APPENDIX E: OCULAR INJURIES & VISION THREATENING CONDITIONS SUMMARY TABLE

#### Eye Care Goals

• Maintain high suspicion for ocular injuries.

• Assess and document visual function.

• Examine for critical physical findings.

• Maintain patient comfort and prevent further injury (e.g., pain medication, anti-emetic, eye shield, elevate head 30º-45º).

• Establish telemedicine contact with eye care specialist; provide photographs or real-time video.

• For eyesight-threating conditions, prioritize evacuation with goal to arrive at an eye surgeon or eye specialist within 24 hours.

• Provide optimal Role 1 care when evacuation goal cannot be met

#### Open globe injury/suspected open globe

Goal-Prevent further damage to the eye, prevent infection in the eye (endophthalmitis), and evacuate to an eye surgeon as soon as possible.

Minimum-Rigid shield, pain control, antiemetic, raise head 30º-45 º. Antibiotic prophylaxis: moxifloxacin 400mg PO daily or levofloxacin 750mg PO daily or ertapenem 1g IV/IO daily.

Better-Add clindamycin 300 mg PO or IV/IO every 8 hours to endophthalmitis prophylaxis.

Best-Detailed ocular exam every 4 hours. Coordinate surgical care within 8 hours of injury.

Ultrasound is contraindicated for suspected OGI because it places pressure on the eye.

#### Retrobulbar hemorrhage/orbital compartment syndrome (OCS)

Goal-Lower the orbital compartment pressure as soon as possible to prevent tissue damage.

Minimum-Prompt recognition (i.e., bulging of eye, increased pressure by palpation, decreased vision, +RAPD). Lateral canthotomy/cantholysis (LCC) within 90 minutes of injury (if evacuation to surgical capability will take more than 60 minutes). Pain control, antiemetic, raise head 30º-45 º.

Better-Minimize patient movement, ice packs, monitor for return of increased intraorbital pressure (IOP).

Best-If rebleeding after initial response to lateral canthotomy/cantholysis, acetazolamide 500mg PO once then 250mg PO 4 times per day. If unable to take PO, 3% hypertonic saline 250ml IV or mannitol 1 g/kg IV over 30-60 minutes. Corticosteroid (e.g. 1g methylprednisolone IV once).

Relative afferent pupilary defect (RAPD), abnormal dilation of pupil when light is shined into injured eye.

LCC is a vision-saving procedure with minimal risk of causing additional ocular injury. When in doubt, perform LCC.

#### Closed globe injury (caused by blunt trauma)

Goal-Identify significant ocular injuries; protect the eye from further injury.

Minimum-Document vision, pain control. Prevent further damage with rigid shield, anti-emetic, raise head 30º-45º.

Best-Hyphema (anterior chamber injury): Topical steroid eye drop (prednisolone acetate 1% 4 times per day) and cycloplegic drop (cyclopentolate 1% 1 drop every 8 hours). Monitor vision and IOP. Treat elevated IOP with timolol eye drops 0.5%, 1 drop twice a day or acetazolamide 500mg PO once then 250mg po 4 times per day. (Note: contraindicated in patients with sickle cell trait). If unable to take PO, 3% hypertonic saline 250ml IV or mannitol 1 g/kg IV over 30-60 minutes.

Best-Retina/optic nerve (posterior chamber injury): Supplemental oxygen. Perform careful ultrasound and transmit images with telemedicine consult.

#### Eyelid laceration

Goal-Prevent infection, protect the eye from further injury.

Minimum-Maintain high suspicion for open globe injury (treat as such if suspected). Keep injured eyelid tissue moist by covering with polyethylene film (food grade).

Better-For foreign body penetration, animal bite, or laceration with visible orbital fat, start antibiotic: moxifloxacin 400mg PO daily or levofloxacin 750mg PO daily or amoxicillin/clavulanic acid 875mg/125mg PO every twelve hours or ertapenam 1 gm IV/IO daily.

Best-Detailed ocular exam. Irrigate and perform temporary closure of wounds. Tetanus and rabies prophylaxis if indicated.

#### Orbital fracture

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

Minimum-Maintain high suspicion for open globe injury. No nose blowing. Pain control, antiemetic, raise head 30º-45º.

Better-Antibiotic moxifloxacin 400mg PO daily or levofloxacin 750mg PO daily or amoxicillin/clavulanic acid 875mg/125mg PO every twelve hours or ertapenam 1 gm IV/IO daily. Initiate nasal decongestant (e.g., Afrin nasal spray twice a day for 3 days) or oral decongestant (e.g., pseudoephedrine 30mg every 6 hours).

