What is the recommended emergency evaluation and initial management for ocular trauma?

Emergency Evaluation and Initial Management of Ocular Trauma

All ocular trauma requires immediate visual acuity testing, thorough examination to rule out globe injury, and urgent ophthalmology consultation for high-risk injuries including suspected open globe, vision loss, high-velocity mechanisms, or orbital fractures with warning signs. 1, 2

Immediate First Aid (Pre-Hospital/Scene)

• Begin copious eye irrigation with tap water for 15-30 minutes immediately for any chemical or thermal exposure, without delay, before transport 1
• Apply a protective eye shield to prevent unintentional touching or pressure on the eye 1
• Instruct patients not to rub their eyes, as this causes further damage 1
• For high-velocity injuries (grinding, nailing, machinery), assume penetrating globe injury until proven otherwise 2

Emergency Department Evaluation

Critical Initial Assessment

The primary goal is to identify sight-threatening injuries requiring immediate intervention. 3

• Test visual acuity immediately using a smartphone eye chart with corrective lenses to establish baseline function 1, 2
• Perform pupillary examination including testing for afferent pupillary defect (Marcus Gunn pupil) 3, 2
• Measure intraocular pressure (IOP) if equipment available and no suspected open globe 3, 2
• Conduct confrontational visual field testing to detect peripheral defects 3, 2
• Inspect with penlight for irregular pupil, eye bleeding, corneal defects, or foreign bodies 1, 2
• Perform slit-lamp examination when available to assess corneal integrity and anterior chamber 3
• Conduct dilated fundus examination (if safe and no contraindications) to evaluate for retinal damage, paying attention to fundus torsion 3

Additional Examination Components for Orbital Trauma

• Check vital signs for bradycardia, heart block, or arrhythmias suggesting oculocardiac reflex from muscle entrapment 3, 2
• Assess for systemic symptoms including dizziness, nausea, vomiting, or loss of consciousness indicating entrapped muscle requiring urgent surgical intervention 3, 2
• Test facial sensation to evaluate for orbital nerve injury 3
• Perform exophthalmometry to measure proptosis or enophthalmos 3
• Conduct detailed sensorimotor examination including versions, ductions, saccades, pursuit, vergence, and alignment in multiple gaze positions 3
• Perform forced duction testing to distinguish muscle restriction from paresis 3

Immediate Referral Criteria (Ophthalmology Emergency)

Absolute Emergencies Requiring Immediate Consultation

• Suspected open globe injury with irregular pupil, eye bleeding after trauma, or penetrating injury from sharp/metal objects 1, 2
• Vision loss after trauma of any degree 1, 2
• Oculocardiac reflex signs (bradycardia, heart block, dizziness, nausea, vomiting, loss of consciousness) indicating entrapped muscle requiring immediate medical and surgical treatment 3, 2
• High-velocity injuries from grinding, nailing, or machinery due to penetrating globe injury risk 1, 2
• Orbital fractures with warning signs including eyelid swelling with pain/erythema, proptosis, pain with eye movements, or movement restriction/diplopia 2

Urgent Referral Within 24-48 Hours

• Persistent foreign-body sensation after initial removal attempts 2
• Visual complaints including blurred vision, floaters, flashing lights, color vision changes, photophobia, visual distortion, field changes, or scotomas 2
• Moderate or severe pain unresponsive to initial management 2
• Persistent diplopia beyond initial evaluation (occurs in 58-68% of blowout fractures) 2
• Corneal infiltration or ulceration suggesting infection 2

Initial Management in Emergency Department

For Corneal Injuries/Abrasions

• Apply broad-spectrum topical antibiotic prophylaxis such as moxifloxacin four times daily 1
• Use topical NSAID such as ketorolac for pain, photophobia, and foreign body sensation 1
• Administer oral acetaminophen or NSAIDs for additional pain relief 1
• Consider cycloplegic agents such as cyclopentolate to reduce ciliary spasm pain 1
• Avoid pressure patching in contact lens wearers due to higher risk of secondary infectious keratitis 3

For Suspected Open Globe

• Apply protective eye shield immediately without applying pressure 1, 2
• Administer empiric systemic antibiotics immediately to prevent intraocular infection 4
• Keep patient NPO and prepare for emergent surgical exploration and primary closure 4
• Do not perform IOP measurement or any maneuvers that apply pressure to the globe 4

Critical Management Pitfalls to Avoid

• Do not start corticosteroids before ophthalmologic examination unless required for concurrent non-ophthalmological conditions, as steroids may worsen infectious conditions or mask accurate diagnosis 2
• Do not perform blind sweeping of conjunctival fornices with cotton buds or glass rods, as this causes additional damage 2
• Do not assume reperfusion eliminates urgency in retinal artery occlusions - the risk of concurrent cerebrovascular events remains high 5

Imaging Studies

• Order CT scan (not MRI initially) if any concern about ferrous-metallic foreign body or to evaluate orbital fractures and entrapment 3
• MRI provides superior soft tissue detail for extraocular muscles and pulley system but only after metallic foreign body is excluded 3
• Consider bedside ultrasound for multiply injured patients when direct examination is limited, but avoid if open globe suspected 6, 7

Special Considerations

Giant Cell Arteritis Evaluation (Age >50)

• Assess for GCA symptoms including temporal tenderness, jaw claudication, weight loss, proximal myalgia, or fever in patients with retinal artery occlusion 3, 5
• Order C-reactive protein (CRP) and/or erythrocyte sedimentation rate (ESR) which are typically elevated in GCA 3, 5
• Initiate systemic corticosteroid therapy immediately if GCA suspected to prevent vision loss in fellow eye 3, 5

Retinal Artery Occlusion

• Treat as medical emergency requiring immediate referral to stroke center within 24 hours, as 19-25% have silent brain infarction on MRI and stroke risk is highest within first 7 days 3, 5
• Consider hyperbaric oxygen therapy (100% oxygen over 9 hours) which has demonstrated efficacy in small randomized trials 3, 5

Follow-Up Requirements

• All ocular trauma patients require ophthalmology follow-up within 24-48 hours to assess for infection or progression 1
• Persistent symptoms mandate specialist re-evaluation regardless of initial impression 1
• Diplopia persisting beyond 6 months is unlikely to resolve spontaneously and warrants definitive treatment 3