November 2015

Ocular Injuries: New Strategies Volume 17, Number 11

In Emergency Department
Author

Anne M. Messman, MD
Assistant Program Director, Assistant Professor, Sinai-Grace

Management Emergency Department, Wayne State University, Detroit, MI

Peer Reviewers

Edmond A. Hooker, MD, DrPH

Abstract Assistant Professor, Department of Emergency Medicine,
University of Cincinnati, Cincinnati, OH
Ocular injuries are common in the emergency department, and Nadia Shaukat, MD, RDMS
Associate Director, Associate Fellowship Director, Emergency
they are the most frequent cause of noncongenital monocular Ultrasound Division, Department of Emergency Medicine, New
blindness in children and adults. This review provides evidence- York Presbyterian Queens, Flushing, NY
based recommendations for the diagnosis, treatment, and dis-
CME Objectives
position of patients with all types of ocular trauma, including
Upon completion of this article, you should be able to:
pain management, the use of antibiotics, cycloplegics, steroids,
1. Diagnose traumatic ocular injuries and order proper imaging
antifibrinolytics, and patching. Bedside ocular ultrasound has studies as necessary.
profoundly expanded diagnostic capability, particularly for the 2. Treat traumatic ocular injuries with the most current
multiply injured patient, and routine management and disposi- recommendations.
tion of patients with corneal abrasions has evolved significantly 3. Identify which patients require admission to the hospital,
which patients should follow up with ophthalmology, and
as well. Diagnosis and management of patients with retrobulbar when disposition will be at the discretion of the treating
hemorrhage is discussed in detail, with resources for performing ophthalmologist.
vision-saving lateral canthotomy. Systematic evaluation and man- Prior to beginning this activity, see “Physician CME Information”
agement of ocular trauma patients will ensure these patients have on the back page. This article is eligible for
the best chance for a favorable final visual outcome. 4 Trauma CME credits.

Editor-In-Chief Nicholas Genes, MD, PhD of Pittsburgh Medical Center, of Emergency Medicine, Vanderbilt Research Editor
Andy Jagoda, MD, FACEP Assistant Professor, Department of Pittsburgh, PA University Medical Center, Nashville, TN
Emergency Medicine, Icahn School Andrea Duca, MD
Professor and Chair, Department of Charles V. Pollack Jr., MA, MD, Stephen H. Thomas, MD, MPH Emergency Medicine Residency,
Emergency Medicine, Icahn School of Medicine at Mount Sinai, New FACEP George Kaiser Family Foundation Università Vita-Salute San Raffaele
of Medicine at Mount Sinai, Medical York, NY Professor and Chair, Department of Professor & Chair, Department of of Milan, Italy
Director, Mount Sinai Hospital, New Michael A. Gibbs, MD, FACEP Emergency Medicine, Pennsylvania Emergency Medicine, University of
York, NY Professor and Chair, Department Hospital, Perelman School of Oklahoma School of Community International Editors
of Emergency Medicine, Carolinas Medicine, University of Pennsylvania, Medicine, Tulsa, OK
Associate Editor-In-Chief Peter Cameron, MD
Medical Center, University of North Philadelphia, PA
David M. Walker, MD, FACEP, FAAP Academic Director, The Alfred
Kaushal Shah, MD, FACEP Carolina School of Medicine, Chapel Michael S. Radeos, MD, MPH Director, Pediatric Emergency Emergency and Trauma Centre,
Associate Professor, Department of Hill, NC Assistant Professor of Emergency Services, Division Chief, Pediatric Monash University, Melbourne,
Emergency Medicine, Icahn School Medicine, Weill Medical College
Steven A. Godwin, MD, FACEP Emergency Medicine, Elmhurst Australia
of Medicine at Mount Sinai, New of Cornell University, New York;
Professor and Chair, Department Hospital Center, New York, NY
York, NY Research Director, Department of Giorgio Carbone, MD
of Emergency Medicine, Assistant
Dean, Simulation Education, Emergency Medicine, New York Ron M. Walls, MD Chief, Department of Emergency
Editorial Board University of Florida COM- Hospital Queens, Flushing, NY Professor and Chair, Department of Medicine Ospedale Gradenigo,
William J. Brady, MD Emergency Medicine, Brigham and Torino, Italy
Jacksonville, Jacksonville, FL Ali S. Raja, MD, MBA, MPH
Professor of Emergency Medicine Women's Hospital, Harvard Medical Amin Antoine Kazzi, MD, FAAEM
and Medicine, Chair, Medical Gregory L. Henry, MD, FACEP Vice-Chair, Emergency Medicine, School, Boston, MA
Massachusetts General Hospital, Associate Professor and Vice Chair,
Emergency Response Committee, Clinical Professor, Department of
Boston, MA Department of Emergency Medicine,
Medical Director, Emergency Emergency Medicine, University Critical Care Editors University of California, Irvine;
Management, University of Virginia of Michigan Medical School; CEO, Robert L. Rogers, MD, FACEP,
William A. Knight IV, MD, FACEP American University, Beirut, Lebanon
Medical Center, Charlottesville, VA Medical Practice Risk Assessment, FAAEM, FACP
Inc., Ann Arbor, MI Associate Professor of Emergency Hugo Peralta, MD
Assistant Professor of Emergency
Calvin A. Brown III, MD Medicine and Neurosurgery, Medical Chair of Emergency Services,
John M. Howell, MD, FACEP Medicine, The University of
Director of Physician Compliance, Director, EM Midlevel Provider Hospital Italiano, Buenos Aires,
Clinical Professor of Emergency Maryland School of Medicine,
Credentialing and Urgent Care Program, Associate Medical Director, Argentina
Medicine, George Washington Baltimore, MD
Services, Department of Emergency Neuroscience ICU, University of
Medicine, Brigham and Women's University, Washington, DC; Director Alfred Sacchetti, MD, FACEP Cincinnati, Cincinnati, OH Dhanadol Rojanasarntikul, MD
Hospital, Boston, MA of Academic Affairs, Best Practices, Assistant Clinical Professor, Attending Physician, Emergency
Inc, Inova Fairfax Hospital, Falls Scott D. Weingart, MD, FCCM Medicine, King Chulalongkorn
Department of Emergency Medicine, Associate Professor of Emergency
Mark Andrew Clark, MD Church, VA Thomas Jefferson University, Memorial Hospital, Thai Red Cross,
Assistant Professor of Emergency Medicine, Director, Division of ED Thailand; Faculty of Medicine,
Shkelzen Hoxhaj, MD, MPH, MBA Philadelphia, PA Critical Care, Icahn School of Medicine
Medicine, Program Director, Chulalongkorn University, Thailand
Chief of Emergency Medicine, Baylor Robert Schiller, MD at Mount Sinai, New York, NY
Emergency Medicine Residency,
College of Medicine, Houston, TX Chair, Department of Family Medicine, Suzanne Y.G. Peeters, MD
Mount Sinai St. Luke's, Mount Sinai
Beth Israel Medical Center; Senior Senior Research Editors Emergency Medicine Residency
Roosevelt, New York, NY Eric Legome, MD
Faculty, Family Medicine and Director, Haga Teaching Hospital,
Chief of Emergency Medicine,
Peter DeBlieux, MD James Damilini, PharmD, BCPS The Hague, The Netherlands
King’s County Hospital; Professor of Community Health, Icahn School of
Professor of Clinical Medicine, Clinical Pharmacist, Emergency
Clinical Emergency Medicine, SUNY Medicine at Mount Sinai, New York, NY
Interim Public Hospital Director Room, St. Joseph’s Hospital and
Downstate College of Medicine, Scott Silvers, MD, FACEP
of Emergency Medicine Services, Medical Center, Phoenix, AZ
Brooklyn, NY Chair, Department of Emergency
Louisiana State University Health Joseph D. Toscano, MD
Science Center, New Orleans, LA Keith A. Marill, MD Medicine, Mayo Clinic, Jacksonville, FL
Chairman, Department of Emergency
Research Faculty, Department of
Corey M. Slovis, MD, FACP, FACEP Medicine, San Ramon Regional
Emergency Medicine, University
Professor and Chair, Department Medical Center, San Ramon, CA
Opening Cases Critical Appraisal Of The Literature
Your shift begins and you pick up your first chart: “eye ir- A literature search was performed using PubMed
ritation.” You talk to the patient and discover that she felt and the Cochrane Database of Systematic Reviews.
the sudden onset of left eye pain and irritation while she Search terms included: ocular trauma, corneal abra-
was applying her eye makeup this morning; she is wor- sion, ocular burn, traumatic iritis, open globe, traumatic
ried she may have scratched her eye with her fingernail. hyphema, retrobulbar hemorrhage, retrobulbar hematoma,
You give the patient's eye a drop of topical anesthetic and lens subluxation, lens dislocation, subconjunctival hemor-
perform a fluorescein examination, which reveals a single rhage, vitreous hemorrhage, retinal detachment, treat-
corneal abrasion. You plan to discharge the patient home ment, diagnosis, trauma, and medicolegal. References
with a prescription for a topical antibiotic and a topical listed in relevant articles were also used, if not previ-
cycloplegic. The patient asks if she can have the bottle of ously identified. The search was limited to articles
topical anesthetic because it was so helpful in relieving in English. The search yielded 2 relevant Cochrane
her pain. You wonder whether this is safe... reviews and 87 relevant PubMed articles
While you are considering this, you are called into the The National Guideline Clearinghouse was also
resuscitation area for a patient involved in a severe motor queried (www.guideline.gov), with 1 relevant article
vehicle crash. The patient was apneic and was intubated noted. Guidelines from the American Academy of
by EMS. The right side of his face is extremely swollen Ophthalmology and from the American College of
and you are unable to examine his right eye, and he is Emergency Physicians were queried; however, there
unable to provide any information about the vision in his were no relevant guidelines.
right eye. His eye seems mildly proptotic, and you wonder Generally speaking, the evidence related to
if you need to be concerned for a retrobulbar hemorrhage. ocular trauma is of intermediate quality. Trials were
Is there anything that can be done at the bedside to evalu- often underpowered and had significant selection
ate for this possibility? Should treatment for retrobulbar bias, making the findings difficult to apply to the
hemorrhage be initiated presumptively in this patient? general population. Studies were also affected by
After your trauma patient is stabilized, you see your poor patient follow-up. Several reasons account
next patient: another eye complaint! This patient was at for these issues. Ocular trauma is relatively rare,
work when an unknown chemical splashed into his left making recruitment into a study and the ability to
eye. He immediately began irrigation, but he continues have an adequately powered study difficult. Poor
to complain of pain and decreased vision in the eye. You follow-up was often an issue because the patient’s
wonder if you should examine the eye first, or initiate symptoms may have resolved, decreasing the likeli-
irrigation of the eye immediately. If the patient feels better, hood of following up and completing the study;
does ophthalmology need to be consulted in the ED? What this was especially true in some studies of corneal
medications should you send home with this patient? abrasion treatment.
In other ocular disease states, no studies were
Introduction identified (eg, in the treatment of iritis). Case reports
have been published, but no quality research has
Ocular injuries can be anxiety-provoking for both otherwise been performed. It appears that the treat-
the patient and the emergency clinician. Eye inju- ment of this entity is based on dogma and tradition.
ries are the leading cause of monocular blindness
in the United States.1-3 They are the most common Etiology And Pathophysiology
cause of noncongenital unilateral blindness in the
pediatric population.4 Ocular trauma can occur as a direct consequence of
Fortunately, most eye injuries are minor and either blunt or penetrating injury. It can also occur
the overwhelming majority are not associated with secondary to a blast injury; this is of particular impor-
significant morbidity.5 Even most ocular burns tend tance in the setting of combat. Blast injury victims are
to be mild and inconsequential in the long term.6 particularly prone to conjunctival laceration, sub-
In patients with mild injury, pain management and conjunctival hemorrhage, vitreous hemorrhage, and,
prevention of secondary infection are the mainstays occasionally, retinal tears and detachments.7
of treatment. Although it is important to discern the mecha-
The polytrauma patient poses a particular clini- nism of injury, it is also important to note that
cal challenge because a proper eye examination may many injuries can be caused by both blunt and pen-
be difficult or impossible. This issue of Emergency etrating trauma. For example, although open-globe
Medicine Practice provides a systematic review of injuries may be thought of as secondary to pen-
best-practice recommendations based on the avail- etrating trauma only, the emergency clinician must
able evidence. be aware that blunt trauma can cause an open-
globe injury. For a basic schematic of the anatomy