Best-Detailed ocular exam. Ice pack for 20 min every 1-2 hours for first 48 hours. Monitor for delayed onset of OCS requiring LCC.

#### Chemical injuries

Goal-Initiate eye irrigation as quickly as possible to reduce damage to the eye, treat the injury to minimize scarring and loss of vision.

Minimum-Immediate irrigation with IV fluid, sterile water, or clean water with at least 2L of fluid. Remove any particulate matter using a cotton tip applicator.

Better-Continue irrigation until pH=7, verified using urine test strip.

Best-Grade I - erythromycin ophthalmic ointment, cyloplegic drops (cyclopentolate 1%), lubrication with artificial tears.

Best-Grade II-IV - topical antibiotic drops (moxifloxacin 0.5% eye drops, 1 drop every 8 hours), topical corticosteroid (tobradex or prednisolone acetate 1%, 1 drop every hour while awake), doxycycline 100 mg po every 12 hours, Vitamin C 2g 4 times per day, 100% O2 for 1hr twice daily.

#### Preseptal and orbital cellulitis

Goal-Recognize infection early and start appropriate antibiotics; evacuate suspected cases of orbital cellulitis to an eye surgeon as rapidly as possible

Minimum-Preseptal: Moxifloxacin 400mg PO daily or levofloxacin 750mg PO daily. Does not cover methicillin-resistant Staphylococcus aureus (MRSA); follow closely for worsening condition.

Minimum-Orbital: IV antibiotics: ertapenem, 1 g IV/IO daily or levofloxacin 500mg IV once a day.

Better-Orbital: Add nasal decongestant (e.g. Afrin nasal spray twice a day for 3 days) or oral decongestant (e.g., pseudoephedrine 30mg every 6 hours).

Best-Preseptal: Trimethoprim sulfamethoxazole DS 1 tablet PO every 8 hours combined with amoxicillin/clavulanic acid 875mg every 12 hours.

Best-Orbital: Continue IV antibiotics. Monitor vision every 4 hours until evacuation.

#### Infectious keratitis

Goal-Prompt recognition and treatment to minimize scarring and loss of vision.

Minimum-Moxifloxacin eye drops 1 drop every 15 minutes for first 2 hours, then 1 drop every hour while awake.

Better-Obtain a culture prior to beginning treatment for sight-threatening keratitis; intense loading dose of moxifloxacin 0.5% eye drops 1 drop every 5-15 min for the first 30-60 minutes (patient can self-administer loading dose if reliable) after culture obtained; then 1 drop every 30-60 minutes around the clock until epithelial defect is closed; cycloplegic eye drop (cyclopentolate 1%), 1 drop every 8 hours for photophobia.

Best-Collagen corneal shield soaked in moxifloxacin drops for transport (5-10 drops) placed over the corneal infiltrate.

#### Angle-closure glaucoma

Goal-Prompt recognition and treatment to decrease intraocular pressure.

Minimum-Diagnose based on signs and symptoms: pain, decreased vision, photophobia, dull or cloudy cornea, fixed mid-dilated pupil, increased IOP by palpation. Acetazolamide 500 mg PO initial dose, then 250mg PO every 4 hours to decrease IOP.

Better-Oral acetazolamide plus topical IOP-lowering eye drops (timolol 0.5%, 1 drop twice a day in the affected eye), antiemetic as needed.

Best-Topical corticosteroid (prednisolone acetate 1%) 1 drop every hour after consultation with eye specialist. IV medication for refractory cases (3% hypertonic saline 250ml IV or mannitol 1 g/kg over 30-60 min).

#### Multi-trauma/thermal burn

Goal-Prevent ocular exposure and corneal injury in high-risk patients.

Minimum-Keep the ocular surface from drying out using lubricants: sterile petrolatum or methylcellulose drops (do not substitute a non-ophthalmic lubricant). For burns, erythromycin ophthalmic ointment or sterile petrolatum every 2-4 hours.

Better-Horizontal taping of eyelids to protect eyes. Evaluate the eyes and instill a lubricant every 8 hours.

Best-Conduct a detailed ocular exam and cover eyes with food grade polyethylene film to protect eyes.

Surgilube should never be instilled into the eye as a lubricant due to corneal toxicity. When used for ultrasound examination, place a thin film over the closed eyelid.