Practice Guidelines: Eye Injuries (continued)

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Practice Guidelines: Eye Injuries

Objective:

  1. To define signs and symptoms that suggests the presence of eye injuries in trauma patients.
  2. To define early and timely treatment plans for patients with eye injuries.
  3. To determine situations and timely delivery for ophthalmologic consultation.

Guidelines:

  1. Follow ABC’s.
  1. During the secondary survey obtain history of the injury as it relates to the eye:
  1. Pain (consider corneal injury)
  2. Visual acuity
  3. Photophobia
  4. History of thermal injury
  5. History of corrective lens use
  6. Previous visual acuity
  7. Ocular Medication (ie., pilocarpine, cyclogyl)
  8. Prior ocular surgery
  1. Perform a physical examination
  1. Eye
  2. Gross visual acuity (ie., count fingers, read label, see light, etc.)
  3. Pupils – shape, size, reactivity, consensual reactivity
  4. Range of motion (ie., entrapment)
  5. Anterior chamber (clear, hyphema, cloudy)
  6. Conjunctiva (scleral hemorrhage, edema, etc)
  7. Cornea
  8. Apply fluorescein after topical anesthetic
  9. Examine with ultraviolet light
  10. Globe (anterior displacement, shape, symmetry)
  11. Retina (tears, hemorrhage, detachment)
  12. Optic nerve (papilledema, disc hemorrhage)
  13. Proptosis
  1. Lids
  2. Laceration
  3. Ecchymosis
  4. Edema
  1. Orbits
  2. Symmetry
  3. Crepitus or instability
  4. Obtain CT scan with 2 mm cuts through the orbits and facial bones
  1. True Emergencies (Therapy should be instituted by E.D. with urgent phone consult with the ophthalmologist)
  1. Chemical burns
  2. Copious irrigation with saline or Ringers lactate for at least 30 minutes. If available irrigating shells can be used.
  3. 5-10 minutes after irrigation, check pH. Continue to irrigate until neutral pH of 7.0
  4. Sweep conjunctival fornices with cotton swab to remove any particles in the deep fornix.
  1. Traumatic retrobulbar hemorrhage with vision loss and / or elevated intraocular pressure
  2. Diamox – p.o. or I.V.
  3. Topical Beta blocker – Timolol
  4. Hyperosmotic agent – Mannitol
  5. Lateral canthotomy and cantholysis
  1. Acute visual loss after trauma
  2. Traumatic optic neuropathy
  3. No vision with an amaurotic pupil
  4. No treatment
  1. Urgent Situations
  1. Orbital Cellulitis (consult to be seen within 6-12 hours)
  2. CT scan of orbit & sinuses
  3. I.V. antibiotics
  4. Obtain a CT of orbit using fine cuts

NOTE: Mucormycosis – consider in all diabetic and immuno compromised patients.

  1. Globe rupture (to be seen within 6-24 hours)
  2. Shield over injured eye
  3. Scan to rule out occult intraocular or orbital foreign body
  4. OR for repair
  1. Corneal Abrasion (ophthalmology consult may come in within 12-48 hours).
  2. Antibiotic ointment and patch
  3. Oral analgesic
  4. NOTE: Do not give topical anesthetic drops to the patient
  1. Corneal foreign body that cannot be removed by ED or Trauma Surgery (Ophthalmology consult may come in within 12-48 hours)
  2. Irrigate
  3. Attempt to remove with cotton tip applicator
  4. Removal using slit lamp
  5. Antibiotic & patch
  1. Traumatic Hyphema (Ophthalmology consult to evaluate in 12-48 hours)
  2. Dilate pupil – Antropine 1%
  3. Topical steroids – Prednisolone 1%
  4. If intraocular pressure is elevated
  5. Beta blocker – Timolol
  6. Iopidine
  7. Diamox – p.o. or I.V.

NOTE: rule out sickle cell disease/trait

  1. Lid Laceration (Ophthalmology consult 12-48 hours)
  2. Discussion between Plastic Surgery and Ophthalmology
  3. If superficial, suture with fine non-absorbable nylon
  4. If through tarsal plate or involves nasolacrimal system, may need repair in OR
  1. Semi-Urgent Situations (Therapy instituted within days or weeks)
  1. Orbital Fracture
  1. If going to OR for repair needs an eye exam prior to OR