Eye Injuries (ALS) >

History Of Present Illness

In this scenario, our crew is dispatched to the home of a 20-year-old woman trimming
some bushes with an electric hedge trimmer. She was not wearing anything to protect
her eyes and a piece of wood struck her in the right eye. She alerts her father who calls
911.

Past medical history :  None. Does not wear eyeglasses or contact lenses.

Medications:  None

Allergies:  None

Social history:  Lives with her father. Denies tobacco, alcohol, or  drugs .

Family history:  None

Last meal:  1 hour ago

Vital  signs :

 Temp  98.8°F (37.1°C)
 BP  118/82
 Resp  16
 Pulse  110
 O 2 sat  99% on room air, 100% on O 2

Blood sugar:  118 mg/dL (6.6 mmol/l)

Physical Exam
General:  Our patient is spontaneously alert and oriented, appears to be anxious and
very uncomfortable.
HEENT:  Right orbit has a small piece of wood impaled in the outer eyelid with blood
oozing from the wound. The eye is closed. Left eye atraumatic. No other trauma noted.
Neck:  Full range of motion, no midline tenderness.
Lungs:  Clear bilaterally.
Cardiac:  Regular, rapid rate and rhythm, no bruising to chest wall. No pain
with  palpation  of chest wall.
Abdomen:  Soft and non-tender, no bruises or  signs  of trauma.
Back:  No evidence of trauma, non-tender.
Extremities:  No evidence of trauma, no pain with palpation, no peripheral  edema .
Skin:  Warm, dry, no wounds, no rashes noted.
Neuro:  Alert and oriented x 3, no motor deficits, non-focal exam, no facial asymmetry,
speech is slow and clear, stroke screen is negative, GCS is 15

Assessment Of This Case

In our scenario, the EMS crew is dispatched to the home of a 20-year-old woman who
sustained an eye injury trimming some bushes with an electric hedge trimmer. She was
not wearing eye protection. She alerts her father who calls 911. There is a 3 cm piece
of wood protruding from the right eyelid, which is closed. The patient has severe eye
pain and is anxious and worried about losing her eyesight.

Eye Injury Statistics

Eye injury statistics 6 :

 Approximately 2 million eye   injuries   in the U.S. each year

o 40,000 resulting in some degree of vision loss
 Projectile   trauma   is the most common form of eye injuries in men, usually
occurring in the workplace or at home during home construction projects.
o Most of these eye injuries occur when eye protection is not being utilized.
It is not uncommon for people to forget to use eye protection outside of
the workplace, where eye protection is often mandatory.
 1/3 of eye injuries occurring in children and   adolescents   are sports related.
Paintball injuries are causing an increasing number of eye injuries in recent
years, with   globe   rupture occurring in 5% of these injuries.

Acerra, J. (Updated 2012, July 30) emedicine.medscape.com. “Globe Rupture” as retrieved from emedicine.medscape.com/article/798223-overview.
6 

The Human Eye

The human eye is a sensory organ that provides visual information to the  brain . As
one of the five senses, vision gives information to the brain about our surroundings.

Residing inside of a bony eye socket, the human eye has the ability to move about
freely using orbital muscles (i.e. extraocular motion). The eyes have many components
that allow us to visualize the world around us. Major components of the eye include:

 Conjunctiva  – outermost layer of the eye; clear protective membrane covering

anterior eye and eyelids.
 Cornea  – anterior surface of eyeball.
 Sclera  – tough, white-colored wall that provides shape to the  globe  and
protection to the eye contents.
 Iris  – muscle fiber ring that allows pupil to constrict or widen.
 Cornea  – clear dome-shaped  lens  over the anterior portion of eye.
 Pupil  – opening in center of iris.
 Aqueous humor  – water-like fluid between the lens and cornea.
 Vitreous humor  – jelly-like liquid in the eye (behind the lens).
  Optic nerve  – main nerve to eye; can be compressed
by  hematoma  (from  trauma ), tumor, or  abscess . Provides vision.
 Oculomotor nerve  (3rd cranial nerve) – controls the muscles that provide
motion of the eyeball and upper eyelid. Also causes constriction of the pupil.
 Eye lid  – protects and lubricates the eyes.
 Eye lashes  – hairs that protect eyes from small particles or injury.
 Orbital muscles  – provide movement of the eyes.
 Opthalmic artery  – arterial supply to the eye; branch of the internal carotid
artery.
 Opthalmic vein  – venous drainage of the eye into the central retinal vein.

Pearls Of Wisdom
Assessment of extraocular motion and pupillary activity can provide important clues
about defects of the muscles and nerves of the eye.

