Trauma (penetrating)

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

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

Symptoms

History of trauma

Pain

Visual loss

Signs

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

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

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

Non pharmacological

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

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)
 

Pharmacological

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

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

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

Lay summary

Full or partial penetration of the outer coat of the eye (the clear part, the cornea or the white part, the sclera) can result from industrial, work-related or DIY injuries, or from assaults with sharp objects. Such injuries occur three times as frequently in males as in females. Because they are so close to the eyeball, the eyelids may be injured also.

The optometrist will check the vision and examine the injured eye to discover the extent of the damage and whether there is full or partial penetration. Any foreign bodies will be noted but not removed. Evidence of damage to the internal structures of the eyeball, such as the lens of the eye, will be looked for.

The optometrist will prescribe or supply pain relief if necessary and make arrangements for the ophthalmologist to see the patient as soon as possible on the same day.

The ophthalmologist, having examined the patient, may arrange investigations such as X-rays or ultrasound and will decide on whether surgery is necessary, and if so how soon. In penetrating injury there is a very rare risk of inflammation in the other eye, a possibility that will be watched for as the patient is followed up.

Trauma (penetrating)
Version 9
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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