Copyright © 2015 EB Medicine. All rights reserved. 2 Reprints: www.ebmedicine.net/empissues

 of the eye, see Figure 1. See Figure 2 for a summary Differential Diagnosis
of many common ocular injuries.
Patients at particular risk for ocular trauma ap- Ocular injuries themselves will not cause mortality,
pear to be those at the extremes of age (ages 5 to 25 but they do have the capacity to cause morbidity.
years and older than 70 years), men, and individuals Table 1 lists possible diagnoses as a result of ocu-
of low socioeconomic status.5 Children aged 5 to 8 lar trauma, grouped according to their ability to
years are at particularly high risk and tend to have threaten the patient’s vision. The majority of ocular
more-serious injuries.5,8 The workplace is a com- injuries have the capacity for permanent vision loss,
mon environment for injury to occur, accounting for although not all vision-threatening injuries will
roughly 20% of all ocular injuries.5,9 A prospective cause permanent visual loss and not all non–vision-
study of 5671 cases of ocular trauma in the United threatening injuries are innocuous.
Kingdom revealed that no form of eye protection
had been worn in 84.6% of cases.8 Most cases of eye
injury are preventable.9 Preventive measures are both Figure 2. A Schematic Of Grossly Visible
extremely important and extremely underutilized. Common Ocular Injuries
From a pathophysiological standpoint, ocular
injuries generally cause direct damage to the injured Abnormal eye move-
ments: always refer Foreign body
structure. This can cause bleeding in various locations
in and around the orbit, lacerations and abrasions, as Distorted pupil:
well as contusions that can damage the iris and ciliary beware pen- Deep laceration of
etrating injury orbit: beware intra-
body.7 In other cases, the damage is indirect, such as Basal tear of iris: orbital penetra-
retrobulbar hemorrhage. Although retrobulbar hem- always refer tion and retained
orrhage involves bleeding, the real damage is due to foreign bodies

optic nerve ischemia. However, the mechanism of this

ischemia has yet to be elucidated.10

Links To Color Images

Hyphema:
always refer
Marginal laceration: Subconjunctival
always refer Epithelial loss: may hemorrhage: if
be missed without it tracks posteri-
To view full-color versions of the images in this issue, scan the QR fluorescein orly, beware orbital
code with a smartphone or go to www.ebmedicine.net/ocular. fracture

Reproduced from The BMJ. Injury to the eye. P.T. Khaw, P. Shah,
Figure 1. Eye Anatomy A.R. Elkington. Volume 328. Copyright 2004 with permission from
BMJ Publishing Group, Ltd.

Cornea
Anterior chamber Table 1. Ocular Trauma Diagnoses
Iris
Ciliary body Posterior chamber
Vision-Threatening Injuries
Lens
• Open globe injury
Vitreous • Retrobulbar hemorrhage
• Ocular burns
Choroid Sclera • Traumatic iritis
Retina Macula • Traumatic hyphema
• Retinal detachment
Optic nerve Vortex vein
• Vitreous hemorrhage
• Posterior vitreous detachment
• Lens dislocation

Reprinted from Critical Care Clinics, Volume 30, Issue 2. Pedro J. Non–Vision-Threatening Injuries
Roque, Nicholas Hatch, Laurel Barr, Teresa S. Wu. Bedside ocular • Corneal abrasion
ultrasound. Pages 227-241. Copyright 2014, with permission from • Subconjunctival hemorrhage
Elsevier. Courtesy of Nicholas Hatch, MD, Denver, CO. • Corneal foreign body

November 2015 • www.ebmedicine.net 3 Mobile app access: www.ebmedicine.net/app

Prehospital Care Emergency Department Evaluation
The overriding goal of prehospital care in the patient History
with ocular trauma is ensuring that the eye does not A detailed history and physical examination should
suffer any further damage during transport to the be obtained in the ocular trauma patient. The only
hospital.2 Perhaps the most important patient group exception to this is in the case of ocular chemical
in which prehospital workers can affect visual out- burn, in which case irrigation is performed prior to
come is in those with ocular chemical burns. Many a detailed history and physical examination. A list of
authors have cited the immediate irrigation of the pertinent historical questions is presented in Table
chemically burned eye as the most important factor 2. If the patient did not receive any irrigation in the
in determining the patient’s final visual acuity.6,11,12 prehospital setting, it should be started immedi-
Chemical and conjunctival erosion is much more ately and continued for 30 minutes. If the patient
common in patients who are not irrigated before was irrigated in the prehospital setting but remains
arrival (86%) than in those who are irrigated before symptomatic, irrigation should be restarted. If the
arrival (24%).13 patient was irrigated in the prehospital setting and
Fluids available to irrigate a chemically burned no longer complains of pain or burning in the eye,
eye include lactated Ringer’s, normal saline, normal the pH can be checked, and if it is neutral, no further
saline adjusted to pH 7.4 with sodium bicarbonate, irrigation is necessary.
balanced saline solution, and tap water. If tap water For all other patients, and for ocular burn pa-
is all that is available, it should be used immedi- tients who have completed irrigation, a specific set
ately.2 A study of 11 patients (12 eyes) found that of questions needs to be addressed. In the patient
balanced saline solution was tolerated the best by with an ocular burn, ask the patient what the offend-
patients, followed by normal saline with sodium ing substance was, if known. In general, alkalis have
bicarbonate, lactated Ringer’s, and finally normal a worse prognosis than acids and cause more ocular
saline; however, there have not been any sizeable tri- damage. An exception to this is hydrofluoric acid,
als to necessarily recommend one fluid over another. which acts like an alkali.2,17
Consideration must also be given to the fact that Determining how the injury occurred and what
balanced saline solution requires reconstitution prior the patient was doing when the injury occurred will
to irrigation and is significantly more expensive than help guide the physical examination.18 The circum-
normal saline and lactated Ringer’s.14 stances surrounding the event should be carefully
There are particular principles that should be questioned. For example, was the patient hammer-
employed to irrigate the eye properly. First, the ing or performing any other metal-on-metal activity?
irrigant should be directed toward the ipsilateral If so, there should be a very thorough examination
temple to avoid splashing into the contralateral eye. for a foreign body, as metal is the most common ocu-
The irrigation should continue for 30 minutes, and lar foreign body.1 It must also be elicited whether the
the pH of the eye should be checked 5 to 10 minutes patient was working with organic or vegetable mate-
later. If the pH is not neutral (7.5-8) at that point, rial at the time of the injury. These particles tend to
irrigation should recommence.2,15 Indirect methods have less momentum and are more likely to embed
of irrigation (eg, with a Morgan Lens) are unlikely to in the anterior globe, and they may not be visible
be performed in the prehospital setting, and will be on CT.19 It should also be considered that strenuous
discussed in the treatment section. physical activity (eg, lifting heavy boxes) can cause a
If particulate matter is seen, it should be re- retinal detachment; in this case, the heavy lifting was
moved with a moistened cotton swab.2 If a penetrat- “traumatic,” although it does not fit the traditional
ing foreign body is noted, it should be left in place
and not removed.2,16 If an open-globe injury is noted
or suspected, the affected eye should be protected Table 2. Pertinent Historical Questions For
without direct pressure on the globe itself. This can Ocular Trauma Patients
be accomplished with a commercial eye shield or a
Styrofoam or plastic cup. Additionally, the head of
• How did the injury occur?
the bed should be elevated to 30°, and pain, vomit- • What are the circumstances surrounding the injury; ie, what was the
ing, agitation, hypertension, and Valsalva maneu- patient doing when the injury occurred?
vers should be controlled, as these can all raise • Was eye protection used?
intraocular pressure. If a traumatic hyphema is seen, • When did the event occur?
open-globe precautions should be observed, as trau- • Is there any history of previous eye surgery?
matic hyphema may be associated with open-globe • What medication(s) is the patient currently taking?
injury.2 • Is there any history of hemoglobinopathy, especially sickle cell
disease?
• Are there any subjective visual complaints?
• For ocular burns: What was the offending substance?

