Photographs by LTC Marcus Colyer (9) and COL Mark Reynolds (10, 11).

Goals

Prevent infection; protect the eye from further injury.

Minimum

- Maintain high suspicion for OGI; treat any suspected open globe as such until surgical capability is available.
- Obtain and document visual acuity from the injured and noninjured eyes.
- If there is any concern for OGI, protect the injured globe and prevent further damage with a rigid eye shield. Polyethylene film (food grade) may be used to cover the eyelid wound under the rigid shield to prevent drying of the injured tissue.
- Initiate pain control as needed.
- Activate evacuation with goal of evaluation by an eye surgeon within 24 hours.

Initiate teleconsultation with photographs.

Better

For foreign body penetration, animal bite, or laceration with visible orbital fat, start antibiotics: moxifloxacin 400mg PO daily or levofloxacin 750mg PO daily or amoxicillin/clavulanic acid 875mg/125mg PO every 12 hours or ertapenem 1g IV/IO daily.

Best

- Initiate a detailed ocular evaluation to include visual acuity, RAPD, and note any suspicious findings.
- Irrigate wound very gently with clean water (or sterile saline, if available).15
- Do not debride any tissue.
- Temporary closure with steristrips
- Tetanus prophylaxis
- Consider the need for rabies vaccination.15

Initiate real-time video telemedicine consultation.

- No altitude restrictions are required for evacuation.

5. ORBITAL FRACTURE

Fracture of the orbital bones occurs when an object that is larger than the width of the orbit (e.g., fist or softball) strikes the orbit. The acute expansion of orbital contents and mechanical buckling forces can result in fractures of the medial wall or orbital floor. This can cause herniation of orbital contents into the surrounding sinuses and entrapment of the extraocular muscles in the fracture site. Physical examination findings consistent with orbital fracture include a palpable and painful step-off along the orbital rim, enophthalmos (globe is further back in the orbit compared with the other eye), restricted eye movement, and numbness below the eye (caused by damage to the infraorbital nerve).16 Trismus and malocclusion may indicate a larger zygomaticomaxillary complex fracture. Orbital fractures are not ophthalmic emergencies but may require surgical treatment to prevent the complication of double vision from ocular misalignment.

Goals

Evaluate for concurrent open or closed globe injury and prevent long-term complications.

Minimum

- Maintain a high suspicion for associated OGI; treat as a suspected open globe until eye surgical evaluation is available.
- Obtain and record visual acuity from the injured and noninjured eyes.
- Instruct the patient not to blow nose. This may force air into the orbit through fracture site, leading to OCS from pneumo-obita, which would require LCC.
- Initiate pain control as needed.
- Raise head 30°–45°.

Initiate teleconsultation with photographs.

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

Better

- Initiate antibiotics if an orbital fracture suspected; this is to prevent sinus pathogens from spreading to the orbital tissues: moxifloxacin 400mg PO daily or levofloxacin 750mg PO daily or amoxicillin/clavulanic acid 875mg/125mg PO every 12 hours or ertapenem 1g IV/IO daily.
- Nasal decongestants such as oxymetazoline (e.g., Afrin; Bayer, http://www.bayer.us/) nasal spray twice a day for 3 days (limit use to 3 days to prevent rebound effect). Oral decongestants, such as pseudoephedrine 30mg every 6 hours, can be used if nasal spray is not available.
- Prevent further injury with antiemetics (ondansetron 4mg ODT/IV/IO/IM every 8 hours as needed).

Best

- Initiate a detailed ocular evaluation to include visual acuity, RAPD, and note any suspicious findings.
- Ice packs for 20 minutes every 1–2 hours for the first 48 hours to reduce swelling.
- Monitor for delayed development of OCS and perform LCC as needed.

Initiate real-time video telemedicine consultation.

NOTES:

- No altitude restrictions are required with orbital fractures, but patient should be monitored for increasing pain and/or decreasing vision from pneumo-orbita OCS requiring LCC.
- An important consideration in orbital floor fractures is the inferior rectus muscle becoming entrapped in the fracture (so-called trapdoor fracture). The resultant traction on the rectus muscle can trigger the oculocardiac reflex and result in intractable nausea and vomiting, symptomatic bradycardia, and possibly heart block. Although this is more common in pediatric patients (termed “white-eye” blow-out fractures), it is not exclusive to the pediatric population and has been reported in young healthy adults. Urgent surgical repair (within 72 hours) is recommended for an entrapped fracture with these symptoms.

6. CHEMICAL INJURIES

Acid (e.g., sulfuric, hydrochloric) and alkali (e.g., bleach, lime, ammonia) burns can cause significant injuries leading to permanent loss of vision and are considered ophthalmic emergencies. Alkali burns are more common and have more potential for damage than acid burns.16 Ongoing ocular care beyond the initial thorough irrigation will be required if evacuation is delayed. Chemical injuries are graded on a scale of I to IV.17 The modified Hughes classification (Table 1) can be used to grade the degree of limbal ischemia that correlates with prognosis. Regardless of the chemical causing the injury, immediate irrigation is the essential first step. Additional treatment will be based on grade of injury. Injuries are graded on the basis of the following examination findings (Figures 12–14):