Chapter 4

Eye Trauma
E. Liang Liu and Ashley Phipps

Brief Introduction
Ocular trauma is a common presentation to the emergency
department in the United States, representing 3% of all ED
visits every year [1] and remains the leading cause of mon-
ocular blindness [2]. Ocular trauma frequently follows
assaults, workplace and sports injuries, and motor vehicle
accidents. The trauma can range from a simple injury such as
a superficial eyelid laceration to an ophthalmologic emer-
gency such as a ruptured globe. The emergency physician
must feel comfortable evaluating and managing these com-
plaints, as trauma patients are at particular risk for vision-­
threatening injuries and increased morbidity [3].

Clinical Presentation
The diagnosis of ocular trauma requires a detailed history
and specifically clarifying the mechanism of injury, especially
whether it was blunt or penetrating. Penetrating injuries can

E. Liang Liu, MD (*) · A. Phipps, MD

Department of Emergency Medicine, UT Southwestern Medical
Center, Dallas, TX, USA

© Springer International Publishing AG, part of Springer 35

Nature 2018
B. Long, A. Koyfman (eds.), Handbook of Emergency
Ophthalmology, https://doi.org/10.1007/978-3-319-78945-3_4
36 E. Liang Liu and A. Phipps

cause minor injuries including eyelid lacerations, subconjunc-

tival injuries, corneal abrasions or lacerations, traumatic iritis,
and lens injuries to more complex injuries such as ruptured
globes. Blunt trauma can result in corneal abrasions, hyphe-
mas, traumatic mydriasis, lens dislocations, vitreous hemor-
rhages, retinal tears and detachments, traumatic iritis,
choroidal ruptures, traumatic optic neuropathy, retrobulbar
hemorrhages, and orbital blowout fractures in addition to
globe ruptures.
Another approach to determining the injury involves iden-
tifying the part of the eye involved. This can be systematically
evaluated by following the layers of the eye. The emergency
physician should consider involvement of both intraorbital
and extraorbital structures. Extraorbital structures include
the eyelid, extraocular muscles, orbital bones, optic nerve, and
brain. Intraorbital structures from outside include the con-
junctiva, cornea, sclera, iris, anterior chamber, lens, posterior
chamber, and retina.
A detailed eye examination is paramount to identifying
the extent and severity of injuries. Where the history is lack-
ing, the examination will also provide clues of the mechanism
and structures of the eye involved. Particular caution should
be taken in the polytrauma patient or patient with other
facial injuries, as these injuries can distract from the ocular
injury.

Differential Diagnosis
A number of both traumatic injuries and medical conditions
can present concurrently. Depending on the mechanism, trau-
matic injuries usually do not isolate one specific part of the
eye or involve just one pathology. An eyelid laceration can
extend to involve the conjunctiva and deeper tissue to result
in a ruptured globe. Subconjunctival hemorrhage, vitreous
hemorrhage, and retrobulbar hemorrhage can occur indepen-
dently but may also be found concurrently.
 Chapter 4.  Eye Trauma 37

In considering ocular traumatic injury with a good mecha-

nism, the physician should also consider the cause of the
trauma and potential complications from the traumatic
injury. The patient may have glaucoma, a corneal ulcer, or a
burn that compromised their vision resulting in the accident.
The eye examination may simply be a presentation of sys-
temic disease. Patients may have a number of reasons to be at
increased risk for infection and coagulopathy that may
worsen an already vulnerable eye that has been injured.
This chapter will cover the following conditions:
1. Eyelid laceration
2. Conjunctival laceration
3. Corneal laceration
4. Traumatic hyphema
5. Iridodialysis/cyclodialysis
6. Ruptured globe
7. Orbital fracture
8. Retrobulbar hemorrhage
9. Intraocular foreign bodies
10. Chemical burn

Clinical Evaluation

History

There are several features of the history that are important

when evaluating for ocular trauma. As mentioned above, one
of most important historical features for ocular trauma is
what the exact mechanism of injury is. Generally speaking,
any suspicion for a penetrating or perforating eye injury
requires prompt evaluation and definitive management. If a
projectile was involved, the size, type, and velocity of the
­projectile are important predictors of severity of damage, as
small high-velocity projectiles increase the risk for a pene-
trating injury, whereas a larger object is more likely to result
in blunt injury such as a fracture of the orbital wall [4].
38 E. Liang Liu and A. Phipps

