Trauma (blunt)

The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.

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Aetiology

  • Blow to the eye: accidental (e.g. RTA, industrial, domestic, sports) or non-accidental (e.g. fist)
  • Also known as ocular contusion

Predisposing factors

Usually unexpected but may be vocational (e.g. boxing)

Symptoms

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

Signs

  • 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
  • Severe cases (usually with some loss of visual function)
    • infraorbital nerve anaesthesia (lower lid, cheek, side of nose, upper lip, teeth) may indicate orbital floor fracture
    • disturbance of ocular motility: restriction or diplopia due to tissue swelling or muscle tethering by orbital (‘blow-out’) fracture
    • enophthalmos (sunken eye) may also indicate orbital fracture
    • 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
    • AC: hyphaema (blood in aqueous), uveitis, flare and cells
    • traumatic mydriasis
    • Iridodialysis (tearing of iris from its attachment to ciliary body)
    • lens: evidence of subluxation, cataract, capsule damage
    • IOP may be increased secondary to uveitis, or reduced because of scleral perforation (rupture of globe)
    • 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 (widened angle recess)
    • vitreous haemorrhage
    • commotio retinae, retinal detachment or dialysis
    • traumatic macular hole
    • globe rupture (full thickness wound of eye wall)
    • relative afferent pupillary defect (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

GRADE Level of evidence and strength of recommendation always relates to the statement(s) immediately above

Non pharmacological
  • 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)

Pharmacological
  • Systemic analgesia e.g. paracetamol, aspirin
  • If there is significant tissue swelling: non-steroidal anti-inflammatory drug (e.g. ibuprofen)

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

  • In cases of corneal abrasion consider topical antibiotic

(GRADE*: Level of evidence=low, Strength of recommendation=weak)
 

Management category

Management depends on severity of injury

Mild cases:
B2: alleviation or palliation; referral unnecessary

A2: first aid measures and emergency (same day) referral to A&E

Possible management by ophthalmologist

  • Assessment and investigation including imaging (e.g. 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 nonvitreoretinal ocular injury in child maltreatment: a systematic review. Eye (Lond). 2017;31(8):1146-54

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

Lay summary

The eye is well protected by the bony structures of the face that surround it (brow, cheek, nose) but it is sometimes injured by a direct blow, which is usually accidental but is sometimes the result of an assault. In mild cases this often results in bruising and swelling of the tissues around the eye (a ‘black eye’) which resolves fully in time leaving no after-effects; painkillers may be the only treatment needed. In more severe cases one or more of the bones of the orbit (the bony cavity in which the eyeball sits) may be fractured and this may cause the eye or one of the muscles that moves it to be displaced. The blow to the eye may also damage the structures inside the eye and
may cause internal bleeding or raised eye pressure. Such cases need to be referred as emergencies to the ophthalmologist.

Trauma (blunt)
Version 12
Date of search 17.08.17
Date of revision 30.01.18
Date of publication 09.05.18
Date for review 16.08.19
© College of Optometrists

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