What is the management for an eye injury with impaired extraocular movements, a flat globe, and decreased visual acuity, with fluorescein testing revealing a potential corneal abrasion or ulcer?

Management of Eye Injury with Impaired Extraocular Movements, Flat Globe, and Decreased Visual Acuity

The appropriate management for this eye injury with impaired extraocular movements, flat globe, decreased visual acuity, and positive fluorescein staining is eye shield placement, CT scan of the orbit, and immediate ophthalmology consultation. 1

Assessment of Severity

The clinical presentation strongly suggests a serious eye injury requiring urgent intervention:

• Impaired extraocular movements: Indicates possible muscle entrapment, avulsion, or cranial nerve damage 2
• Flat globe: Suggests possible globe rupture or severe trauma with loss of intraocular pressure
• Decreased visual acuity: Indicates significant functional impairment
• Positive fluorescein staining: Confirms corneal epithelial defect

Management Algorithm

Immediate Actions:

1. Apply protective eye shield (without pressure on the globe)

   • Prevents further damage to potentially ruptured globe
   • Protects from external contamination
   • Do NOT patch the eye as this increases infection risk 1

2. Arrange urgent CT scan of the orbit

   • CT is preferred over MRI if metallic foreign body is suspected 2
   • Evaluates for:
     • Orbital fractures
     • Muscle entrapment
     • Globe integrity
     • Foreign bodies
     • Orbital hemorrhage

3. Immediate ophthalmology consultation (same day)

   • Required for suspected globe injury, deep lacerations, or lacrimal system involvement 1
   • Ophthalmologist will perform specialized examination including:
     • Slit lamp examination
     • Intraocular pressure measurement
     • Dilated fundus examination if safe
     • Assessment of extent of corneal damage

Contraindicated Actions:

• Do not attempt to measure intraocular pressure if globe rupture is suspected
• Do not instill topical medications until ophthalmology assessment (except lubricants if directed)
• Avoid lateral canthotomy unless specifically indicated for orbital compartment syndrome with confirmed intact globe
• Do not delay imaging or consultation for simple antibiotic administration

Rationale for Management

The presentation of impaired extraocular movements with a flat globe strongly suggests a severe ocular injury that may include:

• Possible globe rupture requiring surgical repair
• Orbital fracture with muscle entrapment
• Severe corneal injury with risk of infection and permanent vision loss

According to the American Academy of Ophthalmology guidelines, urgent ophthalmology consultation is mandatory for suspected globe injury, deep lacerations involving the lid margin, or any signs of significant ocular trauma 1. The flat globe appearance and impaired extraocular movements meet these criteria.

Important Caveats

• If the oculocardiac reflex is triggered (bradycardia, nausea, vomiting), this may indicate muscle entrapment requiring immediate surgical intervention 2
• Fluorescein staining confirms corneal epithelial damage but does not rule out deeper injury
• Rarely, fluorescein administration can cause allergic reactions, including anaphylaxis 3
• The patient should be monitored for signs of increasing orbital pressure (increasing pain, further vision loss, proptosis) which may require emergency lateral canthotomy

By following this management approach, you maximize the chance of preserving vision and preventing complications in this serious eye injury.