The use of eye protection can help the clinician decide

the likelihood of injury and extent of potential injury.
However, penetrating eye injuries can occur even with eye
protection in place. It is also necessary to know exactly
when the trauma occurred and when symptoms started to
understand progression of injury and establish an accurate
timeline. For example, an injury that just occurred would be
less likely to present with secondary sequelae such as infec-
tion and mass effect from hemorrhage, compared to one
that is several hours to days old. Any history of previous
trauma or surgery is also important as any previous compro-
mise to the structural integrity of the eye can increase risk
for reinjury.
Characterizing the patient’s symptoms after the trauma is
essential including:
1. Is there pain or eye discomfort such as a scratchiness or
foreign body feeling?
(a). Does anything make the pain better or worse?
(b). Is there change in pain at rest or on movement?
2. Is there associated photophobia?
3 . Is there any change in vision including loss of vision,
blurred vision, or double vision?
4. Are there any associated non-ocular injuries?
As in any patient with trauma, it is also beneficial to
review the patient’s past medical history. If there are any con-
cerns of abrasions, lacerations, or penetrating injury, the
patient’s last known tetanus immunization should be docu-
mented and tetanus vaccine provided if indicated [5].

Physical Examination

A focused ocular physical examination as described in the

previous chapters is required in all patients presenting with
ocular trauma and can frequently determine the diagnosis
without further testing.
 Chapter 4.  Eye Trauma 39

1. General inspection: If the eyelids are swollen shut, avoid

putting pressure on the orbit in an attempt to pry the eye-
lids open. Instead, insert a bent paperclip or commercial
eyelid retractor under both lids to open the eyelids [5].
(a). How does the eye and orbit look on gross examina-
tion? Is there any periorbital edema, ecchymosis, or
lacerations?
(b). Are any facial fractures noted?
(c). How does the orbit look—Is there any proptosis?
Does the orbit itself look flat compared to the other
eye? If the eye looks flat, a ruptured globe is sus-
pected, and the examination can stop here with place-
ment of an eye shield and emergent ophthalmology
consultation [5]. See the section below for further
management of a ruptured globe.
(d). Any foreign body hidden underneath the upper

eyelid?
(e). What about the pupils—Are they irregular or tear-
drop? Are they equal and reactive? Is there a relative
afferent pupillary defect as may be noted in the setting
of a retinal detachment, vitreous hemorrhage, or ret-
robulbar hemorrhage?
(f). Is there a hyphema present?
2. Visual acuity: Typically this will be decreased, but it is
important to determine whether a decrease is due to cloud-
ing, dryness of the eye, or intraocular cause.
3. Extraocular movements: This is especially important in
trauma to assess as reduced extraocular movements can
suggest a ruptured globe, orbital wall fracture with entrap-
ment of the extraocular muscles, nerve palsy, or r­ etrobulbar
hematoma. If the eyelids are too swollen and the patient is
unable to open the eye, bedside ultrasound can aid in the
extraocular movement exam.
4. Fluorescein testing: This stain helps to evaluate for epithe-
lial defects as well as test for a Seidel’s sign. The Seidel’s
test is used to detect difficult to visualize corneal injuries
that allows leaking of aqueous humor from the anterior
40 E. Liang Liu and A. Phipps

