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The eye and periorbital region are subject to a range of injuries with a wide spectrum of severity and sequelae.


Initial evaluation of ophthalmic trauma, whether by a first responder or an emergency department provider, starts with an assessment of the patient’s overall condition to identify and manage any life-threatening problems. Then the circumstances of the injury must be established. The patient’s level of consciousness may be altered due to substance abuse, psychiatric disease or brain injury, so family members or bystanders may provide crucial collateral information. Specific questions should include whether a blunt or sharp object inflicted the injury; whether the injury occurred at high or low velocity; whether the patient has any prior history of ocular disease or surgery; and when and what the patient last ate and drank.

The next step is ophthalmic examination, of which the extent will depend on the patient’s level of cooperation. The first part does not require significant cooperation and begins with an inspection of the eyes and periorbital tissues for any obvious abnormalities such as lacerations, ecchymosis (Figure 19–1), proptosis, corneal clouding, or gross hyphema. In severe ophthalmic trauma, it is critical to examine the eye as atraumatically as possible to avoid exacerbating the damage. The pupils are examined to determine their absolute and relative sizes and shapes and their responses to direct and consensual illumination. If the patient is conscious and cooperative, visual acuity and confrontation visual fields are tested. Keep in mind that the patient may have broken or lost his or her glasses during the trauma. A pinhole for distance acuity and/or near vision chart and presbyopic reading glasses may be crucial.

Figure 19–1.

Prominent right eyelid ecchymosis and subconjunctival hemorrhage due to blunt trauma suffered in a fall.

If the initial evaluation reveals an injury that warrants further evaluation, ophthalmology consultation is essential. In addition to reviewing the history, the ophthalmologist will perform an external examination, reassess visual acuity and pupillary responses to light, assess ocular position in each orbit, evaluate ocular alignment and motility, if possible perform slitlamp examination of the anterior segment and measure intraocular pressure, and perform indirect ophthalmoscopy of the fundus.


Rapid recognition by emergency care providers of chemical and open globe injuries is particularly important because of the need for emergency intervention to minimize their severity.

Chemical Injuries

In adults, ocular chemical injury is usually due to splash or spray of industrial or agricultural chemical, cleaning solution, automotive fluid, or cement or plaster in the work or home environment or assault with alkali or acid. In children, it is frequently caused by a cleaning solution or detergent.

Regardless of the type ...

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