1. OPEN GLOBE INJURY
OGIs can result from penetrating/perforating trauma or from rupture of the globe due to massive compressive forces (Figures 1–5). Prompt surgical exploration and repair are crucial to restore or salvage vision and to prevent a devastating outcome. Safe and effective closure of an OGI is not yet feasible in a prehospital setting.
Goals
Prevent further damage to the eye, prevent infection in the eye (endophthalmitis), and evacuate to an eye surgeon as soon as possible.
Minimum
Better
Best
Initiate real-time video telemedicine consultation.
NOTES:
Photographs by COL Mark Reynolds.
2. RETROBULBAR HEMORRHAGE / ORBITAL COMPARTMENT SYNDROME
Retrobulbar hemorrhage (RBH) is the most common cause of orbital compartment syndrome (OCS). It is a result of bleeding into the confined orbital space behind the eye, usually associated with blunt trauma (Figures 6 and 7). It is a vision-threatening condition causing increased pressure in the eye, leading to irreversible vision loss. Vision loss typically will occur after approximately 90 minutes of increased pressure.
Photographs by COL Mark Reynolds.
Other causes of OCS include orbital congestion secondary to burn resuscitation and significant orbital emphysema after orbital fracture (pneumo-orbita). OCS from any cause may have a delayed onset. Patients with trauma to the orbit must be closely monitored for development of OCS.
Goal
Lower the orbital compartment pressure as soon as possible to prevent tissue damage.
Minimum
Initiate teleconsultation with photographs.
Better
Best
NOTES:
In thermal burns, consider early LCC (before full OCS develops). Fluid resuscitation requirements will take precedence over the use of medical treatments to reduce IOP.
3. BLUNT / CLOSED GLOBE INJURY
This category includes anterior segment injuries such as hyphema (bleeding into the anterior chamber) and posterior segment injuries such as vitreous hemorrhage and retinal detachment. Blunt trauma can result in severe loss of vision.
©2017 American Academy of Ophthalmology, reprinted with permission.
Hyphema can lead to increased IOP and corneal blood staining. This is graded on the amount of blood in the anterior chamber. The risk of IOP elevation increases with the grade of the hyphema (Figure 8).11
Goal
Identify significant ocular injuries; protect the eye from further injury.
Minimum
Initiate teleconsultation with photographs.
Best
NOTE: Tranexamic acid for prevention of rebleeding in hyphema has not shown any benefit 13 but may be used in multitrauma patients if otherwise indicated.
Posterior chamber injury: Injuries to the retina and optic nerve as a result of blunt injury will result in vision loss. Findings may include decreased visual acuity, vision loss, loss of red reflex through the pupil, positive RAPD, or evidence of vitreous hemorrhage or retinal detachment on ultrasound evaluation.
Initiate real-time video telemedicine consultation.
4. EYELID LACERATION
Lid lacerations can result from either sharp or blunt trauma (Figures 9–11). As with other injuries, the primary concern with lid injuries is the possibility of underlying globe injury. Lid lacerations have a low incidence of infection (unless the causative factor is an animal or human bite). Any avulsed tissue should be preserved in saline and chilled, whenever possible, and sent with the patient—not discarded or debrided. Meticulous closure of eyelid structures with proper magnification is usually required to maintain lid function. If fat is visible in an eyelid laceration, this indicates violation of the orbital septum, a key anatomic barrier to infection. If prolapsed orbital fat is identified, appropriate antibiotic coverage is needed as well as expedited evacuation for surgical exploration and repair. Do not attempt to excise or suture exposed orbital tissue; this can lead to uncontrolled bleeding in the orbit.
Photographs by LTC Marcus Colyer (9) and COL Mark Reynolds (10, 11).
Goals
Prevent infection; protect the eye from further injury.
Minimum
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 real-time video telemedicine consultation.
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
Initiate teleconsultation with photographs.
Better
Best
Initiate real-time video telemedicine consultation.
