Ophthalmic Emergencies 411Ophthalmic Emergencies 411Traumatic Conditions of the Eye
Periorbital haematoma (‘black eye’)
DIAGNOSIS AND MANAGEMENT
1 This is caused by a direct blow. If bilateral, suspect local trauma to the nose
or a basal skull fracture (see p. 31).
2 Perform a thorough stepwise assessment:
(i) Check that the patient can still see, if necessary by opening the
eyelids manually, and record the visual acuity.
(ii) Systematically assess the eye for damage:
(a) examine the cornea for abrasions, the anterior chamber
for hyphaema, the sclera for perforation, the pupil size and
reactions, and the globe for loss of eye movements
(b) check for the presence of a red reflex through the pupil and a
normal fundus.
(iii) Refer any abnormal findings suggestive of one of the above
complications immediately to the ophthalmology team.
(iv) Palpate to see whether the bony margin of the orbit is intact
(a) test that the eye movements are full and the eyeball is not
tethered, suggesting a ‘blow-out’ fracture of the orbital floor
(see p. 432).
3 Request appropriate facial X-rays if a ‘blow-out’ or a malar fracture is
suspected, and refer the patient to the maxillofacial surgery team.
4 Otherwise, give the patient an analgesic such as paracetamol 500 mg and
codeine phosphate 8 mg two tablets q.d.s. and chloramphenicol eye ointment
if the eye is shut.
5 Review the patient within 48 h when the swelling has decreased to re-confirm
the absence of significant ocular damage.
Subconjunctival haematoma
DIAGNOSIS AND MANAGEMENT
Two types are recognized – spontaneous and traumatic.
1 Spontaneous
(i) This may arise from coughing or from atherosclerotic vessels,
particularly in the elderly, and is occasionally associated with
hypertension or a bleeding diathesis.
(ii) Measure the blood pressure and reassure the patient that the
subconjunctival blood will disperse within 2 weeks. No treatment
is needed.