Streaming Fluorescein is Most Suggestive of Penetrating Eye Injury
Streaming fluorescein (Seidel sign) is the pathognomonic finding for a penetrating eye injury, as it demonstrates active aqueous humor leakage through a full-thickness corneal or scleral wound. 1
Understanding the Fluorescein Patterns
Streaming Fluorescein (Seidel Sign) - The Definitive Answer
- Streaming fluorescein represents aqueous humor flowing through a penetrating wound, creating a visible stream of diluted fluorescein that appears as a dark rivulet against the bright green background 1
- This finding is specific for full-thickness globe perforation and indicates an open globe injury requiring urgent ophthalmologic intervention 2
- The mechanism involves intraocular fluid actively leaking through the wound, diluting the concentrated fluorescein on the ocular surface 1
Why Other Options Are Incorrect
Corneal abrasion shows superficial epithelial uptake in a geographic or linear pattern where the epithelium has been mechanically disrupted, but does not indicate penetration through the full corneal thickness 3
Dendritic pattern is characteristic of herpes simplex keratitis, not traumatic injury, and represents viral infection with branching epithelial ulceration 4
Diffuse punctate uptake indicates multiple small areas of epithelial disruption or desiccation, commonly seen with dry eye, chemical exposure, or superficial keratopathy, but not penetrating trauma 4
Clinical Context for This Patient
- Weed-whacker injuries carry extremely high risk for penetrating trauma due to high-velocity projectiles (plant material, rocks, metal fragments) that can perforate the globe 2
- The absence of eye protection significantly increases penetrating injury risk in this mechanism 2
- Hyphema, abnormal pupil/uvea, and visual acuity worse than 20/200 are the most common associated findings with penetrating injuries, present in 76%, 94%, and 77% of cases respectively 2
Critical Management Implications
If streaming fluorescein is identified, this constitutes an ophthalmologic emergency requiring:
- Immediate ophthalmology consultation for surgical repair 2
- Protective eye shield (never patch or apply pressure) 3
- NPO status for urgent operative intervention 2
- Broad-spectrum IV antibiotics to prevent endophthalmitis 2
- Tetanus prophylaxis if indicated 2
- CT imaging to identify intraocular foreign bodies before surgical exploration 2
Common Pitfalls to Avoid
- Do not perform the Seidel test by applying excessive pressure to the globe, as this can extrude intraocular contents through the wound 1
- Never instill topical anesthetics or manipulate the eye if penetrating injury is suspected until definitive examination by ophthalmology 2
- Poor visual outcomes occur in 38% of penetrating injuries (enucleation or no light perception), with gun-related injuries and motor vehicle crashes causing the worst outcomes 2
- Delayed presentation significantly worsens visual prognosis (p=0.036) 2