chamber. The fluorescein dye is applied to the eye over the

site of injury, with particular attention paid to the region of
the suspected laceration. The test is positive when a stream
of fluorescent dye is visualized from the site of injury on
slit lamp examination. While specific, a negative test does
not rule out a full thickness corneal laceration. This is
extremely important to do prior to evaluating the intraocu-
lar pressure. If there is a positive Seidel’s sign, the patient
has a ruptured globe until proven otherwise. Again, put a
protective covering over the eye and do not test intraocu-
lar pressures.
5. Tonometry: Use tonometry to test the intraocular pressure
in those without concern for open globe. This can help aid
in the diagnosis of retrobulbar hematoma and secondary
glaucoma among other conditions.
6. Slit lamp exam: Oftentimes the slit lamp exam can reveal
defects and irregularities that are difficult to visualize with
the naked eye. Examine the eyelid including everting the
lid to search for concealed laceration or potential foreign
bodies. Examine the cornea for any foreign bodies and also
determine if a rust ring can be visualized. Look for defects
in the cornea or sclera or distortion of the anterior cham-
ber structures such as a shallow anterior chamber or a
hyphema. In blunt trauma, rupture can be seen at the lim-
bus. Additionally, cell and flare can be seen on slit lamp
with cases of traumatic iritis [5].
7. Fundoscopy: On fundoscopy, the red reflex may be abnor-
mal, suggesting a defect in the lens, cornea, anterior cham-
ber, posterior chamber, or retina. Retinal injuries, vitreous
hemorrhage, and potential foreign bodies can also be seen
on fundoscopy.
8. Ocular ultrasound: Especially in patients who refuse to
open their eyes due to photophobia or pain, bedside ultra-
sound is an extension of the physical examination that can
provide information necessary for diagnosis. By applying
sufficient lubricating gel, the eye can be protected from the
examination in the case of a ruptured globe. Ultrasound can
 Chapter 4.  Eye Trauma 41

reveal hemorrhage, distortion to the globe, abnormalities in

the anterior and posterior chambers, retinal detachment,
retrobulbar hematoma, lens subluxation or dislocation,
presence of an intraocular foreign body, defects to the optic
nerve, and other pathology.

Clinical Conditions and Management

Though management will depend on the pathology, some
general principles of management are common among trau-
matic ocular injuries. The first step of management is to pro-
tect the eye to prevent further injury which may require
placement of an eye shield. Antibiotics should be given and
tetanus vaccine updated to avoid complications of infection
and tetanus. Supportive care including analgesia and anti-
emetics are required. If open globe is suspected or confirmed,
the patient needs bed rest and supportive measures to mini-
mize increases in intraocular pressure. While follow-up with
ophthalmology is recommended for any eye injury, only a
handful of conditions require immediate consultation
(Table 4.1).

Table 4.1  Ophthalmology follow-up for traumatic injury

Immediate consultation 24-h follow-up
Chemical burns of the eye Anterior hyphema
Perforation of the globe or cornea Blowout fracture
Lens dislocation Retinal injuries
Retrobulbar hemorrhage with increased
intraocular pressure
Lacerations involving the lid margin, tarsal
plate, or nasolacrimal drainage system
Optic nerve injury
42 E. Liang Liu and A. Phipps

Eyelid Laceration

The eyelids are the first level of protection to the eyes, and inju-
ries to the eyelid can significantly impact the underlying eye.
The eyelid’s role is to keep the eyes moist and protected from
foreign bodies. Thus, an injured eyelid can result in eye dryness
and irritation, as well as increasing the risk for infection and
further injury. Eyelid injuries result in significant swelling to the
lid itself. Both penetrating and blunt trauma can cause an eyelid
laceration. Blunt trauma to the cheek or zygoma may be associ-
ated with an avulsion of the medial canthus and a canalicular
laceration. It is important to evaluate the laceration and ensure
it does not involve the lacrimal duct system or the orbit. The
eyelids should always be fully everted to evaluate for deeper
extension. The examination should also include assessment of
the extraocular muscles, as they can be commonly injured. If
ptosis or orbital fat is visible on inspection, the laceration may
extend through the orbital septum, indicating a deeper lacera-
tion with increased risk for infection. Evaluation for foreign
body and globe injury should also be performed via examina-
tion and potentially imaging as needed [5, 6].
Emergency physicians should feel comfortable performing
laceration repair on all partial thickness lid lacerations other
than those affecting the lacrimal system or lid margin. 6-0
nylon sutures should be used and removed within 5 days [1].
Any laceration that is within 8  mm of the medial canthus
should be evaluated for lacrimal system involvement. As the
lacrimal ducts are important for proper drainage of tears, lac-
rimal duct injuries require repair by an ophthalmologist and,
if not treated appropriately, can cause significant morbidity.
Lacerations involving the lid margin will often require repair
by ophthalmology, as any notching of the lid may lead to
improper closure of the eyelids and long-term sequelae [5, 6].

