Prevention is the key, eg wearing goggles, or plastic glasses when near small moving objects or using tools (avoids splinters, fish-hooks, and squash-ball injuries). Always record acuity (both eyes; if the uninjured one is blind take all injuries very seriously). Take a detailed history of the event.
If unable to open the injured eye, instill a few drops of local anaesthetic (tetracaine 1%): after a few mins, comfortable opening may be possible. Examine lids, conjunctiva, cornea, sclera, anterior chamber, pupil, iris, lens, vitreous, fundus, and eye movement. An irregular pupil may mean globe rupture. Afferent pupil defects (p 424) do not augur well for sight recovery. Note pain, discharge, or squint. CT may be very useful (foreign bodies may be magnetic, so avoid MRI).
Penetrating trauma
Refer urgently: delays risk of ocular extrusion or infection. With uveal injury there is risk of sympathetic ophthalmia in the other eye. A history of flying objects (eg work with lathes, hammers, and chisels) should prompt careful examination and x-ray to exclude intraocular foreign bodies. Don't try to remove a large foreign body (knife; dart). Support the object with padding. Transport supine. Pad the unaffected eye to prevent damage from conjugate movement. Consider skull x-ray or CT to exclude intracranial involvement.
Foreign bodies (FB)
Have a low threshold for getting help; FBs often hide, so examine all the eye; for lid eversion seehttp://www.medinfo.ufl.edu/year1/bcs/clist/index.html FBs cause chemosis, subconjunctival bleeds, irregular pupils, iris prolapse, hyphaema, vitreous haemorrhage, and retinal tears. If you suspect a metal FB, x-ray the orbit. With high-velocity FBs, consider orbital ultrasound: pick-up rate is 90% vs 40% for x-rays but skill is needed (not always available in busy A&E departments). Removal of superficial foreign bodies may be possible using a triangle of clean card. Use gentamicin 0.3% drops afterwards to prevent infection.
Corneal abrasions
(Often from small fast-moving objects, eg children's finger-nails; twigs.) They may cause intense pain. Apply a drop of local anaesthetic, eg 1% tetracaine before examination. They stain with fluorescein and should heal within 48h. Apply gentamicin eye ointment, and pad the eye. Send the patient home with analgesics. Re-examine after 24h. If still having a foreign body sensation after removing the pad, stain again with fluorescein. If the cornea stains, repeat the procedure for another 24h. If it still stains after 48h, refer. NB: meta-analyses of small corneal abrasions do not favour using pads.
Burns
Treat chemical burns promptly: instill anaesthetic drops (tetracaine) every 2min till the patient is comfortable. Then hold lids open and bathe the eyes in copious clean water while the specific antidote is sought. Often the patient will not hold the eye open due to excruciating pain. All burns may have late serious sequelae, eg corneal scarring, opacification, and lid damage. Alkali burns are more serious than acid.
Arc eye
Welders and sunbed users who don't wear protection against UV light may damage corneal epithelium. There is a foreign body sensation, watering, and blepharospasm. Instill local anaesthetic drops every 2min. After the second application, excruciating pain can disappear like magic. Apply an antibiotic ointment, pad the eye, and it will recover in 24h. It is a very painful condition so be generous with analgesia.
Finally, remember to think of fat embolus in trauma patients who suddenly complain of visual problems.
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