Ocular trauma (Guidelines)

Following blunt ocular trauma (eg punch, badminton or football injury) a fluid level of blood (hyphaema) may be visible in the anterior chamber between the cornea and the lens inferiorly.

Management:

1. Topical Steroid (Maxidex), four times per day
2. Mydriatic (Cyclopentolate 1%), three times per day.
3. Pressure lowering medication (Dorzolamide / Timolol combination drop), two times per day. 
4. Arrange for follow up with Ophthalmology that day or, if out of hours, the following day.

Depending on the mechanism of injury, there might be a corneal abrasion, and this should be managed as per that protocol

Symptoms:

1. Patient complains of double vision, especially on looking up
2. May have paraesthesia in the distribution of the infraorbital nerve (check, upper lip, plus teeth and gums)

Signs:

1. Restricted upgaze
2. Enophthalmos (affected eye appears further back in orbit)
3. Inferior orbital fracture on Radiology

Management:

1. Refer to Max-Fax service
2. Referral to Ophthalmology plus Orthoptics - that day or, if out of hours, the following day

Trauma can rarely cause an arterial bleed behind the orbital septum, which can lead to a rapid onset of swelling of the lids and proptosis. Unless dealt with very quickly there is the risk of irreversible blindness.

Symptoms:

1. Pain
2. Decreased vision (hand movements only or worse)

Signs:

1. Tense lid swelling
2. Tense proptosis
3. Decreased eye movements
4. May be difficult to prise the lids apart to examine the globe - if available the insertion of a speculum following instillation of topical anaesthetic may help.
5. Unresponsive pupil

Management:

Requires immediate lateral canthotomy.

1. Infiltration of local anaesthetic into the lateral lower lid
2. Disinsert lower lid at the lateral end by placing sharp scissors into the lower lid and cutting downward and laterally towards the orbit (ensuring that the orbital septum is penetrated). There should be a release of the orbital blood which will be under pressure. (video athttps://first10em.com/lateral-canthotomy/)
3. Admit to NTC Ophthalmology

Symptoms:

1. Decreased visual acuity – may be severe, almost always one eye only

Signs:

1. Unresponsive pupil
2. Absence of other eye pathology to explain decreased acuity

Management:

1. Exclude retro-orbital haemorrhage clinically (ie, absence of tense proptosis and decreased eye movements)
2. Analgesia as required
3. Referral to Ophthalmology - that day or, if out of hours, the following morning

NB: There is no evidence for the use of systemic steroid in the management of Traumatic Optic Neuropathy.

Usually result of high impact trauma or sharp trauma, eg. falling whilst intoxicated and striking the eye on a table edge or hammer/chisel injuries.

Symptoms:

1. Pain
2. Decreased vision

Signs:

1. Subconjunctival haemorrhage
2. Hyphaema
3. May have obvious corneal or sclera laceration with prolapsing pigmented tissue

Management:

1. Refer Ophthalmology (out of hours - admit to NTC Ophthalmology with review the next morning)
2. Eye shield
3. CT scan 
4. Nurse propped up
5. Chloramphenicol eye drops 4 times per day
6. IV Ciprofloxacin 400mg twice daily
7. Analgesia
8. Keep nil by mouth from 2am