Eye trauma

Disclaimer These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.  Read the full CAHS clinical disclaimer.

Aim

To guide staff with the assessment and management of eye trauma in children.

Background

Eye injuries may be difficult to assess in the distressed child. Provide analgesia and / or topical anaesthetic early to aid assessment.

Mechanism of injury will provide clues for specific injuries to exclude:

• Blunt trauma with large objects (sporting equipment, fists): 
  • Globe rupture, retrobulbar haemorrhage, orbital rim / blowout fracture, retinal tear, vitreous / retinal haemorrhage, hyphaema, corneal abrasion.
• Sharp objects (wire, sticks, glass) and reasonable force (thrown, fallen onto, flicked):
  • High risk of ocular penetration.
• Small high velocity objects (hammering metal or ceramic):
  • Risk of ocular penetration, retained intraocular foreign body, corneal foreign body.
• In obvious penetrating ocular trauma refer for urgent ophthalmology review and defer detailed examination until theatre. If any concern for penetrating injury, refer to Ophthalmology.
• In significant trauma, exclude retrobulbar haematoma and optic nerve dysfunction urgently (tense proptosis, visual acuity, pupils, eye movements).

Assessment 

• Assessment and management of eye trauma should occur after resuscitation in major trauma, and with consideration of head and C-spine injuries. 
• Consider non accidental injury (NAI) in children with unexplained eye injuries including subconjunctival haemorrhages, particularly in non-mobile infants”
• All injury presentations in children under 2 years must have an Early Childhood Injury Proforma (MR301.3) completed. (internal WA Health only)

History 

• Mechanism of injury: possible exposure to foreign body, chemicals or high velocity projectiles (eg. lawn mowers, power tools, MVA)
• Contact lens use
• Pain, foreign body sensation
• Blurred vision, vision loss, flashing lights/floaters/visual field defect (retinal detachment)
• Tearing, discharge, photophobia
• Diplopia
• First aid provided prior to presentation
• Immunisation status

Examination ⁴

• Provide analgesia and/or topical anaesthetic Tetracaine (amethocaine 1%) hydrochloride
• Avoid eyeball pressure during examination
• Gentle warm compresses/saline gauze will help loosen eyes glued shut by dried blood
• Dry gauze and gentle traction to upper and lower lids will help open eyes swollen shut 
• If adequate assessment is not possible due to lack of co-operation, seek senior or specialist help
• Apply eye shield (if suspicion of open eye injury) after completion of examination to prevent further pressure induced damage.

Examination guide 4
General observation	Red flags - seek urgent senior/ophthalmology review: Proptosis, limit eye movements - retobulbar haematoma Enopthalmia, distorted globe, chemosis, limited movements - globe rupture If suspected penetrating injury/globe rupture do not force the eyelid open
Visual acuity	Must prioritise and document (except in major trauma or chemical burn). In situations when acuity is not obtainable, document attempts made Use age appropriate chart school age - Snellen pre-school - picture or E-charts >2 lines difference between eyes is likely to be significant Fingers and toys, fix or follow <2-3 years Light perception Pin hole testing (if glasses not with child) will correct up to 6/9
Pupils	Shape, light reflex, distortion, size, asymmetry Swinging light test for relative afferent papillary defect (RAPD) swing light from eye to eye; if affected pupil dilates then RAPD is present may be present in retrobular haematoma with optic nerve compression, ruptured globe, large retinal detachment, vitreous haemorrhage
Eye movement	Limited and or painful with: Retrobulbar haematoma Ruptured globe Orbital rim fractures with extraocular muscle entrapment
Visual fields	Deficit with:  Retinal detachment Intraocular foreign body
Peri-orbital region	Palpate orbital rim for bony tenderness or step orbital rim fracture, check eye movements and infraorbital nerve entrapment (sensation over central upper lip/gum) Bilateral peri-orbital bruising consider base of skull fracture
Lids, conjunctiva, sclera	Foreign body; include eyelid eversion and fluroscein exam vertical (frequently linear tracks) corneal abrasions - foreign body under eyelid Eye lacerations full thickness laceration - suspect globe penetration medial third involvement - possible lacrimal duct injury involvement of eyelid margin Sub-conjunctival haemorrhage if posterior extent not visualised suspect orbital/base of skull fracture
Cornea. anterior chamber, iris	Look for obvious foreign body, epithelial defect Perilimbal/cillary injection (re around iris) - anterior chamber injury Hyphema (blood will layer in anterior chamber, dusty/stars on Slit lamp) Fluroscein use cobalt blue light (on Slit lamp, most fundoscopes, Wood's lamp) highlights corneal abrasions, foreign bodies, chemical burns Seidel sign for full thickness laceration fluroscein will appear to "waterfall" with blinking as aqueous humour leaks out Best assessed with Slit lamp if >3 year old and co-operative
Fundoscopy	Vitreous haemorrhage - diminished red reflex, difficulty visualising fundus, red splotches Retinal detachment - grey flap at periphery PanOptic fundsocope - refer to PanOptic Ophthalmoscope Quick Reference Guide in consultants office

