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OCULAR
TRAUMA
Eye injuries are common and are an important cause of
blindness. Early diagnosis and proper treatment are imperative
to prevent blindness.
Superficial injuries
Superficial lacerations of the conjunctiva or cornea do not
require surgical intervention. If a foreign body is not present,
copiously irrigate the eyelid and eye with sterile saline,
apply tetracycline 1% eye ointment and apply an eye pad with
the eyelids closed. Leave the dressing in place for 24 hours,
and then re-examine the eye and eyelids. If the injury has
resolved or is improving, continue applying antibiotic eye
ointment three times daily for 3 days.
Eyelid lacerations
Carry out wound toilet and minimal debridement preserving as
much tissue as possible. Never shave the brow or invert hair-bearing
skin into the wound. If the laceration involves the lid margin,
place an intermarginal suture behind the eyelashes to assure
precise alignment of the wound (Figure
5.18). Carry out the
repair in layers: the conjunctiva and tarsus with 6/0 absorbable
suture, the skin with 6/0 non-absorbable suture and muscle
(orbicularis oculi) with 6/0 absorbable suture (Figure
5.19).
Tie suture knots away from the orbit.
Lacerations involving the inferior lacrimal canaliculus require
canalicular repair. Refer the patient for specialized surgical
management of the duct but, prior to referral, repair the lid
laceration.
Eye
The first objective in the management of eye injuries is to
save sight and to prevent the progression of conditions that
could produce further damage.
Blunt trauma
Hyphaema (blood in the anterior chamber) is caused by blunt
trauma. Check for raised intraocular pressure. If intraocular
pressure is elevated or indicated by a total hyphaema or pain,
administer acetazolamide 250 mg orally every 6 hours. If a
patient has hyphaema, admit to hospital, put on complete bed
rest, sedate, and patch both eyes. Examine and dress the eye
daily. If the hyphaema is not resolving in 5 days, refer the
patient.
Lacerations and penetrating trauma
Manage perforations of the cornea without iris prolapse and
with a deep intact anterior chamber with local atropine (1%
drops or ointment) and local antibiotics (1% eye drops). Dress
the injured eye with a sterile pad and examine it daily. After
24 hours, if the anterior chamber remains formed, apply atropine
1% and antibiotic eye ointment daily for another week.
If the anterior chamber is flat, apply a bandage for 24 hours.
If the anterior chamber does not reform, refer the patient.
Refer patients with perforation of the cornea complicated with
iris incarceration or posterior rupture of the globe. Suspect
a posterior rupture of the globe if there is low intraocular
pressure and poor vision. Instil atropine 1%, protect the injured
eye with a sterile pad and shield and refer the patient to
an ophthalmologist.
Measurement of intraocular pressure
Measure the pressure by means of a Schiotz tonometer. With
the patient prone, instil anaesthetic drops in both eyes. Instruct
the patient to look up keeping the eyes steady. With your free
hand gently separate the lids without pressing the eyeball
and apply the tonometer at right angles to the cornea (Figure
5.20). Note the reading on the scale and obtain the corresponding
value in millimetres of mercury (mmHg) or kilopascals (kPa)
from a conversion table. Verify readings at the upper end of
the scale by repeating the measurement using the additional
weights supplied in the instrument set. Repeat the procedure
for the other eye. An intraocular pressure above 25 mmHg (3.33
kPa) is above normal but not necessarily diagnostic. Values
above 30 mmHg (4.00 kPa) indicate probable glaucoma, for which
the patient will need immediate referral or treatment.
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