Trauma (blunt)

Aetiology

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

Predisposing factors

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

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) producing displaced or distorted pupil
• lens: evidence of subluxation, cataract, capsule damage
• IOP may be increased secondary to obstruction of the trabecular meshwork by blood cells, inflammatory cells or pigment. IOP may be 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) particularly in eyes that have had previous penetrating surgery
• 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

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)

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

Pharmacological

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)

Management category

Management depends on severity of injury

Mild cases:
B2: alleviation or palliation; referral unnecessary
Severe cases:
A2: first aid measures and emergency (same day) referral to A&E

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. 2018 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

Plain language 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 13
Date of search 24.09.19
Date of revision 27.09.19
Date of publication 23.04.21
Date for review 23.09.21
© College of Optometrists

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