Eye injuries occur in 10 percent of nonfatal casualties in military conflicts. Major injuries must be identified early and properly managed if the eye is to be salvaged.

History and Physical Examination

History

• Onset of the problem.

• Duration of the problem.

• Type and degree of injuries.

• Glasses or contact lens wear.

• Factors which improve or aggravate the problem.

Physical Examination

• Irrigate loose debris away. If necessary retract eyelids using topical anesthesia and Desmarres retractors (or bent paper clip).

• Visual acuity - evaluate and record; use pinhole if glasses unavailable.

• Eyelids - check for edema, ecchymosis, burns/chemical injury, lacerations, ptosis, foreign bodies in contact with globe, and avulsed canthal tendon.

• Orbital rim - palpate for step-off, crepitus, subcutaneous emphysema, and record.

• Conjunctiva - assess for chemosis, emphysema, subconjunctival hemorrhage, non-impaled foreign bodies and record.

• Cornea - inspect for opacity, ulceration, foreign bodies. Consider use of fluorescein and a blue light. Record findings.

• Pupil & Iris - assess for PERRLA (pupils equal, round, react to light, and accommodation), iridodialysis, iridodonesis, and record. Assess for Afferent Pupillary Defect (Marcus Gunn Pupil) by the swinging flashlight test and record.

• Anterior chamber - inspect for hyphema, depth (compare to normal side), and record.

• Lens - transparency, displacement, dislocation, and record.

• Posterior chamber - assess for vitreous hemorrhage (black versus red reflex), retinal hemorrhage, tears, detachment, or prolapse and record.

• Globe - inspect for anterior, posterior, or inferior displacement, full range-of-motion (ROM), diplopia, or entrapment. If grossly normal, intraocular tension may be evaluated for gross differences by very gentle digital ballotment through the closed, upper eyelid. Record.

• Ancillary Tests - Consider skull radiographs (Caldwell and Waters view) to evaluate for intracranial foreign bodies, fractures.

Management

Minor injuries (treat locally and return to duty after follow up)

Superficial lid laceration.

• Diagnosis (Dx) - consider occult injury to levator muscle of upper lid, lacrimal canaliculi or underlying eyeball.

• Treatment (Rx) - anatomic closure with fine sutures (6-0 or 7-0), antibiotic ointments as dressing, remove sutures in 3-5 days.

Corneal abrasion

• Dx - History of minor trauma, prominent foreign body (FB) sensation, irregular corneal surface, positive fluorescein staining under blue light.

• Rx - cycloplegia (Cyclogyl 1%, 1 gtt, q12 hours, Homatropine 5%, 1 gtt, QD, or Scopolamine 0.25%, 1 drop (gtt), TID), antibiotic ointment, systemic pain medications as needed, reevaluate every 24 hours until healed. A patch is not recommended. Studies have shown no differences in healing rate between patch and non-patch groups.

Superficial foreign bodies

• Dx - history, visualization

• Rx - remove under topical anesthesia with a cotton tip applicator, 26 gauge needle, fine forceps, corneal spud or battery-powered burr - then treat as corneal abrasion.

Flashburns

• Dx - history of exposure to UV light (such as arc welding) about 12h previously, marked foreign body (FB) sensation and photophobia, red eye and tearing, diffuse punctate defects on fluorescein staining.

• Rx - same as corneal abrasion.

Major injuries (MEDEVAC urgently to an ophthalmologist)

Complex eyelid lacerations

• Dx. These lacerations involve the medial canthus, lacrimal apparatus, levator (poor elevation of upper lid) or lid margin.

• Rx - check carefully for occult injury to the eyeball, record vision, clean thoroughly with Betadine solution (NOT scrub); if MEDEVAC to an ophthalmogist cannot be done within 2 days, close the wound using 6-0 or 7-0 sutures. Place three sutures at the lid margin to reapproximate the eyelash line.

Nonhealing corneal abrasion or embedded foreign bodies (FBs)

• Dx - obvious.

• Rx - record vision, antibiotic drops, cycloplegia, and patch if needed for pain/photophobia.

Hyphema

• Dx - blood in the anterior chamber.

• Rx - record vision daily, Fox (rigid) shield without a patch over the eye, bed rest with head of bed elevated at 30°, stool softeners, Timoptic drops twice a day, and avoid ASA. Sedate as needed.

Vitreous hemorrhage

• Dx - sudden, painless loss of vision or numerous floaters of recent onset; poor or no view of retina, poor red reflex.

• Rx - record vision daily, bed rest with head of bed elevated 30° and avoid ASA.

Retrobulbar hematoma

• Dx - ecchymosis of the lids/eyeball, marked proptosis and limited mobility of the eyeball.

• Rx - record vision and pupil exam every 1/2 hour initially; if marked or progressive vision loss (with no other explanation) cut from the lateral canthal angle to the lateral orbital rim then spread gently into the fat pad behind the eye with forceps to release the hematoma.