Copyright © 2015 EB Medicine. All rights reserved. 4 Reprints: www.ebmedicine.net/empissues

definition of trauma.20 to consulting ophthalmology if there is deteriora-
The patient should be asked whether eye pro- tion of visual acuity, either initially or over time, as
tection was used.7 This has potential medicolegal it is a sensitive sign of injury.25 If a patient wears
implications and should be recorded in the patient’s contact lenses or glasses, visual acuity should be
history. The patient should be asked when the injury measured with these corrective devices in place. If
occurred, as the timing may help narrow the dif- the patient’s corrective device is not available, visual
ferential diagnosis.15 Traumatic iritis can present acuity without the device should be obtained and
up to 3 days later, whereas retinal detachment may then performed again with a pinhole device; visual
not appear until weeks after the injury.21 Determin- acuity abnormalities due to a refractive error should
ing whether the patient has had an eye surgery in improve with a pinhole device.26 If it is not feasible
the past is important, as it has been noted that, for to obtain a formal visual acuity measurement, a
elderly patients after a fall, the rupture of wounds rough estimate of the patient’s visual acuity should
from prior surgery is a significant source of open- be obtained. For example, ask if the patient can
globe injury.3 count fingers, see a hand waving, or perceive light.
Finally, an accurate list of the patient’s current It is important to note that normal visual acuity does
medications and whether the patient has a history not exclude serious injury.18
of any hemoglobinopathies should be obtained.22 The pupil should be examined, specifically look-
Anticoagulated patients are more likely to bleed and ing at the shape, symmetry, red reflex, and reaction
may suffer traumatic hyphema, retrobulbar hemor- to light. An irregularly shaped pupil may indicate
rhage, subconjunctival hemorrhage, and vitreous globe rupture, as seen in Figure 3. Extraocular
hemorrhage more easily than nonanticoagulated movements should be examined to ensure that the
patients. Patients with sickle cell disease should not eyes can move freely in all directions. The anterior
be given carbonic anhydrase inhibitors (a common chamber should be examined for the presence of
component in the treatment of hyphema) because blood, which indicates a traumatic hyphema. (See
they increase the tendency of the red blood cells Figure 4.)
to sickle in the anterior chamber.15,23 The patient A fluorescein examination should also be per-
should also be asked if they are subjectively having formed to identify both corneal abrasions as well
any visual problems, such as decreased visual acuity, as a possible ruptured globe via the Seidel test. The
or whether they are seeing any floaters. Seidel test involves instilling a large amount of
fluorescein and examining the eye for a dark stream
Physical Examination interrupting the fluorescein, an indication of globe
The eye examination begins with a general observa- rupture.17 Corneal abrasions are identified by uptake
tion, looking for evidence of trauma, deformity, or of fluorescein. If vertical or multiple linear abra-
asymmetry. Visual acuity should be obtained and sions are noted during the fluorescein examination,
recorded on all patients.7,18 It should be documented the eyelid should be everted to search for foreign
both initially as well as periodically throughout the bodies that may be trapped under the eyelid, caus-
patient’s time in the ED, as deterioration may occur ing repeated abrasions. Multiple linear abrasions
over time. Strong consideration should be given

Figure 4. Traumatic Hyphema

Figure 3. Irregularly Shaped Pupil
Secondary To Globe Rupture

Edward K. Sung, Rohini N. Nadgir, Adkifumi Fujita, et al. RadioGraph-

ics. Injuries of the globe: what can the radiologist offer? Volume 34,
pages 764-776. Copyright 2014, with permission from the Radiology Robert Scott. The injured eye. Philosophical Transactions B. 2011,
Society of North America. Volume 366, Issue 1562. By permission of the Royal Society.

November 2015 • www.ebmedicine.net 5 Mobile app access: www.ebmedicine.net/app

identified on fluorescein examination are depicted in or ongoing changes in vision. There may also be
Figure 5. significant swelling around the orbit, making evalu-
Fundoscopy and a portable slit-lamp examina- ation of the orbit difficult or impossible.
tion can be performed to examine the retina, look- Vision-threatening injuries should be considered
ing for foreign bodies, and cells and flare seen in at the end of the primary examination. Although
traumatic iritis. The eye should be grossly inspected orbital injuries tend not to affect mortality, they can
for any evidence of proptosis, which may indicate have a profound impact on the patient’s quality of life
an underlying retrobulbar hemorrhage (as seen in and treatment of some injuries is time-sensitive.28
Figure 6). Finally, intraocular pressure should be In general, a brisk reaction to direct and con-
obtained via tonometry or by palpation of the globes sensual light stimuli in a round, concentric pupil
if tonometry is not available. is reliable in excluding a vision-threatening injury
There are some caveats to physical examina- requiring immediate intervention.28 However, if you
tion maneuvers. First, the physical examination are unable to examine the pupil or if the pupil is
of the patient should be tailored to that patient’s abnormal, the possibility of vision-threatening injury
specific complaint, and not all elements need to be needs to be explored further. One option is to obtain
performed on all patients. Also, if an open-globe an orbital CT, although the patient must be stable
injury is suspected or diagnosed, no pressure should enough to leave the ED. Another option is a bedside
be placed on the orbit, meaning that tonometry or ocular ultrasound, which will be discussed in detail
palpation of the orbit should not be performed.16,17 in the ”Diagnostic Studies” section, page 7.
If rupture is obvious, no further examination of the
eye needs to be performed.1 Finally, a high index of Proptosis And Retrobulbar Hemorrhage
suspicion must be maintained for open-globe injury, Although retrobulbar hemorrhage is the most com-
as it may not be obvious. The defect may seal itself mon cause of traumatic proptosis, other causes
off, making the diagnosis on physical examination include bony displacement into the orbit (blow-in
problematic.3 In this case, the Seidel test will be fracture) or swelling of the retrobulbar contents.28,29
negative, so emergency clinicians must be particu- Differentiating between these 3 causes of proptosis is
larly vigilant.27 critical because retrobulbar hemorrhage is the only
one of the causes of proptosis that can potentially
The Multiply Injured Patient benefit from a lateral canthotomy. (See the Clinical
The multiply injured trauma patient poses particular Pathway For Management Of Retrobulbar Hemor-
challenges. There may be life-threatening injuries rhage, page 14.)
present that preclude an assessment of the patient’s There are different ways to distinguish between
eyes. The patient may be obtunded and unable to the causes of proptosis. If the patient is able to
answer questions regarding his or her vision, pain, communicate, a decrease in visual acuity would be
worrisome and point toward a diagnosis of retrobul-
bar hemorrhage.29,30 The same is true of an afferent
Figure 5. Corneal Abrasion With Multiple
Linear Abrasions
Figure 6. Proptotic Eye Secondary To
Retrobulbar Hemorrhage

Reprinted from Journal of Emergency Medicine, Volume 22, Issue 3.

Reprinted from Disease-a-Month, Volume 60, Issue 6. Hercules D. Susi Vassallo, Morris Hartstein, David Howard, Jessica Stetz. Trau-
Logothetis, Scott M. Leikin, Thomas Patrianakos. Management of matic retrobulbar hemorrhage: emergent decompression by lateral
anterior segment trauma. Pages 247-253. Copyright 2014, with canthotomy and cantholysis. Pages 251-256. Copyright 2002, with
permission from Elsevier. permission from Elsevier.

Copyright © 2015 EB Medicine. All rights reserved. 6 Reprints: www.ebmedicine.net/empissues

pupillary defect, which can be obtained in a nonre- and is also very accurate.17,34 One prospective ob-
sponsive patient.29,30 Other cardinal signs of retro- servational study of 61 patients with ocular trauma
bulbar hemorrhage are worsening proptosis, pain, showed 100% sensitivity and 97.2% specificity when
and papilledema. Serial examinations are required to compared with CT, with minimal training of the
monitor for any of these changes. Measuring intra- emergency physician.34 A normal ultrasound of
ocular pressure may be helpful; intraocular pressure an uninjured orbit can be seen in Figure 8. Figure
> 40 mm Hg in a proptosed eye indicates that urgent 9 (page 8) is an ocular ultrasound of retrobulbar
treatment is required.29 hemorrhage, and Figure 10 (page 8) is an ultrasound
From an imaging standpoint, beside ultrasound showing retinal detachment.
or orbital computed tomography (CT) can diagnose
retrobulbar hemorrhage.28,29 In any case, imaging
should not delay treatment if the diagnosis has been
Figure 7. Computed Tomography Image
made clinically.
Showing Glass Intraocular Foreign Body
Diagnostic Studies
In many cases of ocular trauma, the diagnosis will
be made after a detailed history and physical exami-
nation are performed, and specific diagnostic testing
will be unnecessary.

Laboratory Studies
Laboratory studies have limited utility in the patient
with ocular trauma. In coagulopathic patients or
patients unable to provide a reliable history, obtain
prothrombin time (PT) and partial thromboplastin
(PTT) time. If a black patient presents with a trau-
matic hyphema, inquire about or screen for sickle
cell disease or sickle cell trait, as patients with these Reprinted from Ophthalmology, Volume 106, Issue 22. Adalbert
conditions have a higher incidence of secondary Lakits, Rupert Prokesch, Christoph Scholda, Alexander Bankler. Or-
hemorrhage.31 bital helical computed tomography in the diagnosis and management
of eye trauma. Copyright 1999, with permission from Elsevier.

