Goals

- Prompt diagnosis and identification, lowering of IOP.
- Minimum
- Diagnosis
- Pain (often described as a deep pain, similar to tooth pain)
- Decrease in or loss of visual acuity
- Photophobia
- Dull or cloudy appearance of the cornea due to corneal edema
- Fixed, mid-dilated pupil (usually occurs after IOP reaches 30–40mmHg)
- Increased IOP by palpation
- Acetazolamide 500mg PO initial dose, then 250mg PO every 4 hours to decrease IOP. (Note: contraindicated in patients with sickle cell trait.)

Initiate teleconsultation with photographs.

- Activate evacuation with goal of evaluation by an eye surgeon within 24 hours.

Better

- Oral acetazolamide plus topical IOP-lowering eye drops (timolol 0.5%, 1 drop twice a day in the affected eye).
- Administer antiemetics as required by patient symptoms (ondansetron 4mg ODT/IV/IO/IM every 8 hours as needed).

Best

- Topical corticosteroids (prednisolone acetate 1%) 1 drop every hour after consultation with ophthalmology or optometry.
- 3% hypertonic saline 250mL IV or mannitol 1g/kg over 30–60 minutes can be used to decease IOP if the aforementioned interventions are not effective.9

10. EYE CARE IN THE MULTITRAUMA / THERMAL BURN PATIENT

Patients with multisystem trauma who are intubated and sedated are at risk of developing corneal complications due to metabolic derangements and impaired ocular protective mechanisms.22 The presence of thermal facial burns puts the patient at high risk for exposure keratopathy. Loss of the normal blink reflex, impaired tear production, abnormal tear film dynamics, and incomplete eyelid closure, combined with the inability to relay ocular complaints all contribute to the development of exposure keratopathy and increase the risk for infectious keratitis.23 If there is no concern for OGI, ultrasound examination may be performed if personnel are equipped and trained. Patients with head and facial burns with eyelid involvement are especially prone to entropion (with burned eyelash stubs abrading the cornea) as well as exposure keratopathy from scar-related lid retraction and proptosis from orbital congestion (Figures 21 and 22).