3-28
Occult ruptured globe - suspect with history of blunt or impaling injury, dark uveal tissue exposed at junction of
cornea and sclera, a distorted pupil, or a decrease in vision
Traumatic iritis - pain and photophobia
Subconjunctival hemorrhage - bright red area of blood overlying the sclera
Also consider corneal abrasion, corneal ulcer, foreign body, obvious ruptured globe,
Plan:
Treatment
- Cover all injured eyes with a metal shield or other device to prevent further injury.
- Obvious ruptured globe: levofloxacin 500 mg po bid and evacuate immediately.
- Occult ruptured globe: An occult ruptured globe also entails the possibility of endophthalmitis. Treat in
the same manner as an obvious open globe. If an open globe is suspected, protect the eye until definitive
treatment is obtained. - Corneal abrasion:
a. Bacitracin ophthalmic ointment qid.
b. Small or less painful abrasions need not be patched.
c. Diclofenac 0.1% drops qid or systemic analgesics for pain control.
d. Sunglasses reduce irritation from light if the eye is not patched.
e. Remove the patch daily to check for the development of a corneal ulcer and to repeat the fluorescein
stain to monitor healing. The abrasion should heal within 1-3 days.
f. If the trauma causing the abrasion is related to contact lens wear or insertion, there is a higher
incidence of secondary infection with gram negative organisms and the eye should NOT be patched. Use
topical ciprofloxacin or ofloxacin 1-2 drops qid until the abrasion is healed and watch the eye closely
for development of a corneal ulcer. - Corneal ulcer: topical ciprofloxacin or ofloxacin as follows: 1 drop every 5 minutes for 3 doses; 1 drop
every 15 minutes for 6 hours; then 1 drop every 30 minutes. Scopolamine 0.25% 1 drop bid, or systemic
analgesics may be added for pain control if needed. A corneal ulcer is a vision-threatening disorder that
may progress rapidly despite therapy, so evacuate should emergently if pain and inflammation continue to
increase or expedite evacuation even if the ulcer is responding to therapy. - Subconjunctival hemorrhage requires no treatment, but carefully inspect the eye for associated injuries.
If the subconjunctival hemorrhage is massive and causes outward bulging of the conjunctiva
(called chemosis), then suspect an occult ruptured globe and manage as described above. - Hyphema: The primary concerns in this disorder are associated globe rupture, increased pressure in
the eye and permanent damage to vision. Expedite evacuation. Restrict activity to walking only. Rest in
a foot-dependent position to encourage blood to settle in the bottom of the anterior chamber. Do not
let these individuals read. Do not treat them with NSAIDs or aspirin. If evacuation is delayed use
prednisolone ophthalmic drops qid in the affected eye for 3 days. - Traumatic iritis typically resolves without treatment in several days. Severe cases may be treated with
topical prednisolone 1% drops qid for three days if evacuation is not available and no lesion is noted
on fluorescein exam. - Lid Laceration: Any laceration that is full-thickness, involves the lid edge, or is in the medial or lateral
corners (epicanthal folds) should be repaired by an ophthalmologist. Suspect other trauma beneath the
laceration. Repair partial thickness lacerations that are not in the areas mentioned above with simple 6-0
proline sutures, sterile technique, and limited 2% lidocaine in the lid. Do not expose the eye to surgical
scrub or preparation solutions. Do not puncture underlying globe! - Foreign Body: Apply topical anesthesia (1 drop 0.5% proparacaine or tetracaine). Locate and remove
foreign body using enhanced lighting and magnification if available. Evert upper eyelid with a cotton-
tipped applicator to identify foreign bodies there and remove them with a cotton-tipped applicator
moistened with tetracaine. Stain eye with fluorescein to check for a corneal abrasion. If symptoms
persist, irrigate vigorously with artificial tears or sweep conjunctival corners with a moistened
cotton-tipped applicator after applying topical anesthesia. - Although topical steroids should not be given except by ophthalmologists, prednisolone drops will
probably not cause any significant adverse effects in an individual with a fluorescein-negative eye disorder
if used no longer than three days.