Computed Tomography And Magnetic

Resonance Imaging Figure 8. Normal Ocular Ultrasound
CT of the orbit is the modality of choice for traumat-
ic globe injury in the ED.32 Helical CT is often recom-
mended over conventional CT because it is quicker
and has less radiation exposure.33 Figure 7 shows a
CT of an eye with a glass intraocular foreign body.
Although CT is often considered the gold
standard, it has limitations. First, vegetable foreign
bodies can be missed on CT. If a vegetable foreign
body is suspected but not identified on CT, surgical
exploration may be indicated.33 Magnetic resonance
imaging is also an option in this situation (assuming
a metallic foreign body has been excluded).19 Finally,
although CT has been found to be 100% sensitive for
foreign bodies larger than 0.06 mm³, it is only 65%
sensitive for foreign bodies smaller than this.19

Ultrasound
Bedside ocular ultrasound is easily accessible,
inexpensive, well-tolerated, and does not require
patients to leave the ED.29 It is particularly useful in
blunt trauma when there may be too much soft-
Reprinted from Critical Care Clinics, Volume 30, Issue 2. Pedro J.
tissue swelling to retract the eyelids and examine
Roque, Nicholas Hatch, Laurel Barr, Teresa S. Wu. Bedside ocular
the orbit properly.34 It can be performed quickly, ultrasound. Pages 227-241. Copyright 2014, with permission from
typically in 60 to 90 seconds even in difficult cases, Elsevier.

November 2015 • www.ebmedicine.net 7 Mobile app access: www.ebmedicine.net/app

 If bedside ocular ultrasound is undertaken, it is Treatment
recommended to a use a 7.5 to 10 MHz linear ar-
ray transducer, and the orbit should be scanned in Corneal Abrasion
both the long and short axes.35 A large amount of gel Traditional treatment of corneal abrasion includes
should be used over a closed eyelid; sterile gel is not some combination of topical antibiotics, cyclople-
necessary.36 If globe rupture is a concern, ocular ultra- gics, pain management, and eye patching. These
sound is still safe, given the large amount of gel that presentations also provide an opportunity to ensure
is used, although there are some who feel ultrasound that a patient's immunization status is up to date.
usage is contraindicated in these patients.1,35,37
The indicator on the ultrasound probe should be Patching
oriented either towards the patient’s head or the pa- Many studies have concluded that patching may be
tient’s right side. The gain may need to be increased harmful because it decreases the rate of healing and
during the examination to diagnose more-subtle
findings. If the patient is cooperative, it may be help-
ful to have them look in different directions so that
no pathology is missed.36 Table 3 lists conditions Figure 10. Ocular Ultrasound Of Retinal
that may be diagnosed by ocular ultrasound, and Detachment
their associated ultrasound findings.
When using ultrasound to identify possible
foreign bodies, a false positive may be obtained
if there is intraorbital air, as it may mimic a solid
foreign body.19 The patient should be examined
while upright, although this may not be possible
for trauma patients.36

Figure 9. Ocular Ultrasound Of Retrobulbar

Hemorrhage
Reprinted from Critical Care Clinics, Volume 30, Issue 2. Pedro J.
Roque, Nicholas Hatch, Laurel Barr, Teresa S. Wu. Bedside ocular
ultrasound. Pages 227-241. Copyright 2014, with permission from
Elsevier. Courtesy of Nicholas Hatch, MD, Denver, CO.

Table 3. Conditions Diagnosable By

Ultrasound And Their Characteristic
Findings
Condition Ultrasound Finding
Vitreous hemorrhage • String-like echogenicities throughout the
vitreous
Retrobulbar • Hypoechoic fluid behind the globe (see
hemorrhage Figure 9)
• The posterior globe may have a conical
deformation that resolves after lateral
canthotomy38
Lens dislocation • Lens will be seen in an abnormal location
in the globe
Intraocular foreign • Not always visible, but if seen, will be
body distinct echogenic area in or around the
globe
Retinal detachment • Thick, irregular band seen at the area
of detachment in the globe (see Figure
10)40
Globe rupture • Loss of intraocular volume with a dis-
torted size and shape of the globe36
Reprinted from Critical Care Clinics, Volume 30, Issue 2. Pedro J.
Posterior vitreous • Thin, smooth membrane that may remain
Roque, Nicholas Hatch, Laurel Barr, Teresa S. Wu. Bedside ocular
detachment attached to the retina. High gain is
ultrasound. Pages 227-241. Copyright 2014, with permission from
required39
Elsevier. Courtesy of Nicholas Hatch, MD, Denver, CO.

Copyright © 2015 EB Medicine. All rights reserved. 8 Reprints: www.ebmedicine.net/empissues

decreases binocular vision.40-42 A Cochrane review Topical Antibiotics
of randomized and quasi-randomized studies on One study examined the outcomes of 94 patients
the effects of patching in the treatment of corneal with corneal abrasions after removal of a corneal
abrasion analyzed 11 trials dating from 2007 and foreign body and found that there was no difference
prior. No trial found that patching had a favorable in healing in those who received antibiotics and
outcome on pain management. Seven trials with those who did not; however, this study was limited
dichotomous healing outcomes found more favor- by size and had indeterminate power.53 A review
able healing in the nonpatched groups on day 1, al- article from 2013 admits that the evidence to sup-
though there was no significant difference in healing port the use of topical antibiotics in uncomplicated
on days 2 and 3. Their final recommendation was corneal abrasions is lacking, but they recommended
against the application of an eye patch in the treat- that antibiotics should be given if the patient wears
ment of simple corneal abrasions.43 contact lenses, had a foreign body, or had a his-
Although the general recommendation goes tory of trauma with infectious or vegetable matter,
against patching in the treatment of corneal abra- because of the risk of bacterial keratitis.54 Because
sion, it may be useful “as a protective barrier for of a lack of concrete evidence to suggest otherwise,
patients who might continue to rub their eyes (eg, erythromycin ophthalmic ointment should be used
children or persons with cognitive disabilities).”44 4 times per day for 3 days to treat uncomplicated
Some ophthalmologists also still recommend patch- corneal abrasions.
ing for corneal abrasions larger than 10 mm, and the Patients who wear contact lenses require a
Cochrane review admits that more research is need- topical antibiotic with antipseudomonal coverage,
ed regarding patching large corneal abrasions.43,44 typically a fluoroquinolone.15 Contact lens wearers
should be evaluated every day until their abrasion
Topical Nonsteroidal Anti-Inflammatory Drugs has healed. Additionally, if contact lens wearers or
Corneal abrasions can be extremely painful, and any other patients have developed a corneal ulcer,
patching has not been shown to decrease pain. How- they must be evaluated urgently, as these ulcers
ever, topical nonsteroidal anti-inflammatory drugs may cause permanent damage.54 If urgent evalua-
(NSAIDs) have been studied extensively and have tion by an ophthalmologist cannot be guaranteed,
been found helpful in decreasing pain in the first 24 then ophthalmology should be consulted in the ED,
hours without adverse effects on healing of the abra- or the patient should be admitted for ophthalmol-
sion. They also appear to decrease the necessity of ogy evaluation.
oral pain medication in these patients. No significant
adverse effects were reported when used as pre- Topical Cycloplegics
scribed.44-46 A summary of studies on NSAID use for The use of cycloplegics to control pain in corneal
corneal abrasions is presented in Table 4. abrasion is also in need of further research, as only

Table 4. Trials Examining The Use Of Topical NSAIDs To Treat Corneal Abrasion Pain
Study Outcome
Topical ketorolac; prospective single-center randomized placebo-con- Statistically significant pain reduction and fewer subjective complaints
trolled double-blind trial of 100 patients47 (photophobia, foreign body sensation) on day 1 but not on day 2.
Topical ketorolac; prospective single-center randomized placebo-con- No statistically significant difference in pain or healing, but the ketorolac
trolled double-blind trial of 88 patients45 group required significantly less additional oral analgesics (P = .001).
Topical diclofenac; prospective randomized placebo-controlled double- Statistically significant improvement of pain at 2 hours; patients receiv-
blind trial of 49 of patients48 ing diclofenac were 50% as likely to take oxycodone-acetaminophen,
although this was not statistically significant.
Topical indomethacin; prospective randomized double-blind trial of 123 Pain relief from day 0 to day 4 or 5 was significantly better in the indo-
patients49 methacin group (P = .015).
Topical indomethacin; randomized controlled trial of 347 patients50 Pain was decreased at 30 minutes, 12 hours, and 24 hours in the indo-
methacin group (P < .001).
Flurbiprofen; randomized controlled trial; 401 patients divided into 4 The 2 groups that received flurbiprofen had significantly less pain at 24
groups (control; homatropine only; flurbiprofen only; both homatropine hours (P < .05).
and flurbiprofen)51
Topical NSAIDs; meta-analysis of 11 randomized controlled trials of 459 There was no restriction in the type of NSAID used in this study. Topical
patients44 NSAIDs were found to reduce self-reported pain.
Topical NSAIDs; comparative study of 5 trials52 Topical NSAIDs improved pain and other subjective symptoms better
than placebo, and likely decrease the need for oral analgesics.

Abbreviation: NSAIDs, nonsteroidal anti-inflammatory drugs.

