Ocular Trauma

Corneal Abrasion

Background

The cornea is the clear tissue in front of the iris that acts as the “window” of the eye. A corneal abrasion is an epithelial defect usually due to trauma. Patients generally note pain, a foreign body sensation, light sensitivity (photophobia), tearing, and redness. Their vision may be normal or reduced. The epithelial defect stains with fluorescein dye when viewed with blue light.

Treatment

Corneal abrasions typically heal quickly and completely. Antibiotic ointment is often given to help relieve discomfort and to prevent secondary infection. In some cases a topical cycloplegic (dilating drop) is given for pain and photophobia. Patching the eye is somewhat controversial and often not needed. Patients with large abrasions may do better with a bandage contact lens to help relieve pain.

Traumatic Hyphema

Background

A hyphema is blood in the anterior chamber of the eye. A hyphema forms a visible layer of blood while a microhyphema is only visible with slit lamp biomicroscopy.

Most hyphemas are due to trauma and 60% of patients will have damage to the iris insertion called angle recession. Patients have varying degrees of decreased vision, pain, light sensitivity, and redness.

Evaluation

Patients with hyphemas are evaluated with a complete ophthalmic history and eye exam with attention to cornea, intraocular pressure, anterior chamber, iris, and ophthalmoscopy. In African-American patients, a sickle cell prep test and hemoglobin eletrophoresis are done to rule out sickle cell disease. If the posterior eye cannot be visualized, an ocular ultrasound can help rule out posterior trauma.

Management

• Topical steroid (prednisolone acetate 1%) which is tapered as hyphema and inflammation resolve
• Topical cycloplegic (scopolamine 0.25% or Atropine 1%)
• Consider antifibrinolytic agent (aminocaproic acid 50 mg/kg every 4 hours)
• Intraocular pressure control as needed avoiding carbonic anhydrase inhibitors in patients with sickle cell disease and avoiding pilocarpine)
• Counsel patient to avoid aspirin-containing products, sleep with head of bed elevated at a 30 degree angle or higher, metal fox shield over injured eye, and bed rest

Patients are generally examined every day for first three to five days when the risk of rebleed is highest. If the blood is reabsorbing and the intraocular pressure is controlled, then visits can be slowly spaced out.

If there is a rebleed, the intreased blood and increased intraocular pressure may require an emergent anterior chamber washout. This is done to try to avoid corneal blood staining and an uncontrolled intraocular pressure.

Prognosis

The prognosis for vision is generally good in traumatic cases if the intraocular pressure controlled and there is no rebleed. This is very dependent on the amount of original trauma. Patients may be at risk for angle recession glaucoma in the future and need to be followed.

Open/Ruptured Globe

If the trauma is severe enough, the eyeball itself may rupture, often with disasterous consequences. This can be due to a projectile such as a BB, bullet, or piece of glass. Blunt trauma can also cause the globe to rupture at its weakest points, the limbus and beneath the muscle insertions.

Patient with a ruptured globe and those suspected of an open globe generally require surgery within 24 hours. Corneal and/or scleral wounds are closed and the eye is allowed to heal. If more posterior pathology is present, this is often addressed at a later time.

Prevention of Ocular Trauma

Despite many advances in medicine, many cases of ocular trauma leave some permanent damage. Sadly, many cases are preventable with proper precautions. Safety glasses and/or goggles are the key to eye safety.

• Racquetball: always wear safety goggles while playing
• Paintball: do not remove facemask until you are off the playing field
• Use goggles when using hand and power tools