3.

04 Ocular Trauma and Emergencies 

Dr. Cynthia V. Versoza | November 19, 2018

I. EVALUATION OF EYE TRAUMA p 1-3 ▪ Presence of surgical scars denote weak points/ weak
II. OCULAR EMERGENICIES p 3-6 area on the eyeball
• Chemical Burns p3 ▪ Site of rupture will be on the surgical incision when
• Central Retinal Artery Occlusion p4 trauma occurs
• Acute Angle Closure Glaucoma p4 • Prior treatment
• Lid Laceration p4  Determine the current eye medications the patient is taking,
• Corneal Abrasion p 4-5 as it could be continued or discontinued if these medications
• Corneal Foreign Body p5 are contraindicated or will have conflict with the new
• Orbital Fracture p5 medications
• Complications of the Anterior Segment Trauma p5 • Determine any accompanying symptoms
• Complications of the Posterior Segment Trauma p5 o pain, loss of vision, diplopia, irritation, foreign body sensation,
• Complications of Penetrating Trauma p6 other organ system involvement
 Trauma will not only affect the eye and its adnexa but could
also cause fractures of the skull,
OBJECTIVES: o Inhalational injury may cause trauma in the nostrils and airway
1. Extract a relevant medical history • Note Type of injury
2. Perform the necessary ocular examination  Blunt: Globe retained its integrity
3. Recognize the conditions that need prompt referral to an  Penetrating: Partial or full thickness injury to the sclera
ophthalmologist • Identification of foreign body
4. Discuss the principles of management of common ocular  e.g.: vegetative material, metal
emergencies • Determine presence of
o thermal burn, chemical burn, animal bites ( e.g. most
 Editor: Read the notes & exam & hearts & bold words common victims are children bitten by pets, husband playing
Supplementary Book Emphasized around then suddenly wife bites him. LOL)
Audio Recording
Information Notes
   Case: What will you do if you are presented with a case like
this?  
EDITOR’S NOTE:  • First rule in medicine: DO NO HARM
This is the last trans for OPHTHA this year. Good luck and God • Do physical exam CAREFULLY
Bless. All information was taken from the recording and • AVOID unnecessary manipulation if there is obvious rupture
book and PowerPoint. Thank you. 😊 of the globe
o Putting pressure may cause spillage of eye contents and
may result to permanent blindness
I. EVALUATION OF AN EYE TRAUMA • Use STERILE eye drops
HISTORY • Use eye SHIELD to protect the tissue
Trauma • Start IV ANTIBIOTICS
 Ocular Trauma is a common cause of unilateral blindness in
children and young adults.
 The THREAT is losing your sight or BLINDNESS. PHYSICAL EXAM (8-part-eye exam)
Gross External Eye Exam
 Face, lids, conjunctiva
• Presence of chemical injury (either an acid or a base)
o Wash with at least 2L of 0.9% saline solution over at least
one hour ( you can’t just pour one-liter saline into the eye)
 Identify presence of “DCAPBTLS”
o Deformities, Contusions, Abrasions, Puncture/Perforation,
Burn/Bleeding, Tenderness, Laceration, Swelling
 Done prior to Visual acuity
 Face and lids – observe for lacerations, contusion-hematoma
 Conjunctiva - observe for subconjunctival hemorrhage,
Figure 1.  Example of eye trauma either due to accident, lacerations
domestic abuse, or work-related.  Other examples are violent
assaults, fire-cracker injuries, and sports related injuries. Visual Acuity
• Use pocket Snellen’s chart since patients are uncooperative
 Determine NOI (Nature of Incident), DOI (Date of Incident), TOI and it needs to be done quickly.
(Time of Incident), POI (Place of Incident)  Have this when you become Clerks and when you are assigned
 How it happened? & When is happened? & Where? in the Emergency room.
 Necessary when handling medico-legal case
 Patients may seek consult days after incident and the Check for the Pupils (Pupillary Light Reflex) 
duration of the time the patients did not receive any
treatment will affect prognosis • Reaction: Relative Afferent Pupillary Defect (RAPD)
• Past ocular and medical history o First check for reaction.
o Determine presence of systemic co-morbidities  (e.g. o Indication: Very severe retinal damage or you have optic
hypertension, DM, taking anti-coagulants etc.) as these will nerve damage.
affect management, especially if patient will undergo surgery o You can also have profuse bleeding inside globe that’s why
 Be particular with the presence of previous ocular surgery there’s RAPD
Why?