Conjunctival Laceration

Patients with traumatic conjunctival lacerations will often be

asymptomatic, as the conjunctiva is poorly innervated and
vision is rarely affected. If symptomatic, the patient may com-
 Chapter 4.  Eye Trauma 43

plain of pain, tearing, or foreign body sensation. Fluorescein

staining of the conjunctiva and evaluation with slit lamp is
essential to evaluate for an open globe and to identify the
laceration. Management of conjunctival laceration depends
on the depth and extent of the injury. Lacerations smaller
than 1–1.5 cm in length generally heal spontaneously without
intervention. However, if the conjunctiva is not well approxi-
mated or folded over, realignment may be needed. Larger
lacerations require repair by an ophthalmologist. Follow-up
after repair should be within 1  week of the injury for large
lacerations and can be as needed for smaller lacerations. All
of these patients should be given a topical antibiotic ointment
such as erythromycin or bacitracin/polymyxin B [5, 6].

Corneal Laceration

In contrast to the conjunctiva, the cornea is richly innervated.

Corneal pathology including laceration may result in exquisite
pain and associated decrease in vision. If a corneal laceration
is suspected, fluorescein staining and a slit lamp examination
should be performed. If the anterior chamber appears shallow
compared to the unaffected eye or there is a positive Seidel
test, a full thickness corneal laceration is present, equivalent to
a ruptured globe. The eye should be immediately covered with
an eye shield and ophthalmology consulted. If there is no rup-
tured globe, the patient may have a partial thickness corneal
laceration. These patients can be sent home with 24-h follow-
up with ophthalmology, cycloplegic eye drops such as scopol-
amine, and a topical antibiotic [5, 6].

Traumatic Hyphema

Traumatic hyphema occurs when blood enters the anterior

chamber typically due to a blunt injury of the eye. The major-
ity of cases occur in males, with 60% related to sports injury
[7]. Hyphemas are usually self-limited but can result in fur-
ther ocular complications such as obstructing aqueous out-
flow of the anterior chamber resulting in increased intraocular
44 E. Liang Liu and A. Phipps

pressures. Approximately one third of patients with a trau-

matic hyphema have an elevated intraocular pressure [8].
There is also risk for rebleed within 10 days which can result
in secondary glaucoma, corneal blood staining, and damage
to the optic nerve [4]. Typically, patients with hyphema will
have immediate visual compromise at the time of injury.
Examination consists of determining the size of the hyphema,
the location of the blood, and intraocular pressure measure-
ment. An ultrasound can be helpful if the fundus cannot be
viewed, and a CT may be necessary to evaluate for a foreign
body. In the patient with frequent hyphemas or minimal
mechanism of injury, coagulopathy, sickle cell disease, and
anticoagulant use should be considered on the differential.
Hospitalization is required in the setting of high intraocu-
lar pressures, hyphema involving greater than 50% of the
anterior chamber, and in the pediatric population, given its
risk of causing irreversible amblyopia [4, 7]. General manage-
ment with uncomplicated hyphema includes restriction of
activities and minimizing risk of reinjury. Administration of a
cycloplegic (atropine) and corticosteroid eye drops with
patching of the affected eye have also been recommended,
but additional studies also suggest that perhaps these inter-
ventions have no additional benefit [4]. In the setting of
increased intraocular pressure, topical and systemic ocular
hypertension medications including timolol and oral carbonic
anhydrase inhibitors can be helpful. Surgical management
may be necessary to reduce intraocular pressures. Some stud-
ies have indicated antifibrinolytic agents such as aminoca-
proic acid and tranexamic acid may be beneficial, especially
in the prevention of secondary hemorrhage [9, 10].

