Aetiology

Partial or full-thickness injury of outer wall of eye caused by sharp object
Common causes include: assault, industrial or work-related accident, DIY injury

Predisposing factors

Male:female = 3:1

Failure to wear suitable eye protection.

Symptoms of penetrating trauma

History of trauma
Pain
Visual loss

Signs of penetrating trauma

Lid laceration: assess depth, contamination and whether canaliculi involved

Conjunctiva

• hyperaemia and chemosis
• look for foreign bodies
• assess depth of any conjunctival laceration

Corneal laceration

• check depth
• check for signs of perforation (shallow or flat AC, Seidel test +ve)
• possible iris damage (iridodialysis) ± iris prolapse into wound

Lens

• may be subluxated, dislocated, absent, or cataractous

Scleral laceration
Irregular pupil
Iris prolapse
Commotio retinae
Vitreous haemorrhage

Risk of (bilateral) sympathetic ophthalmia (SO)

• incidence from a 2021 systematic review and meta-analysis= 0.19%
• onset of SO can be acute or insidious, and can presentdays to years after the inciting event. Most cases of SO occur within one year and often have recurrent periodsof exacerbation

Differential diagnosis

Non-penetrating (blunt) trauma
Chemical trauma

Management by optometrist

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

DO NOT APPLANATE OR EXERT PRESSURE ON EYE

Take a careful history

• patient’s description of events leading to trauma
• nature of any known foreign body, its speed and size
• check tetanus status
• in cases of suspected IOFB, dilated fundus examination

If there is any suspicion of a full-thickness laceration of the globe

• do not exert any pressure on the eye (including forcing the lids open)
• advise patient not to cough or strain

Check VA (important even if pain and swollen lids make that difficult)
Protect eye by taping over it a rigid plastic shield (e.g. cartella)
If penetrating object is still in the eye do not be tempted to remove it
If iris protrudes from wound do not attempt to push it back
Advise patient to take nil by mouth (except as below*)
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
 

Topical anaesthetic (to aid examination), systemic pain relief and antiemetic as required
*To assist swallowing of tablets, a small amount of water is permissible
(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Management category

A2: first aid followed by immediate referral; no intervention. 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

Orbital X-ray, ultrasound, other investigations 
Surgical management of penetrating injury
Prophylaxis of intra-ocular infection
Follow-up includes examination for possible sympathetic ophthalmia affecting fellow eye (occurs in 0.1% of cases of penetrating trauma)

Evidence base

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

Sources of evidence

Eye trauma. 2018 BMJ Best Practice

He B, Tanya SM, Wang C, KezouhA, Torun N, Ing E. The incidence of sympathetic ophthalmia after trauma: A meta-analysis. Am J Ophthalmol. 2021 Jul 17:S0002-9394(21)00364-0. doi: 10.1016/j.ajo.2021.06.036. (Online ahead of print)

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

Trauma (penetrating)
Version 11
Date of search 12.09.21
Date of revision 25.11.21
Date of publication 07.04.22
Date for review 11.09.23
© College of Optometrists