TRANSCRIBERS Lacuna, Lacsaman, Laluces, Largoza, Pablo EDITOR KIM BH 09178903708  1 of 6

• Peaking
o This can occur when the eye may have suffered a perforating
injury. The eye will try to plug it and send the iris to close that
area. The pupil is no longer round.
o If <24hours and the eye doesn’t look infected – you can push
it back in
o >24 hours – you have to cut it already and close the corneal
laceration.
▪ Possible bleeding at the back that can push the lens
forward
▪ Tumor growing behind the lens
▪ In trauma, there may be bleeding or the natural lens of the
eye is displaced, pushing the iris forward.
o Treatment
▪ Identify the reason causing the shallow chamber
▪ If due to lens displacement – remove the lens
▪ If due to bleeding – evacuate the blood

Figure 2. The iris tries to close the area of perforating injury.

Pupils are abnormal in shape.

Extraocular Muscles (EOMs) 

• Diplopia
o Check for any misalignment and/or poor movement in certain
gazes.
o This is most likely due to a trapped muscle.
• Patient cannot look opposite the fracture site: Suspect trapped Figure 3. Hyphema – blood in the anterior chamber, showing
muscle Grade 1 – 1/4 is affected (UL), 2 – 1/2 is affected (UR), 3 – 3/4 is
o If you have fracture on floor of the orbit, the inferior muscle affected (LL), 4 – whole eye is affected (LR). Treatment: Low
may be trapped, thus preventing the eye from moving upward. grade hyphema, with low eye pressure – Wait for eye to clear out.
o For example, if you have blow-up fracture, and the inferior High grade hyphema that obstructs the eye view, with high eye
rectus is affected, that eye will not be able to move up. pressure, or there is corneal staining (iron from the RBC has
stained the endothelium of cornea) – need to remove the blood by
Confrontation Test and Amsler Grid Evacuation.
• Confrontation test to examine the visual fields
• Amsler Grid to assess the macular area.

Anterior Segment Exam 

• A slit lamp/ophthalmoscope +10/20 diopters will be needed to
have a good anterior segment exam.
• CONJUNCTIVA (Hemorrhage and Laceration)
o Hemorrhage
▪ You can have some hemorrhaging. The conjunctiva
contains blood vessels, although they are very fine that’s
why you don’t always see anybody with a red eye. But
when these vessels rupture, there’s going to be blood all
over and then there’s hemorrhage.
o Laceration Figure 4. Anterior segment that shows the shallowing
▪ a possible trauma/injury to the conjunctiva will cause a
laceration. To determine its presence, you use a cotton • IRIS (Iridodialysis and Iridodonesis)
pledget and gently move the tissue. If you see anything o Iridodialysis – the iris has been torn away from its root. It
that separates, if there is a gap, then you have to deal with turned out to have 2 pupils which causes diplopia. You will
a conjunctival laceration. need to repair this by sewing it back into place.
• CORNEA (laceration, edema, abrasion, ulcer) o Iridodonesis – abnormal movement of the iris.
o Laceration (e.g. Iris prolapsing – remove then put it back in) ▪ The iris should not be moving, but when wavy movement
o Edema is seen, that is iridodonesis.
▪ make the cornea swollen so you cannot see the iris (if ▪ The lens is not in proper position, preventing the iris from
there is high eye pressure or increase IOP then you have moving. Or the iris has dialysis somewhere.
to lower the pressure)
o Abrasion
▪ maybe because of your nail, when you try to remove your
contact lens
o Ulcer – neglected abrasion (need to know what causes the
ulcer so maybe you can use gram stain or KOH)
o Treatment: give antibiotic ointment – why? they will retain
longer in the eye and when you have an oily surface on top
the eyelid will glide smoothly on that area so less painful
• ANTERIOR CHAMBER (Shallowing, Hyphema)
o Shallowing (there is no longer a space between the lens and
endothelium) caused by: Figure 5. Iridodialysis and traumatic cataract after a firecracker
injury.