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1 study was found that examined this question. It treatment of traumatic hyphema. It has been gener-
showed no benefit to the use of cycloplegics, but ally accepted that antifibrinolytics decrease the rate
more research is necessary before a definitive recom- of rebleeding, but whether this has an effect on the
mendation can be made.55 patient’s final visual acuity is questionable.22,56 One
study of 215 pediatric patients found no significant
Summary difference in rebleeding rates between groups given
The patient with a corneal abrasion should be treat- oral tranexamic acid versus placebo (P = .60).59
ed with topical NSAIDs, with or without oral anal- A common problem with systemic antifibrinol-
gesics, and topical antibiotics. The patient should not ytics is that they have many adverse effects, includ-
have the affected eye patched, and should probably ing nausea, vomiting, dizziness, and syncope. These
not be given a topical cycloplegic. A non–contact adverse effects can render the drug difficult or im-
lens wearer can be prescribed erythromycin ophthal- possible to use, particularly in the outpatient setting.
mic ointment to use 4 times per day for 3 to 5 days; Oral aminocaproic acid is also very expensive, often
contact lens wearers can be given levofloxacin 0.5% more than $500 for 30 tablets (www.goodrx.com),
solution to be used (1-2 drops) every 2 hours, while which may be cost-prohibitive for many patients.
awake, for 2 days then every 4 to 8 hours for 5 days. Topical aminocaproic acid is an alternative to
oral aminocaproic acid. One randomized controlled
Traumatic Hyphema trial of topical aminocaproic acid versus placebo
The management of traumatic hyphema is also gel showed favorable trends towards decreasing
controversial with regard to both treatment and rebleeding and improving vision, but neither was
whether these patients require admission. It has statistically significant, secondary to small sample
been traditionally recommended that all patients size.60 Although more research is required, topical
with traumatic hyphema be admitted to the hospital aminocaproic acid appears to be a promising tool in
and placed on strict bed rest, with the eye patched.22 the management of traumatic hyphema, as it avoids
The goal of treating hyphema is to prevent the adverse effects of the systemic antifibrinolytics.
secondary hemorrhage (also called rebleeding). A particular problem in the studies of topical
Rebleeding occurs in roughly 22% of cases and may and systemic antifibrinolytics is the patient popula-
result in permanent vision loss secondary to glau- tion that is studied. In many cases, the patients were
coma, optic nerve damage, and corneal blood-stain- predominantly white. Because sickle cell disease is
ing.22,56 Topical miotics and cycloplegics have not rare in this population, this may skew the results
been found to have a significant effect in preventing and render them inapplicable to the general popula-
rebleeding, although they have been traditionally tion. For example, a study of 238 patients did show
used.22,57 Eye patching may afford the patient with that oral tranexamic acid decreased rebleeding, but
traumatic hyphema some benefit, according to all of the patients in the study were white.61 How-
some studies. One review article found patching to ever, the Cochrane review did find that systemic
increase the patient’s comfort and prevent re-injury, aminocaproic acid, topical aminocaproic acid, and
and advocates for its use in both the inpatient and tranexamic acid all reduced the rate of rebleeding,
outpatient settings.22 However, the Cochrane review although it did not advocate for one particular treat-
of traumatic hyphema found no benefit to patching ment over another.57
in terms of rates of rebleeding.57 So, while patching
may decrease subjective patient complaints, it does Summary
not necessarily have medical benefit. Antifibrinolytics may reduce rebleeding, and all oth-
er therapies have not been found to be helpful.57 Sys-
Corticosteroids temic aminocaproic acid has many adverse effects
Topical or systemic corticosteroid use is another area of and is very expensive, so this must be taken into
controversy, and review articles provide conflicting rec- consideration. Ophthalmology should be consulted
ommendations regarding their use to prevent rebleed- for all cases of traumatic hyphema, and further treat-
ing.22,56 A randomized controlled trial of 43 patients ment decisions should be made in conjunction with
found no difference in rebleeding or final visual acuity the treating ophthalmologist.
in patients receiving oral prednisone versus placebo.58
The aforementioned Cochrane review did not find any Ocular Chemical Burns
benefit to the use of corticosteroids in reducing the rate Copious irrigation is the mainstay of treatment of
of rebleeding; however, it notes that the studies exam- ocular chemical burns. The offending compound
ining this particular question are small.57 should never be neutralized.15,62 If irrigation is
necessary in the ED, several options are available.
Antifibrinolytics The best option is the use of a Morgan Lens. To use
Antifibrinolytics, specifically aminocaproic acid the Morgan Lens, the eye is anesthetized and the
and tranexamic acid, are also commonly used in the lens is placed first under the upper eyelid, then the

Copyright © 2015 EB Medicine. All rights reserved. 10 Reprints: www.ebmedicine.net/empissues

lower eyelid. Fluid runs through the lens and then studied in depth in rabbits, and have proven to be
out of the patient’s eye. It should not be used if it is beneficial; however, data regarding their efficacy in
suspected that a foreign body is present.62 Another humans are lacking.11,64 Topical dexamethasone was
option for direct irrigation is intravenous tubing, studied in rabbits with alkali burns and results sug-
wherein one person holds the patient’s eye open and gested that its administration may help endothelial
another allows the fluid to run out of the intrave- healing; however, a review of human patients did
nous tubing directly onto the patient’s eye.62 The not support this.65,66 The decision to use any of these
patient should be irrigated with at least 2 liters of medications should be made in conjunction with the
normal saline, lactated Ringer’s, balanced salt solu- treating ophthalmologist.15
tion, or water.16 Five to 10 minutes after irrigation, In summary, for ocular burns in the ED, the eye
the pH of the eye should be tested and irrigation should be thoroughly irrigated, a topical antibiotic
should continue if the pH is not neutral. The length should be applied, and all other medications given
of time of irrigation, the solution used, the pH of the should be at the discretion of the treating ophthal-
eye, and the number of times the pH of the eye was mologist. The patient should receive a tetanus im-
tested should all be recorded.63 munization as necessary.17
Once irrigation is complete, the severity of the
burn should be assessed, as this will affect manage- Retrobulbar Hemorrhage
ment and disposition of the patient. The Roper- Retrobulbar hemorrhage is a serious, vision-threat-
Hall classification system is commonly used and is ening injury and must be treated expeditiously. Once
presented in Table 5.15 A photograph of a Roper-Hall ischemia to the optic nerve begins, permanent vision
grade IV injury is seen in Figure 11.15 loss can occur within 60 to 120 minutes.1,17 Treat-
Traditional treatment for grades I and II ocular ment of retrobulbar hemorrhage can be both surgical
burns has included topical antibiotics and artificial and medical. Although most emergency clinicians
tears, whereas grades III and IV were treated with are aware of the lateral canthotomy to surgically
topical steroids, ascorbate, citrate drops, and hospi- treat retrobulbar hemorrhage, a survey of emergency
tal admission.16 Both ascorbate and citrate have been clinicians indicated that most of them did not know
proper medical management of this condition.30 The
emergency clinician has several options, depending
Figure 11. Roper-Hall Grade IV Ocular Burn on the severity of the patient’s symptoms and physi-
cal examination findings.
Ideally, ophthalmology is consulted emergently
and the treating ophthalmologist can manage the
retrobulbar hemorrhage, but this is not always avail-
able in a timely manner. If it is not, the emergency
physician must be prepared to manage the patient’s
retrobulbar hemorrhage.10 If the clinical diagnosis
is obvious and not in question, a lateral canthotomy
with inferior cantholysis should be performed.24
Permanent visual damage is unlikely if decom-
pression is performed within 2 hours of symptom
onset.24 Figure 12 (see page 13) contains a QR code
and URL link to a video demonstration of a lateral
canthotomy procedure. The lateral canthus should
be anesthetized with lidocaine with epinephrine,
Reprinted from Disease-a-Month, Volume 60, Issue 6. Hercules D. then a tissue clamp is placed horizontally across the
Logothetis, Scott M. Leikin, Thomas Patrianakos. Management of lateral canthus for 1 to 2 minutes. The clamp is then
anterior segment trauma. Pages 247-253. Copyright 2014, with removed and sterile scissors are used to incise the
permission from Elsevier.

Table 5. The Roper-Hall Classification System

Grade Prognosis Corneal Condition Conjunctival Limbus
I Good Corneal epithelial damage No limbal ischemia
II Good Corneal haze and iris details visible < 1/3 limbal ischemia
III Guarded Total epithelial loss, stromal haze, and iris details obscured 1
/3 to ½ limbal ischemia
IV Poor Cornea opaque and iris and pupil obscured > ½ limbal ischemia

Reprinted from Disease-a-Month, Volume 60, Issue 6. Hercules D. Logothetis, Scott M. Leikin, Thomas Patrianakos. Management of anterior segment
trauma. Pages 247-253. Copyright 2014, with permission from Elsevier.

November 2015 • www.ebmedicine.net 11 Mobile app access: www.ebmedicine.net/app

 Clinical Pathway
ClinicalFor Emergency
Pathway Department Of
For Management Management Of Multiple
Ocular Trauma
Shocks

YES Concern for ocular burn?

NO

• Irrigate until neutral pH (Class I)

• Consult ophthalmology urgently (Class II)

Is the patient’s vision

YES NO
at baseline?

• If fluorescein uptake on slit lamp

• Treat with medical man- YES Clinical diagnosis of retrobulbar hemorrhage?
examination: corneal abrasion or
agement and/or surgical
radiation injury
management (Class II)
• If cells and flare on slit-lamp exami-
• Consult ophthalmology NO
nation: traumatic iritis
(Class II)
• If blood in anterior chamber: hy-
phema
• If subconjunctival blood: subconjunc- Positive Seidel test or other signs/symptoms sug-
tival hemorrhage Open globe injury gestive of open globe injury?
YES
• If corneal foreign body seen, remove • Place rigid metal shield
and then re-examine eye for corneal (Class III) NO
abrasion (Class II) • Update tetanus vaccina-
• Obtain orbital imaging, if possible tion as needed (Class II)
• Obtain orbital imaging, if
possible Blood in anterior chamber?
• Consult ophthalmology
emergently (Class II)
YES NO

Traumatic hyphema;
consult ophthalmology emergently
(Class III)

• Obtain ocular ultrasound or CT to evaluate for Consult

Was a vitreous hemorrhage, retinal
vitreous hemorrhage, lens dislocation, retinal NO YES ophthalmology
detachment, or lens dislocation seen
detachment, retrobulbar hemorrhage (Class II) emergently
on physical examination?
• Consult ophthalmology emergently (Class II) (Class II)

See class of evidence definitions, page 13.

