A patient presents with a periorbital ecchymosis (“black eye”) from blunt trauma. Medicaly, it’s no big deal; it’ll all get better on its own. You can suggest ice packs, or hot soaks, or both or neither, NSAIDs, etc. But the main point of course is DIAGNOSIS: are there any sight-threatening or other catastrophic complications besides the black eye?
Probably not — but perform a systematic exam as follows:
FIRST — If history of loss of consciousness or concussive symptoms, deal with the Head Trauma in addition to the eye. We won’t discuss this here right now.
- At a minimum, palpate the cervical spine to R/O focal tenderness suggesting fracture (the first thing to do for anyone with head trauma).
Now, on to the eye itself.
1. Look at the pupil. If it’s pear-shaped or otherwise irregular, STOP. There’s likely a ruptured globe.
- Check visual acuity [see below]
- Protect the eye [see below]
Call EMS for transport to an ED [see below]
Checking Visual Acuity:
Use a Snellen chart, at a distance. But when there’s suggestion of a ruptured globe, start simple with the following levels of acuity, from poor to blind:
- Finger-Count at 5 feet (have them count your fingers)
- Finger-Count at 2 feet
- Hand Motion at 2 feet (wiggle your hand and say, “Tell me when it stops.” “Now, tell me when it moves.”)
- Light Projection (in a dark room, shine a penlight from various directions and say, “Point to the light”)
- Light Perception (in a dark room, shine a light directly into the eye and say, “Do you see the light? Tell me when it goes off. Tell me when it goes on again.”)
These are standard levels of acuity used by eye specialists in any context, when the vision is worse than 20/400 (=10/200: a standard Snellen chart, but 10 feet away).
Of course, if the acuity is at least “Finger-Count-at-5-Feet,” do more formal Snellen testing when waiting for EMS.
Protect the Eye
- Place a hard eye shield over the injured eye. Improvise as necessary, e.g. an upside-down paper cup. Goal: prevent patient from touching the eye. If fluid is draining, loosely tape a gauze pad over the eye first, without pressure.
- Keep patient quiet in a dark room. Can consider a pressure patch over the uninjured eye, keeping it still so the injured one doesn’t move along with it.
- For crying children (or adults), consider sedation (parenteral or by rectal suppository).
- For nauseated patients, consider parenteral or rectal anti-emetics (vomiting, or other valsalvas, will extrude more ocular content)
Call an Ambulance — Ruptured Globe requires immediate surgery
- Nothing By Mouth (n.p.o.) [they’re heading to OR]
- Telephone the appropriate hospital’s ER attending. If there’s no ophthalmologist on-call, telephone elsewhere.
2. Pupils appear normal? Check Pupillary Reaction, direct and consensual. If the injured pupil doesn’t react, assume a Ruptured Globe and proceed as for #1 above.
3. Normal Pupils? Do formal Snellen Testing for Visual Acuity, at a standard 20-foot distance, both eyes.
- If injured eye has poor vision, re-check with Pinhole [click here if you don’t remember this all-important concept].
- If visual acuity significantly decreased in injured eye, and “doesn’t pinhole” [i.e. no improvement with pinholing], coax the patient to perform better. Sometimes simple tearing may get in the way of a decent exam.
- Significantly decreased acuity without good explanation? Assume a Ruptured Globe and proceed as for #1 above.
4. Normal Pupils and Normal Acuity (on its own, or with pinholing)? Inspect the entire visible Sclera as best you can.
- Check for fluid leaking. If so, assume ruptured Globe and proceed as for #1 above.
- Check for unilateral exophthalmos or lid lag. These can be signs of a retro-orbital hematoma that can progressively compress the optic nerve, causing blindness
Subconjunctival Hemorrhage? Not necessarily alarming, as long as everything else is normal, & the globe is non-tender [see below]. However, a large or bullous subconjunctival hemorrhage from significant trauma warrants ophthalmology evaluation to R/O a ruptured globe.
Bullous Subconjunctival Hemorrhage:
5. Check for a Hyphema, blood in the anterior chamber.
- Patient must be sitting, or otherwise erect.
- Carefully inspect the bottom of the iris for a tiny layer of red (blood), usually with a peripheral meniscus
- Can do the same using the ophthalmoscope on high positive [black] diopters, that bring the iris into focus
If Hyphema present, call Ophtho. Ask if you should protect the eye with shield as above, and send by Ambulance.
Hyphemas with Ruptured Globes (note irregular pupils):
6. Everything fine so far? Palpate the Globe, not directly of course, but through the closed upper eyelid. Wiggle it very gently back and forth.
- Tenderness suggests an occult Rupture.
- Even more concerning: tenderness PLUS subconjunctival hemorrhage
- Call ophthalmology to discuss: report that your patient experienced blunt eye trauma, visual acuity, pupils, and inspection are all normal, but the globe is tender.
7. Exam normal and no tenderness? Check the extra-ocular movements.
- An EOM deficit suggests entrapment by an orbital fracture. Send to ER for X-rays.
- Tender EOMs is worrisome for a ruptured globe, which is unlikely if there’s no tenderness to palpation as above, & everything else is fine. Call Ophtho to discuss.
8. Inquire if the patient is seeing flashing lights or lots of new floaters?
- Could suggest early retinal detachment. discuss with Ophtho.
9. The eye itself seems perfectly fine? Palpate the orbital bones.
- Focal tenderness suggests an orbital fracture. Warrants an x-ray, and a call to Ophtho if fracture is found. However, as long as the EOMs are full (no entrapment), nothing gets done. Still, Ophtho should follow.
10. Exam is entirely normal, except for periorbital ecchymosis (“black eye”)? Get a good, convincing history of what happened (“I walked into a doorknob” doesn’t fly).
- R/O Domestic Violence. If you miss this, you may be sending your patient home to the Perp.
SUMMARY — Examining the patient with Blunt Eye Trauma1. Pupils
- Irregular, pear-shaped pupil = Ruptured Globe
- Non-Reactive pupil = Ruptured Globe (until proved otherwise)
- Decreased acuity, doesn’t pinhole = Ruptured Globe (until proved otherwise)
- Fluid leak = Ruptured Globe
- Unilateral Exophthalmos or Lid Lag = Retro-orbital Hematoma
- Large / Bullous Subconjunctival Hemorrhage = ? Ruptured Globe
- Level of blood at bottom = Hyphema
- Tenderness suggests Ruptured Globe
If Everything Normal Up to Here6. Check Extraocular Movements (EOMs)
- Deficit = entrapment (orbital fracture)
- Tenderness = risk to Globe
- ? early retinal detachment
- Focal tenderness = possible fracture
- Unconvincing story — suspect Domestic Violence