3.04 OCULAR TRAUMA AND EMERGENCIES God Bless  2 of 6

• LENS (cataract formation, displacement, phacodonesis) II. OCULAR EMERGENCIES
o Cataract formation can be a complication. CHEMICAL BURNS
▪ A blunt trauma to the eye can cause the lens to be
displaced and to suffer from cataract Table 1. Comparison of Alkali and Acid Burns 
▪ An eye with hyphema can probably develop cataract. The CHEMICAL BURNS 
eye that has been hit hard enough that caused it to bleed (Work, house, cleaning, assault)
will probably have some form of dialysis and cataract. Alkali
o Phacodonesis Acid
(MORE DAMAGING)
▪ Abnormal movement of the lens. Presence of this can
Lye (NaOH), caustic potash, Battery acid, industrial cleaner,
indicate that the lens has been displaced. The lens may
fresh lime, plaster, cement, lab glacial acetic acid, (HCL),
be in the center but if it is moving too much, it may tell that
mortar, white wash, fruit and vegetable
the Zonules are torn.
ammonia, fertilizers, preservative, bleach, industrial
o Treatment:
magnesium hydroxide solvents, glass etching agents,
▪ For cataract and impaired vision – cataract removal must
(sparklers)- chemical/ refrigerants, mineral refining
be done
alakali burn, refrigerants, agents, silicone production
tear gas (alkali burns) agents
Protein degeneration, Less damaging, less
Rapid penetration (less than penetrating, precipitates
1 min.), Damage related to tissue proteins (precipitation
alkalinity (the higher the pH forms a barrier that prevents
the more damaging it is) penetration)
EXCEPTION: burns from hydrofluoric acid or from acids
containing heavy metals, which tend to penetrate the cornea
and anterior chamber resulting in intraocular scarring and
Figure 6. Cataract formation (left) and Phacodonesis (right) membrane formation.

• SCLERA & CHOROID (laceration and rupture)

NOTE: 
o Scleral Laceration
▪ may be observed if the choroid is already showing up. By • Treat patients suffering from mace / tear gas as alkali burns.
the time you see the choroid, the conjunctiva may already • Treat patients suffering from sparkler burns (firecrackers) it
be torn as well. as chemical burn and NOT thermal burns.
▪ Make sure to use sterile instruments when repairing eye
structures. Table 2. Roper Hall Classification for Ocular Surface Burn
(Nice to know only)
Grade Prognosis Cornea Conjunctiva
I Good Corneal epithelial No limbal
damage ischemia
II Good Corneal haze, iris < ½ limbal
details visible ischemia
III Guarded Total epithelial loss, 1/3 – ½ limbal
stromal haze, iris ischemia
details obscured
IV Poor Cornea opaque, iris > ½ limbal
and pupil obscured ischemia
Figure 7. Laceration on the Sclera where choroid is seen.