Copyright © 2015 EB Medicine. All rights reserved. 12 Reprints: www.ebmedicine.net/empissues

skin, making an approximately 1-cm incision.10,24 Radiation Damage
Once the lateral canthotomy is performed, inferior Radiation damage can result from welding, snow
cantholysis with incision of the inferior crus should blindness, direct viewing of the sun, and tanning
be performed.10 beds.18,54 The treatment of radiation damage is iden-
Medical management is another branch in the tical to the treatment of corneal abrasion.18,54,68
treatment of retrobulbar hemorrhage. Some authors
recommend that any patient receiving a lateral canthot- Traumatic Iritis
omy should also be provided with medical manage- Most commonly, traumatic iritis presents following
ment, including intravenous corticosteroids, mannitol, blunt trauma. The patient will generally complain
and acetazolamide.24 Lateral canthotomy should never of pain, decreased vision, tearing, and photophobia.
be delayed while awaiting medical management. The typical finding on slit-lamp examination in these
In the case in which the symptoms are equivo- patients is cells and flare in the anterior chamber;
cal and definitive testing is not possible (for what- other findings include decreased vision and conjunc-
ever reason), medical management with mannitol, tival injection around the limbus.15
corticosteroids, and acetazolamide should be Traumatic iritis has surprisingly little mention in
provided; surgical decompression should be per- the ocular trauma literature, and no relevant, quality
formed if symptoms do not improve with medical clinical trials regarding its management in the ED
management alone. Recommended dosages for were found. The traditional treatment for traumatic
these medications (all given intravenously) are: 20% iritis has been topical cycloplegics and close ophthal-
mannitol, 2 g/kg; methylprednisolone, 250 mg or mology follow-up (cyclopentolate 2%, 3 times per
hydrocortisone, 100 mg; and acetazolamide, 250 day until ophthalmology follow-up).7,15
to 500 mg.24,30,66 Care must be used if the patient is
hypotensive, as mannitol and acetazolamide may Retinal Detachment, Posterior Vitreous
worsen hypotension.28,29 Detachment, Vitreous Hemorrhage, And
Lens Dislocation
Open-Globe Injuries Retinal detachment, posterior vitreous detachment,
Open-globe injuries are vision-threatening and vitreous hemorrhage, and lens dislocation may have
require immediate ophthalmology consultation. similar features, making them difficult to distinguish
One of the most important aspects of treatment is to
prevent further injury. The head of the bed should be
placed at 30°, a rigid metal shield should be applied,
Figure 12. Link To Video Of Lateral
and analgesics and antiemetics should be given to
Canthotomy Procedure
control pain and nausea/vomiting.1 Tetanus prophy-
laxis should be provided as needed.1,3
Antibiotics are generally recommended for
prophylaxis against posttraumatic endophthalmitis,
despite the absence of strong evidence for benefit.
Treatment regimens vary; we recommend ceftazi-
dime 1 g every 8 hours and vancomycin 1 g every
12 hours, both for 48 hours, in addition to topical
antibiotics. To view a video of a lateral canthotomy, scan the QR code with a
smartphone or go to: http://www.eyerounds.org/tutorials/lateral-
canthotomy-cantholysis.htm

Class Of Evidence Definitions

Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.
Class I Class II Class III Indeterminate
• Always acceptable, safe • Safe, acceptable • May be acceptable • Continuing area of research
• Definitely useful • Probably useful • Possibly useful • No recommendations until further
• Proven in both efficacy and effectiveness • Considered optional or alternative treat- research
Level of Evidence: ments
Level of Evidence: • Generally higher levels of evidence Level of Evidence:
• One or more large prospective studies • Nonrandomized or retrospective studies: Level of Evidence: • Evidence not available
are present (with rare exceptions) historic, cohort, or case control studies • Generally lower or intermediate levels • Higher studies in progress
• High-quality meta-analyses • Less robust randomized controlled trials of evidence • Results inconsistent, contradictory
• Study results consistently positive and • Results consistently positive • Case series, animal studies, • Results not compelling
compelling consensus panels
• Occasionally positive results

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2015 EB Medicine. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of EB Medicine.

November 2015 • www.ebmedicine.net 13 Mobile app access: www.ebmedicine.net/app

 Clinical
Clinical Pathway
Pathway For Management
For Emergency Of Retrobulbar
Department ManagementHemorrhage
Of Multiple
Shocks

Patient presents with suspected

retrobulbar hemorrhage

NO Can orbit be examined? YES

• Perform bedside ocular Does the patient have any of the

following signs? NO Is visual acuity normal?
ultrasound or CT
• Signs of retrobulbar • Orbital pain
hemorrhage? • Proptosis
• Ophthalmoplagia YES
• Loss of red light reflex
NO YES • Tense, hard globe
• Loss of direct light reflex

YES NO
Consider alternate Consider alternate
diagnosis diagnosis

Diagnosis of retrobulbar hemorrhage

Begin immediate surgical management:

• Perform lateral canthotomy and inferior cantholysis
Begin medical management (should not delay surgery)
• Remove sutures, if present

Timolol eye drops Intravenous drugs Perform definitive surgical treatment

• 20% mannitol, 2 g/kg

• Hydrocortisone 100
mg
• Acetazolamide, 500
mg

Adapted from The Journal of Oral and Maxillofacial Surgery, Volume 65, Issue 2. J.V. Winterton, K. Patel, K.D. Mizen. Review of management options
for a retrobulbar hemorrhage. Copyright 2007, with permission from Elsevier.

Copyright © 2015 EB Medicine. All rights reserved. 14 Reprints: www.ebmedicine.net/empissues

on clinical grounds. Retinal detachment, posterior 12 months, as their use has not been approved in
vitreous detachment, and vitreous hemorrhage can this population.76
all cause the patient to see floaters or flashes of light,
and can cause blurred vision or visual loss.37,69 Lens Patients With Sickle Cell Disease And
dislocation can cause pain, blurred or double vision, Coagulopathies
and photosensitivity.37 The treatment of traumatic hyphema differs in
Patients with complaints suspicious for any patients with sickle cell disease versus the general
of these diagnoses should have a thorough ocular population. Carbonic anhydrase inhibitors, frequent-
examination performed. As mentioned previously, ly used in the management of traumatic hyphema,
advanced imaging (such as ultrasound) can help should be avoided in patients with sickle cell
distinguish these entities. Although no particular in- disease, as they increase the chance of the red blood
tervention needs to be performed by the emergency cells sickling in the anterior chamber.15,23 Meth-
clinician, ophthalmology should be consulted emer- azolamide can be used in these patients in place of
gently if any of these diagnoses are suspected.1,70,71 carbonic anhydrase inhibitors.1
Patients with coagulopathies are more prone
Subconjunctival Hemorrhage to bleeding and therefore have an increased risk of
Subconjunctival hemorrhage will present with a traumatic hyphema and retrobulbar hemorrhage.
well-defined bright-red area on the sclera. Gener- As with any coagulopathic patient with unwanted
ally, the patient is otherwise asymptomatic and bleeding, consideration must be given to whether
has, at most, mild pain and no visual defects. This reversal of the coagulopathy is warranted. There
injury is not vision-threatening, and will resolve are specific recommendations to reverse vitamin K
on its own without any intervention.72 Irritation antagonists in the case of retrobulbar hemorrhage.77
may be reduced by the use of artificial tears and No specific recommendations have been made re-
warm compresses.68,72 garding reversal of other agents in the case of retro-
bulbar hemorrhage, or at all in the case of traumatic
Corneal Foreign Body hyphema. These decisions are probably best made in
If a corneal foreign body is identified, it should be conjunction with the treating ophthalmologist.
removed, as long as it is not penetrating. Removal
should be first attempted with irrigation. If this Controversies And Cutting Edge
is unsuccessful, a moistened cotton swab can be
used.1,18,62 If this is still unsuccessful, a 25-gauge nee- Topical Anesthetics For Corneal Abrasion
dle can be used, but an experienced clinician should The use of topical anesthetics, long regarded as
perform this.54,62 If a rust ring is present, it should be dangerous and playing no role in the outpatient
removed within 24 hours, but it does not necessarily management of patients with corneal abrasion, has
need to be removed by the emergency clinician.62 been called into question. Studies of topical anes-
thetics have yielded conflicting results. It appears
Special Populations that usage of topical anesthetics for < 48 hours is
probably not harmful, but may not actually improve
Pediatric Patients pain control.78,79 Prolonged use of topical anesthetics
Pediatric patients with ocular injuries can be par- can be harmful and has the potential to cause blind-
ticularly challenging, and a high index of suspi- ness.80 Given the conflicting data regarding topical
cion must be maintained in this population so that anesthetics, more research is necessary before most
injuries are not missed. One issue is the difficulty practitioners will feel comfortable prescribing them
of obtaining an accurate history from the pediatric for their patients.
patient.18 Also, children frequently downplay the
mechanism of action of their injury, which may lead Hospital Admission For Traumatic Hyphema
to a false sense of reassurance to the emergency In addition to conflicting opinions regarding the
clinician that a serious injury is unlikely.3 optimal medical management of patients with trau-
Corneal abrasion should be evaluated as a matic hyphema, there is significant debate regarding
possible diagnosis in the infant who is crying with whether patients with traumatic hyphema require
an unknown etiology. Fluorescein examination is routine admission to the hospital. Antifibrinolytics
recommended if a cause for the crying cannot be can be given topically, and other treatment modali-
elucidated.73 ties such as bed rest and eye patching can be done at
Treatment of corneal abrasions is the same in home, leading some to argue that routine admission
the pediatric population as in the adult population, is no longer necessary, assuming the patient is able
as are the management principles for other ocular to follow up with ophthalmology.
traumas.74,75 An exception is topical fluoroquino- The pediatric population has been of particular
lones, which should be avoided in patients aged < interest to researchers of this topic. A prospective

November 2015 • www.ebmedicine.net 15 Mobile app access: www.ebmedicine.net/app

case series of 35 children with traumatic hyphema Oxygen Therapy For Ocular Burns
treated in the outpatient setting was examined.4 An interesting development in the treatment of ocular
Of interest, elevated intraocular pressure was not burns is the use of oxygen therapy. A prospective
an exclusion criterion; these patients were simply comparative case series of 22 patients (24 eyes) stud-
treated with timolol if their intraocular pressure was ied the effects of oxygen in patients with grade III to
> 24 mm Hg and they were discharged home. The IV ocular burns that were a result of either thermal or
patients were not given antifibrinolytic agents. The chemical damage. The patients received 100% oxygen
rebleeding rate in this population was 8.6%, which is delivered via simple mask at a rate of 10 L/min for 1
reasonable given that rebleeding rates in the litera- hour, twice daily, in addition to “standard” medical
ture range from 3.5% to 38%.57 Patients did undergo therapy. The medical therapy was at the discretion of
daily follow-up examinations by an ophthalmolo- the treating physician and was not standardized. It
gist. This study demonstrates that outpatient man- was found that the patients receiving oxygen experi-
agement of traumatic hyphema is possible, but close enced quicker healing of their corneal defects (15.23
follow-up must be assured.4 A retrospective chart days vs 59.9 days, P < .001), quicker revascularization
review of 138 pediatric patients with hyphema also of ischemic areas (14.54 days vs 45.09 days, P = .001)
supports the notion that hyphema can be managed and improved final visual acuity as measured by the
in the outpatient setting. No one in this study expe- logarithm of the minimal angle of resolution (0.40 vs
rienced rebleeding; however, the study population 1.11, P = .018).82 Oxygen therapy may be a promising
was predominantly white.81 adjunct to the treatment of severe ocular burns.

