Emergency Medicine

TRAUMATIC CONDITIONS OF THE EYE

Ophthalmic Emergencies 415

2 There is intense pain, watering and blepharospasm occurring after a few
hours. Fluorescein staining reveals a pitted corneal surface due to a superfi-
cial punctate keratitis.

3 Instil local anaesthetic drops and mydriatic/cycloplegic drops. Double-pad
the eyes shut until the return of normal sensation and the blepharospasm
settles.

4 Give an analgesic such as paracetamol 500 mg and codeine phosphate 8 mg
two tablets q.d.s. Recovery occurs within 12–24 h.

BLUNT TRAUMA TO THE EYE

DIAGNOSIS AND MANAGEMENT

1 Always consider injury to the eye in any trauma to the face. Eye examination
must not be omitted just because other injuries appear more dramatic or
periorbital oedema obscures the eye.

2 Blunt trauma may cause a sequence of injuries from the front to the back of
the eye. Systematically exclude each one:
(i) Periorbital haematoma or subconjunctival haemorrhage.
(ii) Corneal abrasion or laceration.
(iii) Bleeding into the anterior chamber, called hyphaema. This may
be microscopic or macroscopic with formation of a fluid level.
(iv) A fixed pupil or torn iris, known as traumatic mydriasis and
iridodialysis, respectively.
(v) A dislocated lens or subsequent traumatic cataract.
(vi) Vitreous haemorrhage, causing a dull or absent red reflex and
obscuring the fundus.
(vii) A retinal tear, with retinal detachment seen as a dark, wrinkled,
ballooned area diametrically opposite any resultant visual field
defect.
(viii) Retinal oedema (commotio retinae) seen as whitish areas of
oedema, usually associated with haemorrhage.
(ix) Optic nerve damage, causing blindness with no direct pupillary
response to light.
(x) Ruptured globe, with marked visual loss, a soft eye, and shallow
anterior chamber.
(xi) Retrobulbar haematoma, with pain, proptosis and a fixed, dilated
pupil.
(xii) Orbital fracture, usually a ‘blow-out’ fracture of the orbital floor
(see p. 432).

3 Refer a patient with any of the complications above from (ii) through to (xi)
directly to the ophthalmology team. Do not allow the patient home in the
meantime, but arrange for them to lie quietly and semi-upright, pending
expert assessment.