Intraocular Pressure (IOP) TREATMENT

• Defer palpation tonometry if suspecting penetrating trauma or
open glaucoma, otherwise you will squeeze out the eye.
Vitreous and Retina 
• Vitreous Hemorrhage - can’t see the inside the eye anymore,
can cause glaucoma
• Retinal hemorrhage, tear, edema, foreign body
• Usage of ophthalmoscope
o Direct ophthalmoscope (this what you should have)
▪ magnified view but only in a limited area
o Indirect ophthalmoscope
▪ gives wider but smaller view of the retina but lets you see
everything (preferred by retina specialist)
• Approach Considerations
o Vitreous hemorrhage - evacuation of the blood.
o Retinal tear - anatomically reattach the retina and close off
the hole
o Edema- medications
o Foreign bodies- surgically remove the FB. (especially iron)
▪ Glass – SOMETIMES if it’s not moving (encapsulated),
we don’t touch it anymore.
• WASH THE EYE!
• Proparacaine - topical anesthetic (every 20 mins - Why 20
mins? Because the effect of the medication lasts only for 20
mins.)
• Perform lavage with at least  2000ml of normal saline 0.9%
until pH is close to normal (7.3-7.7). Just put an IV line and let it
drop on your eye for an hour.
• Check conjunctival fornices and palpebral conjunctiva for foreign
bodies (gently sweep with cotton that is soaked with
proparacaine, cotton pledgets, evert lids)
• Medications:
o Atropine- induce relaxation → relieves the ciliary spasm →
relives the pain
o Antibiotic eye drops
o Carbonic anhydrase inhibitors - agents that lower the eye
pressure
• Analgesics: Paracetamol 500mg tablet, Meperidine 50-100mg
IM for pain
• Referral to other specialists: ENT/IM- aspirated inhaled, or
swallowed chemical. [Befriend them]

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 CENTRAL RETINAL ARTERY OCCLUSION (CRAO) PHYSICAL EXAMINATION
HISTORY • Very red Ciliary injection ( Very red/ Bloody red conjunctiva)
 Painless loss of vision (<20/400)  CRAO and Retinal • Hazy cornea
detachment • Mid-dilated pupil, unreactive ( moderately dilated pupil)
• Comorbidities: Vaso-occlusive disease (diabetes, • Increased IOP –  as hard as your glabella
hypercholesterolemia, hypertension or all of this) • Shallow anterior chamber
 History of TIAs: stroke of the eye, embolic or inflammatory,
vasculitic disease that causes transient loss of vision.
 Transient – description of the patient: dumilin ang paningin
tapos dahan dahan lumiwanag
• Cause: poor blood flow in the eye or occlusion because of
embolus (atheroma, calcium deposits of diseased heart valves,
septic and non- septic fibrin, platelet thrombus)

PHYSICAL EXAMINATION
• VA < 20/400
o Better: if patient has cilioretinal artery supplying Figure 9. Acute Angle Closure Glaucoma
papillomacular nerve fibers
o Worse (NLP): if with choroidal ischemia due to concomitant TREATMENT
ophthalmic artery occlusion  ALWAYS LOWER THE IOP/ EYE PRESSURE
o Fundus: milky white retina, cherry red spot, minimal • Acetazolamide, IV mannitol, Glycerine
hemorrhage
• Topical -blockers
 Patient has no light perception like completely blind, you’ll
 To reduce production of aqueous humor
have to consider that there may be also involvement of the
• Laser iridotomy
ophthalmic artery. You retain this vision if cilioretinal artery is
 Use laser to make holes on your iris to treat affected eye
unaffected. ( choroidal ischemia due to ophthalmic artery
and prophylaxis for the other eye
occlusion in addition to CRAO)
 Stroke - no blood supply therefore the fundus would look pale,
EYELID LACERATION
milky white.
HISTORY
 If intact cilioretinal artery - cherry red spot, minimal
hemorrhage. • Fight, attack or accident

PHYSICAL EXAMINATION
• Determine extent - Check for globe injury
• Determine involvement of other structures
o Canaliculi, levator muscle, lacrimal gland
• Determine if there is tissue loss

Figure 8. Central Retinal Artery Occlusion with cherry red spot.