Scene Survey
As soon as the crew arrives on scene, the  lead   medic immediately calls for a thorough
scene survey to ensure the scene is safe for the patient and crew and an interview with
the patient’s father. Our lead medic also makes contact with the patient, introduces
himself, and speaks in a calm and reassuring manner. Being calm and reassuring to the
patient with an eye injury is very important as the patient may have severe discomfort
and be understandably anxious. When treating a patient with an eye injury, it is
essential that you gain the patient’s trust early in the call by remaining calm and
speaking in a non-threatening tone. Building a rapport and gaining your patient’s trust
increases the chance the call will run more smoothly, and it may help you uncover
clinically relevant information.

As with any call, your priority must always be to ensure scene safety for both your
patient and for your crew and to perform a thorough scene survey. It is critical in this
type of scenario to consider all possible causes and be prepared to administer pain
management when appropriate. Assess the patient’s ABCs and initiate oxygen therapy,
if appropriate. Conduct a thorough history and physical exam and assess the patient’s
vital   signs , including a temperature

ABC's
Our patient’s airway is clear without  signs   of obstruction. Breathing is unlabored with
a rate of 16. Our patient’s pulses are regular and strong at a rate of 110.

Our patient is extremely anxious. When questioned, she says she did not fall, she
denies other   trauma   or recent illness, and she has no history of eye disease. She
does not wear glasses or contact lenses. Simultaneously, another crew member is
interviewing the patient’s father and has looked for any additional dangers that may be
a scene safety issue.

As soon as the ABCs are completed, our   lead   medic initiates a SAMPLE history and
asks other pertinent questions using OPQRST. A head-to-toe exam is performed.
Simultaneously, the patient’s father is also being interviewed.

Vital Signs
Vital  signs   are very important in the eye   trauma   patient, particularly if the patient
will be receiving pain   medication . Vital sign abnormalities may clue you in to the fact
that the patient has sustained other   injuries   that the patient may not be aware of
due to the distraction of an eye injury. Information about the patient may be limited or
difficult to obtain due to anxiety and pain from the injury. Remember not
to   neglect   any of the vital signs. Temperature and a blood glucose check may
provide useful information as there may be other contributing factors leading to the
injury (i.e.   hypoglycemia ).

A SAMPLE History
S igns and   symptoms
A llergies (foods, medications, external sources)
M edications (including eye drops)
P ast (pertinent) medical history
L ast (oral intake) meal or liquids
E vents leading to this problem

An "OPQRST" Approach To Obtaining Clues

O nset – when did the pain/discomfort begin?
P rovokes – what brought the pain/discomfort on and made it better/worse?
Q uality – how would you describe the pain/discomfort?
R adiates/Region/Referral – where is the pain/discomfort and where does it go?
S everity – how would the patient rate the pain/discomfort on a “1 to 10 scale”?
T ime of onset – how long has this pain/discomfort been occurring?

Pearls Of Wisdom
Remember, be thorough, obtain a thorough history and scene survey, and be sure to
rule out any other possible  injuries .

Considerations For Assessment Of The Eye

When assessing the patient with an eye complaint, the answers to the following
questions can be helpful.
  When did   symptoms   or injury occur?
 What were you doing when the injury occurred (i.e. cutting, sawing, using tools,
operating machinery, hammering metal)?
 Was there   trauma ? Fall?
 Pain? Itching? Foreign   body   sensation?
 History of eye problems or eye surgery?
 Is there any eye pain or redness?
 Do you have any loss of vision? Sudden or slow onset?
 Do you have double vision ( diplopia )?
 Do you have   sensitivity   to light (photophobia)?
 Is there any discharge coming from the eye?
 Do you normally wear corrective lenses or contacts?
 Were you wearing eye protection when the injury occurred?
 Did the eye injury occur during a vehicle crash (i.e. seatbelt, air bag
deployment)?

Patients with eye  injuries   may be distracted and very anxious about their injuries.
When assessing eye injury patients, there are important considerations to keep in
mind:

 A ruptured or perforated   globe   may be difficult to identify.

 Do not put unnecessary pressure on the globe (intraocular leakage may occur).
 Impaled objects should not be removed.
 Small foreign objects penetrating or irritating the globe may be difficult to see.
 Small children with eye injuries may be uncooperative and unwilling to
allow   evaluation   of injuries.
 Sometimes, if the eye is already covered, avoid manipulating the eye, and limit
your exam rather than opening a traumatized eye.

Physical Exam Tips

Physical exam of patients with eye  injuries   can often be challenging. Remember,
personal protection for the crew is always a good idea when assessing patients due to
the risk of exposure to body fluids.

