What are the primary care guidelines for managing a patient of any age with a punch to the eye, potentially causing injuries such as retinal detachment or orbital fracture, with or without underlying medical conditions or symptoms like vision changes or pain?

Management of Eye Trauma from Blunt Force (Punch to the Eye)

Any patient presenting with a punch to the eye requires immediate ophthalmology referral to rule out vision-threatening injuries including open globe injury, retinal detachment, and orbital fractures, as 24% of blowout fractures present with serious ocular injury and 5.5% result in complete vision loss. 1

Immediate Primary Care Assessment

Critical History Elements

• Visual symptoms: Document any vision loss, flashes, floaters, peripheral visual field loss, or diplopia 2
• Timing and mechanism: Exact details of the trauma including force and direction of impact 2
• Red flag symptoms: Nausea, vomiting, dizziness, or loss of consciousness (may indicate oculocardiac reflex from muscle entrapment requiring urgent surgical intervention) 2, 3

Essential Physical Examination

• Visual acuity testing in both eyes: This is the single most critical initial assessment to detect vision-threatening pathology 1, 3
• Pupillary examination: Check for afferent pupillary defects indicating optic nerve or severe retinal injury 2, 3
• External inspection: Look for active bleeding from the eye (hard sign of open globe requiring immediate surgical consultation) 1
• Extraocular movements: Test in all directions to identify restriction or entrapment 2, 3
• Vital signs: Monitor for bradycardia or heart block indicating oculocardiac reflex 2, 3

Critical Warning Signs Requiring Immediate Ophthalmology Consultation

Never manipulate or apply pressure to the eye if open globe injury is suspected 1

• Active bleeding from the eye = open globe injury requiring immediate surgical exploration 1
• Severe vision loss or no light perception 1
• Bradycardia, nausea, vomiting with restricted eye movements = muscle entrapment with oculocardiac reflex requiring urgent surgery 2, 3
• Visible deformity, enophthalmos, or hypoglobus 2, 3

Immediate Management in Primary Care

If Open Globe Suspected

• Apply rigid eye shield without any pressure to prevent extrusion of intraocular contents 1
• Do not manipulate the eye 1
• Immediate ophthalmology consultation for urgent surgical exploration and primary closure 1
• Do not delay surgical consultation for imaging if diagnosis is clinically obvious 1

If Closed Globe Injury

• Measure intraocular pressure if equipment available and no concern for open globe 2
• Perform confrontational visual field testing 2
• Document all findings meticulously 4, 5

Imaging Considerations

CT orbit without contrast with fine cuts and multiplanar reconstructions is the imaging study of choice, with 94.9% sensitivity for intraorbital foreign bodies 1

• Order CT if patient is stable and there is concern for orbital fracture or intraorbital foreign body 1, 3
• MRI is contraindicated if metallic foreign body is suspected 1
• Do not delay ophthalmology referral for imaging 1

Referral Pathways

Same-Day Ophthalmology Referral Required For:

• Any vision loss or visual field defect 1, 5
• Pupillary abnormalities 3, 6
• Restricted eye movements or diplopia 2, 3
• Suspected orbital fracture 2, 3
• Vitreous hemorrhage, pigment, or signs of retinal pathology 2
• Any concern for globe injury 1, 5

Urgent (Within 24-48 Hours) Ophthalmology Follow-up For:

• New onset flashes or floaters (2% risk of developing retinal breaks in weeks following trauma) 2
• Minimal symptoms but documented trauma to globe 4, 5

Follow-up Within 1-2 Weeks For:

• Resolved symptoms with normal initial examination, to monitor for delayed complications including retinal detachment (63.6% of traumatic retinal detachments diagnosed within 6 weeks of injury) 3, 7

Common Pitfalls to Avoid

• Never reassure and discharge without ophthalmology evaluation when there is documented blunt ocular trauma, as serious injuries may not be immediately apparent 6, 5
• Do not miss delayed retinal detachment: 31.2% of traumatic retinal breaks are diagnosed within 24 hours, but 63.6% present within 6 weeks 7
• Do not apply pressure or patches if any concern for globe rupture 1
• Do not perform forced duction testing in primary care if open globe is possible 2
• Visual prognosis is significantly better when retinal pathology is diagnosed within 6 weeks of injury, emphasizing the importance of prompt ophthalmology referral even for seemingly minor trauma 7