TREATMENT Figure 10. Examples of Lid Laceration

• Within 24 hours from onset of symptoms
• Correct precipitating event TREATMENT
o Decompress orbit if acute retrobulbar hemorrhage • Clean wound first – irrigate it with saline, betadine
o Decrease IOP if acute glaucoma attack • Give antibiotics, anti-tetanus, anti-rabies, cold compresses
 Dislodge embolus • Repair wound
o Mechanically collapse the arterial lumen and cause prompt o 5-0 Chromic/Vicryl/Dexon
changes in blood flow o 6-0 Silk
o Ocular massage using a 3-mirror contact lens for 10 secs,  For GP, you could actually close this one. Clean it first, irrigate
then release for 5 secs, to obtain central retina artery pulsation with saline, betadine, or hydrogen peroxide. Once you’re sure
or cessation of flow that there is no foreign body in the area, you can close it.
• Carbonic anhydrase inhibitors
• Sublingual isosorbide dinitrate (10mg) to dilate peripheral CORNEAL ABRASION
blood vessels and decrease resistance HISTORY
• IV methylprednisolone for possible arteritis • Fingernail or object to the eye; Contact lens overuse
• 95% O2 / 5% CO2 air mixture to dilate retinal vessels • UV burns from welding
• Paracentesis of aqueous humor to decrease IOP
SIGNS AND SYMPTOMS
ACUTE ANGLE CLOSURE GLAUCOMA • Pain – very painful
HISTORY • Photophobia
• Sudden, painful, blurring of vision • Tearing
• Associated severe eye redness, headache, and nausea/vomiting • Lid swelling
 Massive headache on the same side as the affected eye- • Blurring of vision
IPSILATERAL HEADACHE • Epithelial defect

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 TREATMENT
• Imaging
• Antibiotics
• Anti-inflammatories
• Consult ENT once fracture is fixed so that the eye can move freely

Complications of the ANTERIOR Segment Trauma

Figure 11. Corneal Abrasion with Fluorescence staining.

TREATMENT
• Remove foreign body
• Antibiotic eye drops/ointment
• Cycloplegic eyedrops to relieve the ciliary spasm
o Eye ointment will be a better choice because it retains longer
• Eye patch to cover the other eye
o Minimizing the movement of the eye, not preventing
movement

CORNEAL FOREIGN BODIES (FB)

HISTORY
• Patient was hit by foreign body or draft blew an FB into the eye Figure 13. Examples of Complication of the Anterior Segment
Trauma
TYPES OF FOREIGN BODIES
• Metallic – Problem is the rust ring that will develop • Hyphema – blood in the anterior chamber
o As seen in carpenters or welders • Sphincter Tear
o The foreign body and the rust ring must be removed  Located at the pupil area
• Vegetable – risk of infectious keratitis  Pupil appears dilated because of the tear
o Must also be removed • Iridodialysis
 The iris is torn away from its origin
PHYSICAL EXAMINATION • Vossium Ring
• Check how deep the FB, to determine if it can be removed during  When you have the iris imprinting, leaving some fragments
slit lamp or at the operating room on the surface of the capsule
• Check other places for possible foreign bodies • Cataract
o Tarsal and bulbar conjunctiva, sclera • Lens Dislocation
• Angle Recession
TREATMENT  If you have hyphema following blunt trauma to the eye, you
• Remove the foreign body (Superficial or Deep FB) will likely have angle recession as well
o Irrigation, cotton pledget, 25G needle under slit lamp • Globe Rupture
• Antibiotic eyedrops
• Patch the eye for 24 hours Complications of the POSTERIOR Segment Trauma

ORBITAL FRACTURE
HISTORY
• facial trauma with intraocular injury
• Causing the inferior portion of the orbit to collapse which results
in trapping of the ocular muscle
• Commonly a fracture that entraps orbital fat, the inferior rectus,
and bone fragments

SIGNS AND SYMPTOMS

• Periorbital bruising ( pasa)
• Enophthalmos – the eye is pulled inward ( eno =in)
o The palpebral fissure will be smaller because the eye is
retracted backward
• Diplopia – the result of trapped muscles Figure 14. Examples of Complication of the Posterior Segment
Trauma

• Commotio Retinae – retinal edema

• Choroidal Rupture
 A break in the choroid
• Avulsion of Vitreous Base
 The vitreous becomes detached
• Retinal Detachment
• Macular Hole
• Optic Neuropathy
Figure 12. (L) Example of Orbital Fracture (R) Bruising around
the eye is a common symptom of a blowout fracture. • Retinal Dialysis