Examination of the eye:

When examining the eyes of a patient in the pre-hospital setting, follow an organized
and methodical approach to ensure nothing goes unnoticed:

 Examine the exterior portion of the eye.

 Inspect eyelids, eye lashes, and tear ducts for anything abnormal (i.e. injury,
secretions).
 Measure visual acuity – asking patient to count number of fingers being
displayed.
o If the patient normally uses eyeglasses, visual acuity should be checked
with the use of eyeglasses.
 Use a penlight to assess the pupils – Distortion? Asymmetry? Responsive to
light? Irregular pupils can be caused by several possibilities, including previous
 eye surgery, previous   trauma , and   multiple sclerosis . An irregular teardrop
pupil can sometimes be seen with acute trauma secondary to rupture of
the   iris .
 Assess   ocular   motility – can the patient symmetrically move his or her eyes in
all directions? Deficiencies may suggest a cranial nerve palsy.

What Is An Afferent Pupillary Defect (Marcus-Gunn

Pupil)?
When shining a light into the eye, the other eye’s  pupil   should also normally constrict.
When swinging the light to the other eye, the pupil will dilate, instead of the normal
constriction, because the light is not reaching the   optic nerve . Can be caused by
anything blocking light to the optic nerve (i.e. bleeding or retinal disease) or optic nerve
pathology.

Treatment Of Eye Injuries In The Field

Management of eye  injuries   in the field includes:

 Patient safety, reassurance, and frequent reevaluations are the mainstays of eye
injury management.
 Maintain airway.
 Apply O 2   (if appropriate and tolerated).

Chemical exposure:

 Continuous irrigation of eyes.

Impaled objects:

 Protective covering over eye.

 Cover both eyes to minimize eye movement.
 Positioning patient for comfort (i.e. semi-fowlers).
 Spinal immobilization (if spinal injury suspected).
 If paramedic care is available, initiate an IV, provide pain management, EKG
monitoring, and blood glucose.
 Elevating  the  head  approximately  40  degrees  will  help  minimize 
intraocular pressure, which can be helpful with suspected   globe   perforation.
 Stabilize penetrating objects and cover the affected eye with ocular shield or
rigid device and   bandage  unaffected eye.

Eyeball protruding from the eye:

 Moist dressings should be gently applied to globe if exposed to prevent globe

from drying.
 Cover entire eye area with a protective container (i.e. disposable drinking cup).
Bleeding eye:

 Apply dressing and pressure as needed.

Other caveats:

 Irrigate the eye (i.e.   normal saline ,   sterile   water) if globe is intact.

 Do not irrigate an eye if there is   penetrating trauma   to the globe or   cornea .
 Medicated eye drops for ocular pain (i.e. tetracaine) are sometimes used for pre-
hospital pain management. These medications are only used if the globe is intact
without concern for penetrating globe trauma or globe perforation.
 Removal of contact lenses (only if able to do so without causing further injury).

Note:   Covering both eyes is often helpful as it will help minimize unnecessary eye
movements.

 
A   hyphema   characterized by bleeding into the   anterior chamber   of the eye, can occur following blunt trauma to the eye.  This condition should be
considered a sight-threatening emergency.  (Left) Actual hyphema. (Right) Illustration.

Eye-Related Diagnoses
Required time in course (45 minutes) must be fulfilled to record course completion
Corneal abrasion   – essentially, a superficial scratch of the outer surface of the eye –
common  symptoms  include pain, foreign body sensation. Examination may reveal
mild  conjunctivitis . Common causes include an accidental fingernail scratch,
contact  lens  use, makeup brushes, and foreign bodies.

Corneal  laceration  – similar to corneal abrasion, except may present with mild

bleeding. 

Ultraviolet keratitis  – “sunburn of the eye” – can be caused by exposure to sun (or
tanning beds) or when welding without proper eye protection. Symptoms typically
include eye redness, tearing, and pain.

Corneal foreign bodies  – common foreign bodies include small pieces of wood, metal,
or plastic. Items can become embedded in the cornea. Foreign body sensation, eye
tearing, and discomfort are common complaints.

Lid lacerations  – management with  sterile   dressing  and gentle pressure.

Orbital blow-out fractures  – injury often involves fracture of the inferior orbit.
Sometimes, if the inferior rectus muscle is entrapped within the fracture, the patient
will be unable to gaze upwards with the involved eye and will typically complain of
double vision (i.e.  diplopia ). These patients often require surgery.

Globe  rupture  – symptoms often include pain and decreased vision in the involved
eye. These  injuries  can be catastrophic and can be made worse if not managed
correctly. Proper management includes covering the eye with a metal shield or other
device that prevents movement of the involved eye. Elevate the head. Provide pain
control per department  protocol . Provide anti-emetics per department policy. Vomiting
can increase intraocular pressure and should be avoided.

