Aetiology

Blow to the eye and/or periorbital tissues: accidental (e.g. Road Traffic Accident, falls, workplace injuries, domestic, sports-related) or non-accidental (e.g. assault)
Also known as ocular or orbital contusion

Predisposing factors

Blunt trauma occurs most frequently in young males
Falls cause a quarter of cases in people aged >60 years

Symptoms of blunt trauma

Pain varies from mild to severe
Epiphora
Visual loss (variable)
Photophobia
Possible diplopia

Signs of blunt trauma

Mild cases (usually with good corrected vision)

• eyelid swelling (oedema), ecchymosis (bruising)
• conjunctival chemosis, subconjunctival haemorrhage
  • unexplained subconjunctival haemorrhages in babies and young children may indicate non-accidental injury
• corneal abrasion
• possible small hyphaema
• possible mild anterior chamber (AC) Inflammation

Severe cases (usually with some loss of visual function), variable presentation including:

• disturbance of ocular motility: restriction or diplopia due to tissue swelling or muscle tethering by orbital (‘blow-out’) fracture
• enophthalmos (sunken eye) typically indicates orbital fracture; proptosis may also occur (e.g., due to retro-orbital haemorrhage)
• among paediatric patients, orbital floor blow-out fractures may occur with minimal soft-tissue signs (‘white-eyed blow-out
  fracture’)
• nasal bleeding (direct trauma, or could indicate skull fracture)
• corneal oedema or laceration
• anterior chamber (AC): hyphaema, uveitis. AC may be deep or shallow if lens zonules have been compromised.
• traumatic mydriasis
• iridodialysis (tearing of iris from its attachment to ciliary body)
• angle recession (widened angle recess)
• lens: evidence of subluxation, cataract, capsule damage
• ring of pupil margin pigment on anterior lens capsule (Vossius’s ring)
• IOP may be increased secondary to obstruction of the trabecular meshwork by blood cells, inflammatory cells or pigment. IOP may be reduced e.g. scleral perforation (rupture of globe) or cyclodialysis cleft
• the likelihood of traumatic glaucoma following ocular contusion is increased where there is increased pigmentation of the trabecular meshwork, elevated baseline IOP, hyphaema, lens displacement and angle recession
• vitreous haemorrhage (absent or poor red reflex)
• commotio retinae (clouding or whitening of the retina), retinal tear/detachment or dialysis
• traumatic macular hole
• globe rupture (full thickness wound of eye wall) particularly in eyes that have had previous penetrating surgery e.g. extracapsular cataract surgery, trabeculectomy, or corneal transplantation 
• optic nerve avulsion
• relative afferent pupillary defect (RAPD) (typically indicates traumatic optic neuropathy)

Differential diagnosis

Other causes of acute red eye
Pre-septal cellulitis

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

Careful history required, including mechanism and time of injury
Lid oedema: cold compress to ease swelling
(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Dilated fundus examination
(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Systemic analgesia e.g. paracetamol, aspirin, ibuprofen
Non-steroidal anti-inflammatory drug (e.g. ibuprofen) where there is significant tissue swelling
(GRADE*: Level of evidence=low, Strength of recommendation=strong)

In cases of corneal abrasion consider topical antibiotic
(See Clinical Management Guideline on Corneal Abrasion)
(GRADE*: Level of evidence=low, Strength of recommendation=weak)

Consider cycloplegia to alleviate pupil spasm (e.g. gutt cyclopentolate 1% twice daily) 
(GRADE*: Level of evidence=low, Strength of recommendation=weak)

Consider topical steroids e.g. prednisolone, for traumatic inflammation. Steroids should be avoided if corneal abrasion present
(GRADE*: Level of evidence=low, Strength of recommendation=weak)

Management category

Management depends on severity of injury

Mild cases:
B2: alleviation or palliation; referral normally unnecessary

Severe cases:
A2: first aid measures and emergency (same day) referral to A&E
Emphasise to the patient the urgency of the condition and instruct them to attend the local hospital eye department or hospital A&E the same day, explaining that you will leave a message so that they are expected. Telephone the department to explain what you have done, preferably leaving your message with a doctor or other health care professional

Possible management by ophthalmologist

Assessment and investigation including imaging (e.g. ultrasound, X-ray, CT, MRI)
Treatment of globe rupture where present
May require hospital admission

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation  (www.gradeworkinggroup.org)
 

Sources of evidence

Alteveer J, Lahmann B. An evidence-based approach to traumatic ocular emergencies. Emergency Medicine Practice 2010;12(5):1-21

Betts T, Ahmed S, Maguire S, Watts P. Characteristics of non-vitreoretinal ocular injury in child maltreatment: a systematic review. Eye (Lond). 2017;31(8):1146-54

Eye trauma. 2023 BMJ Best Practice

Kuhn F, Morris R, Witherspoon CD, Mester V. The Birmingham Eye Trauma Terminology system (BETT). J Fr Ophtalmol. 2004;27(2):206-10

Lecuona K. Assessing and managing eye injuries. Community Eye Health. 2005;18(55):101-4

Sihota R, Kumar S, Gupta V, Dada T, Kashyap S, Insan R, Srinivasan G. Early predictors of traumatic glaucoma after closed globe injury. Arch Ophthalmol. 2008;126(7):921-6

Yew CC, Shaari R, Rahman SA, Alam MK. White-eyed blowout fracture: Diagnostic pitfalls and review of literature. Injury. 2015;46(9):1856-9

Trauma (blunt)
Version 15
Date of search 10.12.23
Date of revision 29.03.24
Date of publication 09.04.24
Date for review 09.12.25
© College of Optometrists