Eyes Wide Split

The major types of penetrating eye injury are:

• eye lid lacerations
• corneal lacerations
• scleral lacerations
• perforating trauma (+/- an exit wound) including occult foreign body penetration (e.g. when metal strikes metal)

There may also be associated injuries to:

• intraocular structures — e.g. lens, iris, retina
• extraocular structures — e.g. lids, extra-ocular muscles, orbital bones, optic nerve and brain

History

• symptoms — visual disturbance or loss of vision, pain at rest or on movement, and diplopia.
• mechanism of injury — any suspicion of penetrating eye trauma requires prompt assessment so that urgent ophthalmology referral can be made.
• Use of eye protection
• type of projectile and velocity — small high-velocity projectiles are at higher risk of penetrating injury.
• history of previous trauma or surgery that may compromise the structural integrity of the eye.

in addition to the usual AMPLE history for trauma.

Examination — if penetrating injury is possible, but not obvious, carefully assess for:

• pupil — a teardrop-shaped pupil may be caused by iris prolapse through a corneal laceration.
• slit lamp — look for defects in the cornea or sclera or distortion of the anterior chamber structures (e.g. a shallow anterior chamber with a self-sealing corneal laceration), hyphaema. Check under the eyelids for a concealed laceration/ rupture.
• visual acuity — usually decreased
• red reflex — may be abnormal
• fundoscopy — look for foreign bodies and retinal injury.

If penetrating injury is obvious, only a cursory examination is needed — make the referral!

Urgent referral to an ophthalmologist is indicated. CT scan of the orbit may be performed following discussion with an ophthalmologist to check for ocular or orbital foreign bodies.

Management involves:

• The patient is kept nil by mouth, with strict bed rest.
• Supportive care including analgesia and antiemetics as required.
• Apply an eye shield (not a pad) to protect the eye, but avoid applying pressure that will increase intraocular pressure leading to extrusion of ocular contents.
• Start broad spectrum IV antibiotics (see Q9). Do not apply any topical agents if there is a penetrating eye injury as the preservative is toxic to ocular contents.
• Tetanus immunisation as required.

• permanent loss of vision — enucleation may be necessary
• corneal ulcers — may lead to delayed perforation.
• infection — e.g. endophthalmitis
• sympathetic ophthalmia — enucleation of the severely traumatised eye should be performed initially or within 1-2 weeks to prevent this in the severely damaged eye

Seidel’s test is used to detect aqueous humor leaking from a corneal wound.

Fluorescein dye is applied to the region of the suspected laceration. The test is positive when a stream of fluorescent dye emanating from the site is visualised on slit-lamp examination.

A negative test does not rule out a full thickness corneal laceration.

Check out this fantastic and brief video at RootAtlas.com showing a positive Seidel’s test and the signs of a corneal laceration.

• Superficial wounds less than about 1-1.5cm long generally heal spontaneously. If the conjunctiva is rolled back on itself it may need to be realigned.
• Deeper and more extensive lesions require sutures (e.g. 9-0 absorbable), and are usually repaired by an ophthalmologist.
• Large lacerations are seen for follow up in a week, small lacerations can be reviewed as needed.

Inflammation of the uninjured eye occurring weeks to months after the initial insult to the injured eye.

• pathophysiology — an autoimmune response to the normally sequestered uveal tissues of the injured eye becoming exposed with injury.
• clinical manifestations — pain, photophobia, and decreased visual acuity.
• management — ophthalmology referral for treatment with steroids and  immunosuppressants. Symptoms may be reduced by enucleation of the blind injured eye even after sympathetic ophthalmia has developed.

Endophthalmitis is inflammation, often due to infection, involving all the deep structures of the eye.

• Pathophysiology — complication of blunt globe rupture, penetrating eye injury, foreign bodies, and ocular surgery. Causative organisms are usually Staphylococcus, Streptococcus, and GNBs (e.g. Bacillus).
• Clinical manifestations — pain and visual loss; chemosis, and hyperemia of the conjunctiva, and the infected chambers are hazy or opaque.
• Management — topical, intraocular and systemic antibiotics.

The Australian Therapeutic Guidelines suggests the following, unless alternative specialist advice is given:

• ciprofloxacin 750 mg (child: 20 mg/kg up to 750 mg) orally, as a single dose
• vancomycin 25 mg/kg up to 1.5 g (child less than 12 years: 30 mg/kg up to 1.5 g) IV, as a single dose