3.04 OCULAR TRAUMA AND EMERGENCIES God Bless  5 of 6

 Complications of PENETRATING Trauma B. iris sphincter tears
C. intact globe
D. inflammatory cells in anterior chamber
5. Disrupted axonal transport.... nerve fiber layer of the retina
A. berlin’s edema
B. commotio retinae
C. optic nerve head avulsion

Answer key: 1C 2C/D 3B 4C 5B

QUIZ (Self-test  )
6. Signs of acute angle closure glaucoma include the
following, EXCEPT
A. Ciliary injection
B. Irregular miotic pupil
C. Hazy cornea due to bedewing
D. Ocular pain
Figure 15. Examples of Complication of Penetrating Trauma E. Blurring of vision
7. Which of the following red eye conditions would require
• Shallow Anterior Chamber early recognition due to their potentially vision threatening
• Uveal Prolapse nature
 Prolapse of any part of the uveal tract’s three parts – Iris, A. Internal hordeolum
Choroid, Ciliary body B. Viral conjunctivitis
• Damage to the Lens and Iris C. Chemical burn
• Vitreous Hemorrhage D. Blepharitis
E. Nasolacrimal duct obstruction
• Tractional Retinal Detachment
8. A patient presents with a one-day history of severe eye
• Endophthalmitis
pain and marked blurring of vision. Upon doing your
 A global infection of the eye that may indicate retained
ophthalmologic examination, you note that the patient has
foreign bodies or an undetected scleral tear
a mid-dilated pupil with a firm eyeball. Based on this, your
primary consideration would be
SUMMARY
A. Corneal abrasion
• Rapid evaluation (relevant details) and first aid B. Contact lens over wear
• Minimal handling if globe is suspected to be penetrated C. Bacterial conjunctivitis
• Protect injured tissues from further damage D. Acute angle closure glaucoma
• Use sterile eyedrops 9. The following conditions require IMMEDIATE intervention
• Refer to an ophthalmologist for further evaluation and treatment or treatment:
A. endophthalmitis and orbital rim fracture
REFERENCES B. canalicular transaction and intraocular foreign body
1.  Self-Instructional Materials in Ophthalmology, 2nd Edition, C. chemical burn and central retinal artery occlusion
Edited by Valbuena and Castillo [Page 221-234] D. hyphema and central retinal vein occlusion
2. Dr. Versoza’s PowerPoint presentation (2018) E. scleral laceration and commotion retinae
3. 2020B recordings 10. This step in the ocular examination may be deferred if
globe rupture is suspected:
QUIZ (Ancient) A. visual acuity
1. What condition would you apply management first before B. gross examination
doing an 8-part eye exam? C. extraocular muscle movement test
A. Blowout Fracture D. palpation tonometry
B. Acute Angle Closure Glaucoma E. direct fundoscopy
C. CRAO 11. A patient who figured in a vehicular accident was referred
D. Lid Laceration from another hospital with a diagnosis of traumatic optic
2. You noted a corneal ulcer on the left eye of a 40y/o farmer, neuropathy. What examination will help confirm this
who have been hit by the grass he is cutting. What should diagnosis?
you do prior to referring to an ophthalmologist? A. Hirschberg light reflex test
A. apply topical steroids B. swinging flashlight test
B. flush with saline C. flashlight test using a slit beam
C. place an eyelid patch D. extraocular muscle movement test
D. put a corneal bandage lens E. lid elevation test
3. A 28-year-old suffered a blow in his right eye. Seeing that 12. What clinical finding is not seen in a patient with orbital
the globe is intact, you continued with the eight-part eye floor fracture?
exam. The pertinent findings that you noted are periorbital A. ecchymosis
ecchymosis and the presence of blood filling about 3/4 of B. diplopia
the anterior chamber. What would you advise the patient? C. hypesthesia
A. administer topical antibiotics D. limited extraocular muscle movements
B. admitted for observation E. exophthalmos
C. anti-tetanus shot
D. send patient home Answer key: 6B 7C 8D 9C 10D 11B 12E
4. The following are signs of iris injury, EXCEPT
A. constricted pupils

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