Acid and alkali injuries  – should be vigorously irrigated with water or saline for at least
30 minutes. These injuries, particularly alkali injuries, can be devastating due to
the  necrosis  they can cause to the vital structures of the eye.

Retinal detachment  – separation of inner layers of retina, often from blunt eye trauma.
Sometimes seen in sports-related injuries (i.e. boxing). This is a painless condition.
Common symptoms of patients with a retinal detachment are “flashing lights” or
“curtain” or “veil” being placed over the eye. This is an ocular emergency.

Hyphema  – bleeding in the  anterior chamber  of eye.

Immediate Treatment

 Scene safety
 ABCs/oxygen
 Place patient in position of comfort
 Spinal immobilization (if spinal injury suspected)
 History
 Vital  signs
 Physical examination
 Applying protective eye covering (impaled objects)
 Continuous irrigation of eyes (chemical exposures)
 Paramedic care (IV, pain management, EKG, blood glucose).

Pearls Of Wisdom
Eye  injuries   can be extremely painful and can cause overwhelming discomfort
and   fear  about losing eyesight. Be comforting, be compassionate, provide timely
care, place the patient in position of comfort, and continue reassurance. If ALS care is
available, provide pain management as appropriate.

 Preliminary Diagnosis
Based on the clues of our patient having severe eye pain, bleeding, and swelling after
sustaining an  impaled object   to the right eye, our initial   field diagnosis   is “right eye
injury with possible   globe   perforation.”

Common Causes Of Eye Injuries

Ocular   injuries   commonly occur because of blunt,   penetrating trauma , or burns.

Causes of blunt trauma to the eye include:

  Motor vehicle collisions
 Motorcycle collisions
 Falls
 Assaults

Penetrating Injuries To The Eye Include:

 Lacerations
 Foreign objects (i.e. pencils, metal shavings)
 Impaled objects

Blunt Trauma To The Eye Can Include:

 Hyphema   – bleeding in   anterior chamber   of eye

 Orbital blow-out fractures – fracture of the orbital wall (usually inferior wall)
 Retinal detachment   – separation of retina from eye structure

Ocular Burns

Ocular   burns can damage the eye and   lead   to serious eye damage or loss of sight.
Burns to the eyes can occur from:

 Chemicals (i.e. acids, alkali)

 Heat sources (i.e. open flame)
 Light sources (i.e. arc welder)

Prompt identification and treatment of these   injuries   is critical. Chemicals or irritating

substances still in contact with eyes should be flushed continuously to help minimize
damage to the patient’s eyes.

Consequences Of Ocular Injuries

 Damage to the eye  globe   or   optic nerve   may present with vision loss not

improved by blinking.
 Damage to the extraocular muscles or   fracture   of the orbit may present with
double vision.
 Superficial eye   injuries   may be due to corneal irritation or a foreign object
behind the eyelid.

Documentation
It is important when treating eye injury patients in the field that you document your
scene findings, patient assessment, and factors contributing to the injury. Where was
the patient when the injury occurred (i.e. garage, work)? What was the patient doing
when the injury occurred (i.e. cutting, sawing, using tools, or machinery)? Did the eye
injury occur during a vehicle crash (i.e. seatbelt, air bag deployment)? Was the patient
wearing eye protection when the injury occurred? What time did the injury occur? Does
the patient use corrective lenses? Was the eye injury related to a fall? Was there any
blunt,  penetrating trauma   or perforation to the   globe   of the eye? What type of
object impacted or impaled the eye? If there is an object impaled in the patient’s eye,
was it covered and protected in an appropriate manner? Was there any chemical or
substance causing injury to the eyes, and if so, are the eyes being irrigated as
appropriate? Also, was there any pain management provided to the patient, and if so,
did it resolve or minimize the pain? Asking the right questions and providing thorough
documentation for these questions can be instrumental in continuation of the patient’s
care.

What Happened To Our Patient?

At the Emergency Department, our patient was evaluated and diagnosed with an orbital
perforation of the right eye due to a wood splinter impaled in the  globe . She also had
significant lacerations of the eyelids and  sclera . The object was removed with a
surgical repair of both the globe and eyelids by an ophthalmologist in the Operating
Room. The patient slowly regained vision in the right eye after several weeks of
healing.

Eye  injuries  can be potentially devastating and can cause overwhelming concern for

any patient. Remember that providing a calm and reassuring approach to your patient
can be very important to minimizing further exacerbation of an eye injury. Protecting
the eye from further injury and providing pain and nausea management to the patient
can be very beneficial.

