Eye injuries

Penetrating eye injury

Eyeball punctured — object may or may not still be in eye

Do not

• Do not try to remove object if it is still in eye — may cause more damage
• Do not let person eat or drink anything — may need operation — consider IV fluids

Check

• Eye assessment — only do what is needed to confirm — do not do lid eversion
• Immunisation status — tetanus

Do

• Medical consult to send to hospital
• Keep person calm — advise them not to cough, sneeze, strain
• Give antiemetic to stop vomiting before transport
• Give pain relief
• Give ceftriaxone IV — adult 2g, child 50mg/kg/dose up to 2g — doses — single dose
• If person upset or agitated — give sedation
• If promethazine used as antiemetic — this should be enough
• If promethazine not already used and 2 years or over — give promethazine oral/IM — adult 25mg, child 0.5mg/kg/dose up to 25mg — doses — single dose
• If not enough or under 2 years — medical consult
• Give oxygen to target O₂ sats 94–98% OR if moderate/severe COPD — 88–92%
• Put loose fitting shield over eye to prevent eye contents being pushed out — do not use eye pad under shield
• If person still very agitated or distressed — medical consult about giving midazolam

Foreign body (something in eye)

Something stuck on or in surface of eyeball, eg sand, seed, metal

Check

• Eye assessment — always look under eyelid

Do

• If thing in eye is stuck over pupil OR if rust ring visible after it is removed — medical consult
• Wash eye out with water — may remove objects especially if lots of small foreign bodies, eg sand
• Try to remove object/s with sterile cotton bud wet with normal saline or anaesthetic drops
• If this doesn’t work — put in topical local anaesthetic and try again
• If still doesn't work — try to remove with 25G needle mounted on 2mL syringe as handle, if skilled
• Give chloramphenicol 1% eye ointment, 4 times a day (qid) for up to 5 days
• Do not touch eye with tube — Figure 7.17
• If cornea (eye surface) damage — see Corneal ulcers or infection

Blunt eye injury

Commonly caused by fist, elbow, finger, ball, rock

Check

• Eye assessment if possible
• Can be hard to see into eye if eyelids are swollen — gentle, steady pressure will usually allow you to open eyelids
• If not — consider using analgesia and emergency eye lid retractor — see Eye procedures
• If you can’t get eyelids open — medical consult to send to hospital to be properly examined
• Do not wait for swelling to go down

Do

• If double vision, reduced eye movements, numbness around eye or upper gum (signs of ‘blowout’ fracture of eye socket) — medical consult to send to hospital. Specialist will arrange scan
• If pupil shape or responses irregular, ruptured globe, bleeding inside eye, no red reflex seen — medical consult to send to hospital
• If none of the above — treat as uncomplicated black eye with ice and rest
• After acute care — refer to optometrist to monitor for post-traumatic complications

Bleeding inside eye

Check

• Hyphema  (bleeding into front of eye) — look for fluid level at bottom of iris while sitting up Figure 7.18

• Retinal or vitreous haemorrhage  (bleeding into back of eye)
• Will be hard to see — red reflex may be dull
• May have developed very poor vision since being hit

Do not

• Do not give aspirin, heparin or NSAIDs — may cause more bleeding

Do

• Medical consult to send to hospital
• Keep person calm and lying down
• Put pad over both eyes —using 2 pads for each eye
• If this upsets person too much — let them sometimes uncover good eye

Subconjunctival haemorrhage (bleeding into white of eye)

Check

• BP — may be high
• Medicines — bleeding may be due to overdose of anticoagulant
• Try to see back edge of patch of blood (bleed)
• If you can see back edge — Figure 7.19 — not serious and should get better by itself in a week
• If you can’t see back edge — Figure 7.20 — could be skull fracture if history suggests significant trauma — medical/specialist consult

Chemicals in eye

Do first

Immediately irrigate (wash out) eye with water or normal saline only — for at least 30 minutes

• In clinic — give local anaesthetic drops first — will make irrigation easier
• Use IV-giving set to run normal saline steadily over eye while holding lids open
• Outside clinic — use plenty of any available clean water — put eye under tap or hose OR have person put face in bowl of water. Ask them to blink vigorously

Do not

• Do not waste time
• Do not wash out with anything except water or normal saline
• Do not stop washing out too soon

Ask

• Try to find out type of chemical
• Alkalis like concrete, lime, plaster, bleach are more dangerous than acids like car battery fluid, toilet cleaner, rust removers
• Alkalis may need to be washed out for 2–3 hours

Do

• Irrigate (wash out) eye for at least 30 minutes
• Test pH of eye every 15 mins — using pH test strip or pH pad on urine dipstick to conjunctival fornix (pocket between the lower eye lid and globe) — until pH is 7 or same as unaffected eye
• Urgent medical consult
• Eye assessment
• Make sure whole surface of eye, under eyelids, in corners is all washed and completely clean — double evert lid — see Eye procedures
• Local anaesthetic drops will make this easier
• If large patch of damage to cornea (eye surface) — medical consult to send to hospital
• 5 minutes after stopping wash out — test pH again. If pH has changed — keep washing out until pH 7 or same as unaffected eye

UV keratitis (flash burns)

Red sore eyes caused by sudden bright light, eg ultra violet light from arc welder. May not be aware of it until several hours later

Check

• Eye assessment — make sure there is not something in eye

Do

• If anaesthetic needed to examine eye — put in 2 drops of topical local anaesthetic
• Put chloramphenicol 1% eye ointment in both eyes straight away
• THEN chloramphenicol 1% eye ointment, 3 times a day (tds) for 2–3 days
• Do not touch eye with tube — Figure 7.17
• Give pain relief
• Cool compresses (eg clean cool towel) may help
• Remind person to use appropriate eye protection next time

Follow-up

• If not getting better after 1 day — medical consult