Iridodialysis/Cyclodialysis

Iridodialysis is when a portion of the iris becomes discon-

nected from the ciliary body, while cyclodialysis is when the
actual ciliary body becomes detached from the sclera
(Fig. 4.1). These patients will often be asymptomatic but can
 Chapter 4.  Eye Trauma 45

Figure 4.1  Traumatic iridodialysis in a patient hit by a rock in the

eye while landscaping

have vision changes such as diplopia or photophobia.

Iridodialysis is sometimes referred to as the development of
a “secondary pupil,” as the resulting iris defect will make the
eye look like there are two pupils. These injuries often times
have a concomitant hyphema [1]. The primary complication
is elevated intraocular pressure resulting in acute glaucoma.
Urgent follow-up with ophthalmology is required [6].

Ruptured Globe

A ruptured globe can occur with penetrating and blunt

trauma. Patients will present with decreased vision and eye
pain. Exam findings can include an irregular or peaked pupil,
hyphema, subconjunctival hemorrhage or chemosis, flat or
deep anterior chamber compared to the unaffected eye, dis-
located lens, or new cataract. If a ruptured globe is suspected,
avoid any pressure on the eye and cover it with an eye shield
immediately. Fluorescein staining can be completed to evalu-
ate for Seidel’s sign. A CT scan of the brain and orbits should
be performed with 1 mm sections to evaluate for the ruptured
globe as well as any intraocular foreign body. An emergent
ophthalmology consultation is needed. Patients should be
46 E. Liang Liu and A. Phipps

made NPO, placed on bedrest, and told to avoid straining

(Valsalva, bending over) to avoid increasing the intraocular
pressure. Antiemetics should be given as needed to prevent
vomiting, as again this increases intraocular pressure. Systemic
intravenous antibiotics should be started immediately. In
adults, cefazolin or vancomycin in addition to ciprofloxacin is
recommended, while in children, cefazolin and gentamicin
are recommended. All patients need to receive tetanus pro-
phylaxis if greater than 5 years since their previous vaccina-
tion, as well as pain medications as needed [5, 6, 11].

Orbital Fracture

Orbital fractures typically occur due to blunt trauma. Signs

and symptoms can include pain especially with eye move-
ment, inability to move the eye in a certain direction, diplo-
pia, and crepitus after nose blowing. The most common
orbital fractures are orbital floor through the maxillary sinus
and medial wall through the ethmoid sinus. With an orbital
floor fracture, the patient may complain of pain and difficulty
with upward gaze secondary to entrapment of the inferior
rectus muscle. A medial wall fracture may cause complaints
of pain and difficulty looking side to side. Sensation loss infe-
rior to the eye and ipsilateral nose often indicates an inferior
orbital sensory nerve injury.
Plain radiographs of the skull are rarely used for detecting
orbital fractures. Several studies have shown a poor sensitivity
of 64–78% for detecting orbital fractures on plain films. A CT
scan of the orbits is the gold standard for detecting orbital
fractures, with increased sensitivity of 79–96% [1]. Patients
with an orbital fracture and entrapment, or those exhibiting
signs of the oculocardiac reflex (bradycardia, heart block, syn-
cope), need urgent follow-up with ophthalmology within 24 h
for surgical repair. All other patients can be discharged home
with follow-up within 1–2 weeks. Patients should be instructed
to avoid blowing their nose and use ice packs as needed for
pain and swelling. In immunocompromised patients or uncon-
trolled diabetics, consider a week course of oral antibiotics
such as cephalexin, erythromycin, or doxycycline [5, 6].
 Chapter 4.  Eye Trauma 47

Retrobulbar Hemorrhage

Retrobulbar hemorrhage typically occurs after significant

blunt trauma. Patients will present with decreased vision and
also have significant associated periorbital swelling and
ecchymosis. The eye may look proptotic with tense eyelids
that are very hard to open, chemosis, and subconjunctival
hemorrhage. If the hemorrhage is significant, orbital com-
partment syndrome can develop, as the orbit is a relatively
enclosed space surrounded by bony walls and an inflexible
orbital septum [1]. This increase in pressure can compress the
optic nerve leading to ischemia. If not recognized quickly,
within 90  min of ischemia, the nerve damage can become
permanent. After evaluation for open globe with fluorescein
staining and ensuring its absence, intraocular pressure should
be measured. If there is evidence of optic neuropathy such as
a dilated or nonreactive pupil or the intraocular pressure is
greater than 40 mmHg, an immediate lateral canthotomy and
cantholysis should be performed [5, 6].