Management

Approach to specific injuries

Penetrating eye injury / Suspected globe rupture

• Penetrating or blunt trauma with distorted globe, hyphema, chemosis, loss of vision/red reflex/eye movements, asymmetric pupil, RAPD
• Emergent ophthalmology referral
• Analgesia
• Anti-emetics to prevent vomiting /raised intraocular pressure
• Protective hard shield over eye if tolerated
• Do not apply pressure to globe
• Do not attempt foreign body removal
• Keep fasted
• IV Antibiotics, tetanus
• Consider imaging (X-Ray or orbital CT) if intraocular foreign body suspected.

Retrobulbar haematoma with optic nerve compression

• Blunt or major trauma causing compartment syndrome of eye
• Tense proptosis, limited eye movements, decreased visual acuity, RAPD
• Emergent ophthalmology referral
• Analgesia
• CT may assist in diagnosis if unclear
• Requires urgent surgical decompression; do not delay opthalmological referral for CT.

Corneal burns (strong acid/alkali)

• Copious irrigation (≥ 2 litres of 0.9% sodium chloride over 20 minutes) ASAP
  • Set up a bag of IV 0.9% sodium chloride with a standard infusion line to irrigate.
• Topical local anaesthetic +/- analgesia will facilitate irrigation
• Evert eyelid to remove excess chemical/debris
• Check pH with pH sticks/ litmus paper: pH 6.5-8.8 acceptable
• Urgent ophthalmology referral
• Contact Poisons Information Centre 13 11 26 for other chemicals.

Orbital wall / Blow out fracture 

• Blunt trauma to orbit – look for entrapment (inferior rectus muscle: can’t look up /infraorbital nerve: sensation upper lip/gum)
• Analgesia, no nose blowing
• CT facial bones (less radiation than plain X-Ray facial views) – discuss with senior emergency doctor
• Urgent ophthalmology referral
• Plastics/maxillofacial surgical referral (especially if entrapment present). 

Eyelid laceration 

• Analgesia, tetanus prone wounds
• Exclude penetrating eye injury
• Urgent ophthalmology referral for exploration/repair
  • If involving medial third of eyelid – possible nasolacrimal duct injury
  • If involving eyelid margin, tarsal plate, canthi
  • If significant tissue loss/distortion
• Minor lacerations superficial to tarsal plate – consider repair in ED or semi-urgent ophthalmology referral.

Full thickness corneal/sclera lacerations

• Analgesia, tetanus
• Keep fasted
• Semi-urgent ophthalmology referral.

Hyphaema

• Blunt trauma with blood in anterior chamber
• Gross layering of blood or ‘dust/stars’ on slit lamp exam
• Urgent ophthalmology referral if suspected acute glaucoma
• Analgesia, bed rest, head elevated 45 degrees
• Do not apply dilating drops (may precipitate acute glaucoma).

Retinal detachment 

• Blunt trauma with loss of vision, shadow/curtain on fundoscopy
• Urgent ophthalmology referral.

Vitreous or retinal haemorrhage

• Blurring or loss of vision, haemorrhage visible on fundoscopy
• Urgent ophthalmology referral.

Post traumatic iritis

• Blunt trauma, pain on accommodation
• Local anaesthetics do NOT improve pain
• Semi-urgent ophthalmology referral.

Corneal foreign body

• Local anaesthetic for assessment/removal
• Use fluorescein to exclude full thickness penetration (Seidel sign) and embedded eyelid FB (multiple linear vertical abrasions)
• Evert eyelid to ensure no foreign body embedded in eyelid
• Small foreign bodies may be removed by flushing with normal saline, cotton bud or needle in ED if co-operative
  • Use slit lamp for older children
• Metal foreign bodies (grinders) may leave a residual rust ring:
  • Discharge with chloramphenicol ointment qid to soften rust ring
  • Follow up in eye clinic for completion of removal in 1-3 days
• Refer large, deep or central corneal foreign bodies for removal.

Corneal abrasions

• Local anaesthetic to facilitate examination (not for discharge for ongoing use)
• Simple analgesia
• Evert eyelid to exclude foreign body
• If large or involving visual axis refer follow up with ophthalmology within 24 hours.

Bibliography

1. Lueder, GT (2011) Paediatric Practice Ophthalmology, 1st Ed, McGraw-Hill Education LLC.
2. Cameron P et al (2018) Textbook Of Paediatric Emergency Medicine, 3rd Ed, Elsevier
3. Kliegman RM & Geme JS (2019) Nelson Textbook Of Pediatrics, 21st Ed, Elsevier.
4. Gardiner MF (2021) Approach to eye injuries in the emergency department, UpToDate. (Accessed July 9th 2021).

Endorsed by:	Coordinator Nursing - Surgical	Date:	Dec 2021
		Review date:	Dec 2024

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