Ocular Trauma Management Principles

Initial Approach & Triage - Eyes on the Prize

• Prioritize systemic stability (ABCDEs).
• History: Mechanism (blunt, penetrating, chemical), timing, prior eye conditions, tetanus status.
• Initial Exam: Visual Acuity (VA - each eye separately!), pupils (RAPD), Extraocular Movements (EOMs), confrontational fields.
• ⚠️ Avoid IOP check, manipulation if open globe suspected.
• Protect eye: Rigid shield (Fox shield). NO eye patching with suspected open globe.
• Systemic analgesia, antiemetics (prevent Valsalva), tetanus prophylaxis.
• Imaging: CT orbit (bone/foreign body), B-scan (if media opaque).
• Triage:
  • Emergent: Chemical burns (irrigate STAT!), open globe, retrobulbar hemorrhage.
  • Urgent: Hyphema.

⭐ Any full-thickness scleral or corneal laceration constitutes an open globe injury and is a surgical emergency.

History & Ocular Examination - Peeking at Problems

• History:
  • Mechanism: Blunt, sharp, chemical, projectile (velocity, material).
  • Symptoms: Vision ↓ (degree, onset), pain, diplopia, photophobia.
  • Key details: Prior eye conditions, tetanus status, last meal.
• Ocular Examination: 📌 (VA-PEMS-IOP-FUNDUS: Visual Acuity, Pupils, External/Motility, Slit-lamp, IOP, Fundus)
  • Visual Acuity (VA): Essential baseline.
  • Pupils: Size, shape, RAPD (Grades 1-4).
  • External & Motility: Lids, adnexa, proptosis, restrictions.
  • Slit-lamp: Cornea (abrasion, perforation), AC (cells, flare, hyphema), iris, lens.
  • IOP: Measure if no open globe suspected.
  • Fundoscopy (dilated if safe): Vitreous, retina, optic disc.

⭐ Seidel’s test (using fluorescein dye) is crucial for detecting occult or sub-clinical aqueous leaks from corneal or scleral perforations.

Imaging & Investigations - X-Ray Vision Activated

• CT Scan (Orbital):
  • IOC for IOFB (metallic), orbital fractures, occult globe rupture.
  • Axial & coronal views, 1-2 mm thin cuts; bone & soft tissue windows.
• B-Scan Ultrasonography (USG):
  • Opaque media (e.g., hyphema, vitreous hemorrhage).
  • Detects RD, choroidal detachment, non-radiopaque IOFB (wood, glass).
  • ⚠️ Caution: potential open globe injury.
• X-Ray (Orbital):
  • Initial screening for radiopaque IOFBs.
  • Limited detail & localization capabilities.
• MRI:
  • Organic IOFBs (e.g., wood) if CT inconclusive.
  • ⚠️ CONTRAINDICATED if suspected metallic IOFB.

⭐ CT scan (axial and coronal views, 1-2 mm thin cuts, bone and soft tissue windows) is the investigation of choice for suspected intraocular foreign body (IOFB), especially metallic or inorganic ones.

Core Management Strategies - Healing the Hurt

• Priorities: Preserve vision, alleviate pain, prevent infection, limit inflammation.
• Initial Steps:
  • Systemic stabilization (ABCDE).
  • Gentle ocular examination; assess globe integrity.
  • Protect eye: Rigid shield (Fox shield) if open globe suspected. NO eye patch.
  • Pain control: Systemic analgesics.
  • Anti-emetics: Prevent Valsalva, ↓IOP risk.
  • Tetanus prophylaxis.
• Therapeutic Modalities:
  • Medical: Topical/systemic antibiotics, cycloplegics, corticosteroids (judiciously), lubricants.
  • Surgical: Indicated for globe rupture, penetrating injuries, intraocular foreign bodies.

⭐ In chemical injuries, immediate and copious irrigation (e.g., with Ringer's lactate or normal saline) for at least 15-30 minutes or until neutral pH (7.0-7.4) is achieved is the most critical first step, even before detailed examination.

High‑Yield Points - ⚡ Biggest Takeaways

• Immediate assessment and thorough history are paramount in ocular trauma.
• Visual acuity is the single most important prognostic factor.
• Suspected open globe injury requires urgent surgical repair and avoidance of pressure.
• Chemical burns demand immediate, copious irrigation (e.g., Ringer's Lactate, Normal Saline).
• Intraocular Foreign Bodies (IOFBs) often necessitate CT scan for localization and surgical removal.
• Manage hyphema with bed rest, head elevation, and cycloplegia; avoid NSAIDs.
• Always consider tetanus prophylaxis and broad-spectrum antibiotics in penetrating trauma_