NOTES:
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):
Grade I
Cornea Epithelium - Less than one-third loss
Corneal Clarity - Iris details clearly visible
Limbal Ischemia - No ischemia
Grade II
Cornea Epithelium - More than one-third epithelial loss
Corneal Clarity - Iris details blurred but visible
Limbal Ischemia - Less than 25% ischemia
Grade III
Cornea Epithelium - Complete epithelial loss
Corneal Clarity - Pupil can be seen
Limbal Ischemia - 25%–50% ischemia
Grade IV
Cornea Epithelium - Complete epithelial loss
Corneal Clarity - Opaque cornea
Limbal Ischemia - More than 50%
Grade I injuries may have corneal epithelial damage but a clear cornea, no corneal opacity, and no limbal ischemia.
These injuries generally carry a good prognosis for recovery. Irrigation and topical care are frequently the only required interventions.
Grade II through IV injuries will have corneal haze or opacity and limbal ischemia.
These injuries will have a guarded prognosis and will require more intensive treatment. Grading is determined by the most severe finding. For example, an eye with a clear cornea but showing limbal ischemia would be classified as grade II or higher.
Goals
Initiate eye irrigation as quickly as possible to reduce damage to the eye, treat the injury to prevent or reduce scarring and visual loss.
Minimum
Photographs by The University of Iowa and EyeRounds.org (12) and ©2017 American Academy of Ophthalmology, reprinted with permission. (13, 14).
Better
Best:
Grade I:
Grades II–IV:
7. PRESEPTAL AND ORBITAL CELLULITIS
Infection anterior to the orbital septum (usually involving the eyelid) is termed preseptal cellulitis. Preseptal cellulitis will present with tenderness, swelling, and erythema of the eyelids, with no orbital findings (e.g., no sign of proptosis, eye movement restriction, or change in vision). Preseptal cellulitis can generally be managed with oral antibiotics, but the possibility of methicillinresistant Staphylococcus aureus (MRSA) must be considered.
Infection in the orbit (posterior to the orbital septum) can occur as a result of adjacent sinusitis, skin infection, puncture wounds, or orbital foreign bodies. Multiple organisms, including staphylococcal, streptococcal, and gram-negative bacteria, are usually responsible. Orbital cellulitis has the potential to progress rapidly and may lead to irreversible loss of vision or intracranial extension. Orbital cellulitis presents with pain, proptosis, conjunctival injection, decreased vision, and loss of ocular mobility (which may cause double vision).
Goal
Recognize infection early and start oral antibiotics for preseptal cellulitis and IV antibiotics for orbital cellulitis. Evacuate to an eye surgeon as rapidly as possible if orbital cellulitis is suspected.
Preseptal cellulitis (Figure 15)
Best
Trimethoprim sulfamethoxazole DS 1 tablet PO every 8 hours combined with amoxicillin/clavulanic acid 875mg every 12 hours.
Orbital cellulitis (Figure 16)
Minimum
Initiate teleconsultation with photographs (include full facial views).
Better
Nasal decongestants such as oxymetazoline (e.g., Afrin) nasal spray twice a day for 3 days (limit use to 3 days to prevent rebound effect); this will aid in draining of contributing sinusitis. Oral decongestants, such as pseudoephedrine 30mg every 6 hours, can be used if nasal spray is not available.
Best
Initiate real-time video telemedicine consultation.
8. INFECTIOUS KERATITIS (CORNEAL ULCER)
Infections in the cornea can lead to corneal scarring and permanent effects on vision (Figures 17 and 18). The most common risk factor for corneal ulcer is contact lens use.
Goal
Early recognition and treatment to prevent long-term scarring of the cornea.
Minimum
Better
Best
NOTE: Topical steroid drops may be useful to reduce inflammation after the infection is controlled with topical antibiotics. Initiation of topical steroid drops should only be done under the direction of an eye care specialist after teleconsultation.
Herpes simplex virus (HSV) keratitis is an additional form of keratitis that usually occurs in patients with a history of previous episodes. HSV keratitis may demonstrate a specific dendritic staining pattern with fluorescein (Figure 19). After recognition, treatment can be initiated with oral acyclovir (400mg PO 5 times per day).
9. ANGLE-CLOSURE GLAUCOMA
Blockage of the normal flow of aqueous fluid in the anterior chamber of the eye will lead to increased IOP. If left untreated, blood flow to the posterior segment of the eye will be affected, leading to irreversible vision loss. The aqueous drain system can become blocked owing to anatomic variations, changes in lens size, inflammation, and trauma (Figure 20).
Goals
Initiate teleconsultation with photographs.
Better
Best
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).