, 2
- Use topical ocular hypotensive agents perioperatively to prevent sudden IOP elevation 1
- Consider medical therapy including:
- Topical beta-adrenergic antagonists
- Topical alpha2-adrenergic agonists
- Topical, oral, or intravenous carbonic anhydrase inhibitors 1
3. Open Globe Injury
If open globe injury is present:
- Immediate surgical repair is required
- Administer systemic antibiotics to prevent endophthalmitis
- Avoid ocular massage or pressure 3
4. Intraocular Foreign Body
If intraocular foreign body is detected:
- Surgical removal is indicated
- Poor prognostic factors include:
- Full-thickness laceration ≥5mm
- Vitreous hemorrhage
- Zone III injury (posterior to equator) 3
Follow-up Care
Short-term Monitoring
- Daily assessment of:
- Visual acuity
- Intraocular pressure
- Anterior chamber inflammation
- Retinal status
Long-term Management
- Monitor for development of:
Prognosis
The prognosis for central eye injuries following CPAP explosion is guarded, with studies showing:
- Up to 45.82% of patients with explosive eye injuries have final vision ≤4/200 3
- 9.59% of eyes with explosive injuries ultimately require removal 3
Pitfalls and Caveats
Do not miss concurrent cerebrovascular events - Up to 24% of patients with retinal artery occlusion have concurrent cerebrovascular accidents 1
Beware of initially normal-appearing anterior segment - Despite a normal-appearing anterior segment, posterior rupture may be present 4
Consider delayed complications - Monitor for development of proliferative vitreoretinopathy, which is more common with perforating injuries (47.06%) than penetrating injuries (8.79%) 3
Recognize risk factors for poor outcomes - Poor presenting vision, full-thickness laceration ≥5mm, vitreous hemorrhage, and intraocular foreign bodies are significant negative predictors for visual outcomes 3
Don't delay treatment - Prompt recognition and appropriate treatment are essential when outcome depends on timely management 5