Glossary
Adolescents  : Persons who are 12 to 18 years of age.
Anterior Chamber  : The anterior area of the globe between the lens and the cornea that
is filled with aqueous humor.
Bandage  : Material used to secure a dressing in place.
Blowout Fracture  : A fracture to the floor of the orbit usually caused by a blow to the
eye.
Blunt Trauma  : An impact on the body by objects that cause injury without penetrating
soft tissues or internal organs and cavities.
Body  : In the context of the uterus, the portion below the fundus that begins to taper
and narrow.
Brain  : Part of the central nervous system located within the cranium; contains billions
of neurons that serve a variety of vital functions.
Cover  : Obstacles that are difficult or impossible for bullets to penetrate.
Dressing  : Material used to directly cover a wound.
Ecchymosis  : Localized bruising or blood collection within or under the skin.
Evaluation  : Collection of the methods, skills, and activities necessary to determine
whether a service or program is needed, likely to be used, conducted as planned, and
actually helps people.
Fear  : Also sometimes referred to as a phobia, this is an anxious feeling, usually about
specific things or situations.
Field Diagnosis  : A determination of what a paramedic thinks is the patient's current
problem, usually based on the patient history and the chief complaint.
Fracture  : A break or rupture in the bone.
Globe  : The eyeball.
Hematoma  : An accumulation of blood in the tissues beneath the skin; a potential
complication of IV therapy.
Hyphema  : Bleeding into the anterior chamber of the eye; results from direct ocular
trauma.
Impaled Object  : An object that has caused a puncture wound and remains embedded in
the wound.
Injuries  : Any unintentional or intentional damage to the body resulting from acute
exposure to thermal, mechanical, electrical, or chemical energy or from the absence of
such essentials as heat or oxygen.
Lead  : Any one of the conductors, composed of two or more electrodes, in the ECG that
shows the electrical conduction in the heart.
Lens  : A transparent body within the globe that focuses light rays.
Necrosis  : The death of tissue, usually caused by a cessation of its blood supply.
Neglect  : Refusal or failure on the part of the caregiver to provide life necessities, such
as food, water, clothing, shelter, personal hygiene, medicine, comfort, and personal
safety.
Ocular  : Pertaining to the eye.
Optic Nerve  : Either of the second cranial nerves that enter the eyeball posteriorly,
through the optic foramen.
Palpation  : Physical touching for the purpose of obtaining information.
Penetrating Trauma  : Injury caused by objects that pierce the surface of the body, such
as knives and bullets, and damage internal tissues and organs.
Pupil  : The circular opening in the center of the eye through which light passes to the
lens.
Retina  : A delicate 10-layered structure of nervous tissue located in the rear of the
interior of the globe that receives light and generates nerve signals that are transmitted
to the brain through the optic nerve.
Retinal Detachment  : Separation of the inner layers of the retina from the underlying
choroid, the vascular membrane that nourishes the retina.
Sensitivity  : The ability to recognize a foreign substance the next time it is encountered.
Signs  : Indications of illness or injury that the examiner can see, hear, feel, smell, and
so on.
Skull  : The structure at the top of the axial skeleton that houses the brain and consists
of 28 bones that comprise the auditory ossicles, the cranium, and the face.
Sterile  : The destruction of all living organisms; achieved by using heat, gas, or
chemicals.
Symptoms  : The pain, discomfort, or other abnormality that the patient feels.
Trauma  : Acute physiologic and structural change that occurs in a victim as a result of
the rapid dissipation of energy delivered by an external force.
References

1.
Tintinalli, J. E. (2011).  Emergency Medicine   (7th ed.). New York: McGraw-Hill.
2. Caroline, N.L. (2013).   Nancy Caroline’s Emergency Care in the Streets   (7th
ed.). Massachusetts: Jones and Bartlett Publishers.
3. American College of Surgeons Committee on   Trauma   (2012)   Advanced
Trauma Life Support Student Course Manual   (9th ed.). Chicago.
4. Duong, H. (Updated 2013, June 6) emedicine.medscape.com
“Eye   Globe   Anatomy” as retrieved
from  emedicine.medscape.com/article/1923010-overview#a30 .
5. “Anatomy of the Eye” as retrieved from   http://www.emedicinehealth.com   on
2011, June 28.
6. Acerra, J. (Updated 2012, July 30) emedicine.medscape.com. “Globe Rupture” as
retrieved from  emedicine.medscape.com/article/798223-overview .
7. “Rupture Clinical Presentation” as retrieved
from   http://emedicine.medscape.com   2011, June 29.

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