Intraocular Foreign Bodies

Intraocular foreign bodies can often be seen with metal

workers or welders, with up to 80% of cases occurring with
hammering [1]. Generally the patient has a history of some
eye trauma or with the feeling that an object hit the eye.
Usually these patients have pain or foreign body sensation
and photophobia, and they may have vision changes. Certain
metals such as iron, steel, tin, and copper as well as organic
material can cause significant inflammation. Bedside ultraso-
nography or a CT scan of the orbits can be used to evaluate
for an intraocular foreign body. However, it is important to
remember that some organic material will not be seen on CT
scan [1]. Consider a ruptured or open globe which is often
associated with this injury. If an intraocular foreign body is
found, discuss with ophthalmology. Most patients will require
antibiotics and urgent surgical removal to prevent infection.
If the decision is made to not remove the intraocular foreign
48 E. Liang Liu and A. Phipps

body, close ophthalmology follow-up is needed for serial

exams to evaluate for delayed inflammation or infection
requiring intervention [6].

Chemical Burn

Chemical burns are ocular emergencies and require copious

irrigation immediately, unless a ruptured globe is suspected.
Irrigation is recommended continuously for 30 min with nor-
mal saline or lactated ringers. This can be facilitated with the
use of topical anesthetic and an eye speculum to hold the eye
open. It is important to ensure the lids are everted and the
entire surface is irrigated. Never attempt to neutralize an
alkali burn by instilling an acid or vice versa, as this can lead
to further harm. After irrigation, wait 10 min and then check
the pH using litmus paper. Irrigation is repeated until the pH
is between 7 and 7.4. A moistened cotton-tipped applicator
can be used to remove any material from the conjunctival
fornices. Also determine the type and time of exposure.
Alkali injuries are more common, as alkaline substances are
frequently present in household products such as lye, ammo-
nia, drain cleaners, and fertilizers [12]. Alkaline substance
causes liquefactive necrosis which can penetrate deep into
the tissue, while acids cause coagulation necrosis which rarely
penetrates deeply into the tissue [5, 6, 11].
After irrigation, the eye should then be fully examined
looking for any conjunctival blanching, chemosis, hemor-
rhages, and corneal opacification. Fluorescein staining can
help evaluate for an epithelial defect, and intraocular pres-
sure should always be measured to evaluate for swelling due
to the chemical burn. These patients all need urgent ophthal-
mology follow-up within 24  h. They can generally be dis-
charged with topical antibiotic ointment, pain medication,
frequent preservative-free artificial tears while awake, and
cycloplegic drops. If the burn is severe, topical steroid drops
may also be prescribed [5, 6, 11]. However, prescription of
topical steroid drops should only be done in association with
an ophthalmologist.
 Chapter 4.  Eye Trauma 49

Disposition
Complications of ocular trauma include permanent loss of
vision, corneal ulcers that may lead to delayed perforation,
infection especially endophthalmitis, and sympathetic oph-
thalmia. Sympathetic ophthalmia is an autoimmune-­mediated
response to the uninjured eye that occurs weeks to months
after the initial injury. This can occur if enucleation of the
severely traumatized eye is not performed initially or within
1–2 weeks after severe damage, as the uveal tissue that is typi-
cally sequestered becomes exposed with injury. Patients pres-
ent with pain, photophobia, and decreased visual acuity.
Management requires ophthalmology evaluation and typi-
cally treatment with steroids and immunosuppressants.

Pearls/Pitfalls
–– If a ruptured globe is considered, immediately place an eye
shield and consult ophthalmology.
–– Most traumatic eye injuries can be properly treated in the
emergency room and discharged home with urgent oph-
thalmology follow-up.
–– Don’t forget to think of other associated injuries that may
have occurred with the trauma such as intracranial or cer-
vical spine injuries.
–– Wearing eye protection does not prevent injury but can
significantly reduce it.

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