Blunt Eye Trauma

Examining the patient with Periorbital Ecchymosis (“Black Eye”)
1.  Pupils
  • Irregular, pear-shaped pupil = Ruptured Globe
  • Non-Reactive pupil = Ruptured Globe (until proved otherwise)
2.  Visual Acuity
  • Decreased acuity, doesn’t pinhole = Ruptured Globe (until proved otherwise)
3.  Inspect Sclera
  • Fluid leak = Ruptured Globe
  • Unilateral Exophthalmos or Lid Lag = Retro-orbital Hematoma
  • Large / Bullous Subconjunctival Hemorrhage = ? Ruptured Globe
4.  Inspect Iris (pt. sitting / erect)
  • Level of blood at bottom = Hyphema
5.  If all normal so far, Palpate Globe (gently wiggle eye through closed upper eyelid)
  • Tenderness suggests Ruptured Globe
6.  Inquire about flashing lights, or new onset lots of floaters
  • Maybe early retinal detachment

If Everything Normal Up to Here

7.  Check Extraocular Movements (EOMs)
  • Deficit = entrapment (orbital fracture)
  • Tenderness = risk to Globe
8.  Palpate Orbital Bones
  • Focal tenderness = possible fracture
9.  Confirm History
  • Unconvincing story  —   suspect Domestic Violence
A)  Cover eye with hard shield (e.g. tape on an upside-down paper cup)
B)  Keep patient in dark room
C)  Consider sedation (parenteral or rectal)
D)  If nauseated, consider anti-emetic (parenteral or rectal)
E)  NOTHING BY MOUTH  —  strict n.p.o.  [heading to OR]
F)  Call destination ER Attending to confirm there’s Ophtho on-call