Risk Management Pitfalls For Ocular Injuries (Continued on page 17)

1. “I didn’t have time to do proper visual acuity 3. “I didn’t realize I had to record so much spe-
testing.” cific information about the trauma.”
Visual acuity is, essentially, a “vital sign” of the It is extremely important from a medicolegal
eye. Formal visual acuity testing with a Snellen standpoint to record specific information
chart or other device typically takes less than regarding the trauma. If the patient presented
2 minutes and is an essential component of the with visual complaints without a clear history of
patient’s physical examination. If the patient is trauma, it should be ascertained what they were
unable to complete this, then a rough estimate doing at the time of onset of symptoms, as heavy
of the patient’s visual acuity should be obtained. lifting may be the “trauma” that precipitated the
Can the patient count fingers, see a hand ocular injury (eg, retinal detachment). This is
waving, or read? There may be later medicolegal also very important for workers' compensation
implications regarding visual acuity, particularly cases.20 Ocular pain while hammering or
in cases of workers' compensation, so this must performing some other metal-on-metal activity
be documented.7,18,26 is also important to elicit, as it places the patient
at risk for an intraocular foreign body.1
2. “I thought I should examine the patient’s eye
prior to irrigation.” 4. “The patient had severe trauma with other life-
The patient’s best chance of a favorable visual threatening injuries, so I didn’t really examine
outcome following an ocular burn is immediate his eyes.”
and copious irrigation. Even if other life-saving The fact that a patient may have life-threatening
measures must be instituted simultaneously, injuries or a swollen face that precludes direct
irrigation should begin immediately. Whatever examination of the globe does not absolve the
fluid is most readily available (normal emergency clinician of the responsibility to
saline, lactated Ringer’s, tap water) should evaluate for and treat vision-threatening injuries.
be used.6,11,12 Record the length of time of CT of the orbit can be very helpful, particularly
irrigation, the solution being used, the pH of if the patient is already to receive a CT of the
the eye, and the times when the pH of the eye head. If the patient is not stable enough to leave
was tested.63 Additionally, it is the responsibility the ED, bedside ultrasonography is a good way
of the emergency clinician to ensure that triage to evaluate for vision-threatening injuries.32,33,36
staff is aware of the time sensitivity of irrigation
in these patients so that they are treated
expeditiously.86

Copyright © 2015 EB Medicine. All rights reserved. 16 Reprints: www.ebmedicine.net/empissues

Disposition sive inpatient treatment with ascorbate and citrate
was actually harmful in patients with grade I or II
Corneal Abrasion injury and recommends against routine admission of
The vast majority of patients with a corneal abra- these patients.11 Given that the optimal management
sion can be discharged home. Circumstances under of patients with ocular burns has not yet been estab-
which ophthalmology should be consulted in the lished, it is prudent to make a disposition decision
ED are: (1) the presence of significant visual deficits; after discussion with an ophthalmologist. Patients
(2) injury that is associated with a corneal infiltrate with grades III or IV injury almost certainly require
or ulcer, or (3) if the corneal abrasion is due to a admission.
penetrating eye injury. In general, the patient should
be instructed to follow up with an ophthalmologist Traumatic Hyphema
within 1 day; however, ophthalmology follow-up is As discussed in prior sections, there is a movement
generally unnecessary if the abrasion is smaller than towards discharging home patients with traumatic
4 mm, provided there are not visual acuity deficits hyphema. A retrospective study of 314 cases of
and the patient’s symptoms are improving.15 traumatic hyphema supports this stance, stating
that, “A case could be made for allowing patients
Ocular Burn who present with hyphema to go home with
Disposition of the patient with an ocular burn instructions to minimize physical activity and to re-
depends on the severity of the burn. A comparative turn promptly should they develop symptoms of a
study of 121 patients (177 eyes) showed that inten- rebleed.”83 This study did not find any factor (age,
sex, mechanism of injury, grade of initial hyphema)

Risk Management Pitfalls For Ocular Injuries (Continued from page 16)

5. “I already examined the eye once, why do I 8. “My patient states that he cannot follow up
need to examine it again?” with his ophthalmologist until next week. I
If the patient has any change in symptoms or thought that was soon enough.”
if any procedure is performed on the eye (eg, This depends on the ocular injury sustained.
corneal foreign body removal), the eye should However, generally, the patient will need much
be re-examined and these results should be closer follow-up, often within 24 hours. The
recorded. Changes in the patient’s symptoms inability to follow up must be taken into consid-
may indicate an evolving pathology that eration when formulating a treatment plan for a
requires attention, and the eye should be re- patient.
examined to evaluate for this possibility.87
9. “I thought all corneal abrasions were the
6. “I thought that topical steroids were indicat- same.”
ed!” It must be discerned whether the patient with
Although topical steroids may be used to treat a corneal abrasion wears contact lenses. If con-
myriad of ocular conditions, they can be poten- tact lenses are worn, then the patient will need
tially harmful to the eye and their effects need to a topical antibiotic that has antipseudomonal
be monitored closely. properties, and the patient must be told not to
wear contact lenses until the corneal abrasion
7. “The patient’s eye injury occurred at work and has resolved.15
I forgot to ask whether he was wearing any eye
protection.” 10. “The Seidel test was negative, so I didn’t think
Whether the patient was wearing eye protection the patient had a globe rupture.”
is particularly important, especially if the The Seidel test can be negative if the area of
trauma occurred at work.7 The patient may globe rupture or laceration is small and has
ultimately require workers' compensation. sealed off. A high index of suspicion must be
maintained, primarily based on the mechanism
of injury.3,18,27 Ultrasound and CT can aid in the
diagnosis of a globe rupture.32,33,36

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to increase the risk of rebleeding. Notably, the admission of hyphemas > 50% in size, and consulta-
patients in the study who did experience rebleed- tion of ophthalmology in all cases.22
ing experienced no adverse effect on their visual Given the controversial nature of the disposition
outcome. Another study of 238 patients found low of the patient with traumatic hyphema, ophthalmol-
vision and elevated intraocular pressure to increase ogy should be consulted in the ED for management
the chance of rebleeding.61 of these patients. Special attention should be paid
A retrospective chart review of 154 patients to patients who may be noncompliant or will have
with traumatic hyphema also leans towards out- difficulty following up with an ophthalmologist.
patient management, arguing that the patients in However, if the patient is reliable and able to follow
their study who did have adverse visual outcomes up, the emergency clinician should be aware that the
would not have had their clinical course improved patient may be potentially discharged home.
with hospitalization. Again, this population was
predominantly white and was very compliant with Other Injuries
follow-up. Their final recommendation was to admit The disposition of other injuries is more straight-
patients with intractable elevated intraocular pres- forward. Patients with open-globe injuries require
sure, rebleeding, or predicted poor compliance, and ophthalmology consultation in the ED to prevent
to consider admission in patients with severely de- posttraumatic endophthalmitis and for treatment of
creased vision, total hyphema, or a history of sickle their injury.56,85 A patient with a retrobulbar hemor-
cell disease.84 Another author advocates for the rhage needs admission to monitor for any change in
vision. A reasonable approach for the patient with
proptosis without visual changes is hospital admis-
Time- And Cost-Effective sion with visual acuity checks every 1 to 2 hours.66
Strategies At the other end of the spectrum, patients with
traumatic iritis or subconjunctival hemorrhage can
generally be safely discharged home with ophthal-
• Many ophthalmic medications are quite ex- mology follow-up. Patients with corneal foreign
pensive, and the emergency clinician should bodies can be discharged home if the foreign body
be aware of this, particularly if the patient is was successfully removed. If the patient has a rust
uninsured or has a high prescription copay. ring, they should follow-up with ophthalmology
Some medications are on the “$4 per month” within 24 hours. If removal of the corneal foreign
list, available at many pharmacies, so local body results in a corneal abrasion, then the patient
pharmacies should be consulted to see if any should be treated for the corneal abrasion.
common ophthalmic medications are on this Retinal detachment, vitreous hemorrhage, pos-
list. Many of these lists are available online. terior vitreous detachment, and lens dislocation all
Erythromycin ointment, gentamicin solution, require evaluation by the ophthalmologist and will
polymyxin B sulfate/trimethoprim solution, very likely require hospital admission as they may
and tobramycin solution are generally on this require repair in the operating room.69,70
list. Topical NSAIDs often cost $50 or more, as
do cycloplegics, aminocaproic acid, and topical
fluoroquinolones. Summary
• Bedside ocular ultrasound is a skill that all emer-
gency clinicians should strive to learn. It is not a Ocular trauma is a serious cause of morbidity and
difficult procedure to perform, and it can have a a leading cause of blindness in all populations. Al-
profound impact on the patient’s management. though the majority of these injuries are preventable,
It may obviate the need for a formal CT, sav- many people do not wear proper eye protection
ing time, money, and radiation exposure. While and present to the ED with a traumatized eye. The
ultrasound should be attempted, and it may absolute first priority is immediate irrigation if the
increase the speed with which it is diagnosed, patient has an ocular burn. Otherwise, a thorough
a negative ultrasound may be encountered and history should be performed, with special attention
does not rule out retrobulbar hemorrhage. As paid to the patient’s ocular history, as well as any
such, a lateral canthotomy is still recommended history of acquired or congenital coagulopathy or
if the clinical scenario indicates a retrobulbar sickle cell disease or trait. The patient’s orbit and
hemorrhage. surrounding structures should be examined both
• Ophthalmology should be consulted early in the grossly as well as with the assistance of fluorescein
patient’s clinical course once a vision-threaten- staining, a slit-lamp, and fundoscopy. Visual acu-
ing injury is suspected or diagnosed. In many of ity must be measured. Special care must be taken in
these cases, the patient’s treatment and disposi- multiply injured patients, as they may not be able
tion will hinge on the ophthalmologist’s recom- to provide any information regarding ocular pain
mendation. or vision changes; clinical examination, ultrasound,

Copyright © 2015 EB Medicine. All rights reserved. 18 Reprints: www.ebmedicine.net/empissues

and CT are particularly helpful in these patients. If a 1. Romaniuk VM. Ocular trauma and other catastrophes. Emerg
vision-threatening injury is suspected, ophthalmol- Med Clin North Am. 2013;31(2):399-411. (Review)
2. Serrano F, Stack LB, Thurman RJ, et al. Traumatic eye inju-
ogy should be consulted and the patient will likely ries: management principles for the prehospital setting. Jems.
require advanced imaging and possible hospital 2013;38(12):56-62. (Review)
admission. Patients with more benign entities such 3. Colby K. Management of open globe injuries. Int Ophthalmol
as corneal abrasion, traumatic iritis, corneal foreign Clin. 1999;39(1):59-69. (Comparative study)
bodies, and subconjunctival hemorrhage will very 4. Rocha KM, Martins EN, Melo LA Jr, et al. Outpatient
management of traumatic hyphema in children: prospective
likely be discharged home, generally with instruc- evaluation. J AAPOS. 2004;8(4):357-361. (Prospective case
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ocular trauma is not encountered frequently, having 5. Negrel AD, Thylefors B. The global impact of eye injuries.
a step-wise approach to the evaluation and manage- Ophthalmic Epidemiol. 1998;5(3):143-169. (Review)
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emergency and continuing problem. Burns. 2000;26(8):689-
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2011;366(1562):251-260. (Review)
Case Conclusions 8. Macewen CJ. Eye injuries: a prospective survey of 5671
cases. Br J Ophthalmol. 1989;73(11):888-894. (Prospective
observational study; 5671 cases)
After some quick research, you realized that your first 9. May DR, Kuhn FP, Morris RE, et al. The epidemiology of
patient, the woman with the corneal abrasion, should be serious eye injuries from the United States Eye Injury Reg-
discharged home with a topical antibiotic and a topical istry. Graefes Arch Clin Exp Ophthalmol. 2000;238(2):153-157.
(Comparative study; 8952 patients)
NSAID, and that it was safest not to let her take home
10. Vassallo S, Hartstein M, Howard D, et al. Traumatic ret-
the bottle of topical anesthetic. She did not wear contact robulbar hemorrhage: emergent decompression by lateral
lenses, so you decided to use topical erythromycin 0.5% canthotomy and cantholysis. J Emerg Med. 2002;22(3):251-256.
ointment. She followed up with her primary care doctor 2 (Case report)
days later and had complete resolution of her symptoms 11. Brodovsky SC, McCarty CA, Snibson G, et al. Management
of alkali burns: an 11-year retrospective review. Ophthal-
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Your motor vehicle crash patient was unable to leave the patients, 177 eyes)
ED, so you decided to perform a bedside ocular ultrasound, 12. Connor AJ, Severn P. Use of a control test to aid pH assess-
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11 patients, 12 eyes)
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Rhegmatogenous retinal detachment treatment guidelines.
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controlled trial; 40 patients)
76. Bradley JS, Jackson MA. The use of systemic and topical
a. Corneal abrasion
fluoroquinolones. Pediatrics. 2011;128(4):e1034-e1045. (Prac- b. Ocular burn
tice guideline) c. Traumatic iritis
77. Vigue B. Bench-to-bedside review: Optimising emergency d. Subconjunctival hematoma
reversal of vitamin K antagonists in severe haemorrhage -
from theory to practice. Crit Care. 2009;13(2):209. (Review)
78. Waldman N, Densie IK, Herbison P. Topical tetracaine used for
2. What physical examination maneuver should
24 hours is safe and rated highly effective by patients for the be performed in a patient with multiple linear
treatment of pain caused by corneal abrasions: a double-blind, corneal abrasions seen on fluorescein examina-
randomized clinical trial. Acad Emerg Med. 2014;21(4):374-382. tion?
(Randomized controlled trial; 116 patients) a. Slit-lamp examination to look for cells and
79. Ting JY, Barns KJ, Holmes JL. Management of Ocular Trauma
in Emergency (MOTE) Trial: A pilot randomized double-
flare
blinded trial comparing topical amethocaine with saline b. Orbital CT to look for an intraocular foreign
in the outpatient management of corneal trauma. J Emerg body
Trauma Shock. 2009;2(1):10-14. (Randomized controlled trial; c. Tonometry to evaluate for elevated
47 patients) intraocular pressure
80. Erdem E, Undar IH, Esen E, et al. Topical anesthetic eye
drops abuse: are we aware of the danger? Cutan Ocul Toxicol.
d. Eversion of the eyelid to search for a foreign
2013;32(3):189-193. (Retrospective review; 8 patients, 12 eyes) body
81. SooHoo JR, Davies BW, Braverman RS, et al. Pediatric trau-
matic hyphema: a review of 138 consecutive cases. J aapos. 3. Proptosis can be caused by which of the fol-
2013;17(6):565-567. (Retrospective review; 138 patients) lowing?
82. Sharifipour F, Baradaran-Rafii A, Idani E, et al. Oxygen
therapy for acute ocular chemical or thermal burns: a pilot
a. Bony displacement into the orbit (blow-in
study. Am J Ophthalmol. 2011;151(5):823-828. (Comparative fracture)
study; 22 patients, 24 eyes) b. Retrobulbar edema
83. Kearns P. Traumatic hyphaema: a retrospective study of 314 c. Retrobulbar hemorrhage
cases. Br J Ophthalmol. 1991;75(3):137-141. (Retrospective d. All of the above

November 2015 • www.ebmedicine.net 21 Mobile app access: www.ebmedicine.net/app

4. A 2-year old black patient presents to the ED 7. Current recommendations most support treat-
with a traumatic hyphema. He was recently ing corneal abrasions with which of the fol-
adopted and his medical history is unknown. lowing?
Which of the following laboratory tests would a. Topical cycloplegics
be the most beneficial to obtain in this patient? b. Oral antibiotics
a. Complete blood count c. Eye patching
b. Basic metabolic panel d. Topical NSAIDs
c. Sickle cell screening test
d. Blood cultures 8. Which of the following should be performed
in addition to a lateral canthotomy in the treat-
5. A patient was cutting wood when he felt some- ment of retrobulbar hemorrhage?
thing fly into his eye. He had immediate pain. a. Superior cantholysis
Orbital CT was within normal limits. Which of b. Medial canthotomy
the following is the next best imaging study to c. Inferior cantholysis
obtain on this patient to evaluate for an intra- d. Dissection of Whitnall tubercle
ocular foreign body?
a. CT with intravenous contrast 9. A patient presents to the ED with a corneal
b. X-ray abrasion of her right eye. She normally has
c. Magnetic resonance imaging 20/20 vision in both eyes, but vision in her
d. No further imaging is necessary since the right eye is now 20/100. What is the best dispo-
CT was within normal limits sition for this patient?
a. Discharge home with instruction to follow
6. Which of the following would be the most use- up with ophthalmology in 3 to 7 days
ful in evaluating an unstable trauma patient b. Discharge home with instructions to follow
with significant periorbital swelling? up with ophthalmology in 24 hours
a. Bedside ocular sonography c. Consult ophthalmology in the ED
b. Computerized tomography d. Obtain an orbital CT then admit the patient
c. Magnetic resonance imaging for further management
d. Slit-lamp examination
10. Which of the following injuries is the least
likely to necessitate hospital admission?
a. Traumatic lens dislocation
b. Traumatic iritis
c. Traumatic vitreous hemorrhage
d. Traumatic retinal detachment

Coming Soon In
Emergency Medicine Practice
An Evidence-Based Approach To Intracerebral Hemorrhage
In Anticoagulated Patients (Stroke CME)
AUTHORS: progression; however, the optimal approach has been debated.
Natalie Kreitzer, MD Because there are no targeted therapies in the treatment of ICH,
Assistant Professor of Emergency Medicine; Fellow, Neurocritical current strategies to improve outcome rest largely on reducing the
Care and Neurovascular Emergencies, University of Cincinnati, risk of hematoma expansion early in treatment, as each milliliter of
Cincinnati, OH expansion decreases the patient’s chances of living independently.

Opeolu Adeoye, MD, FACEP, FAHA This issue reviews the history and physical elements that
Associate Professor of Emergency Medicine, University of are important to obtain in the ED, including airway control,
Cincinnati, Cincinnati, OH blood pressure management, frequent reassessment, reversal
strategies, and the need for rapid consultation, ICU admission, and
Intracerebral hemorrhage (ICH) is a devastating disease that must possible transfer. Data are quite limited at this point regarding
be recognized immediately in the emergency department. Unlike optimal coagulopathy reversal in the setting of the novel oral
ischemic stroke, which has a large body of evidence supporting anticoagulants, but these patients will inevitably present, and the
intravenous tPA and endovascular treatment, there are no targeted emergency clinician must be aware of new developments and
modalities for treatment of ICH. Anticoagulated patients with become involved in developing local protocols to manage these
ICH require rapid reversal of coagulopathy to cease hemorrhage patients.

Copyright © 2015 EB Medicine. All rights reserved. 22 Reprints: www.ebmedicine.net/empissues

Now Available!
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Controversies, Volume I
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• Pediatric Trauma Update – an organ-specific approach to treating pediatric trauma

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 Physician CME Information
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