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THERE ARE AN ESTIMATED 2–3 million emergency department (ED) visits in the United States for eye complaints, with estimates projected to increase due to a declining ophthalmology workforce and challenges in access to care resulting in more emergency department (ED) visits for eye complaints (Kim et al., 2022; Lee et al., 2019; Patel et al., 2023). Most patients who present to the ED have nontraumatic eye complaints (Channa et al., 2016); however, an analysis of the National Emergency Department Sample data set found that approximately one third of ED visits for eye complaints are related to eye trauma, which is more common during the summer months, in males, and in patients between the ages of 20 and 60 years (Kim et al., 2022; Ramirez et al., 2018). Approximately one third of all eye-related ED visits in the United States annually are for traumatic eye injuries (Channa et al., 2016; Go et al., 2022; Kim et al., 2022). Ocular trauma, which is often preventable, is a leading cause of unilateral blindness and vison impairment (Cheung et al., 2014; Go et al., 2022). Ocular trauma is more prevalent in White males, ages 45–64 years, and the most common causes are motor vehicle accidents, followed by fall-related accidents, and infection (Cheung et al., 2014).
Given the prevalence of eye-related ED visits, it is important that ED providers understand how to recognize and treat eye complaints to rapidly identify urgent and emergent eye conditions requiring prompt referral and treatment to promote optimal visual outcomes and prevent disability (Channa et al., 2016). This article: (1) reviews eye anatomy and physiology, (2) discusses the approach to the eye examination (i.e., external, internal, and slit lamp), and (3) provides selected common nonemergent and emergent eye complaints within the broad categories of traumatic injuries, red eye, and acute vision loss. For each complaint, a review of essential history questions, examination techniques, differentials to consider, and ED management has been presented.
EYE ANATOMYThis section covers ocular and adnexal structures. Bony structures have also been described herein.
Ocular and Adnexal StructuresFigure 1 shows the adnexal structures, the tissues surrounding the eye, and the inner eye anatomy. The internal ocular structures are protected by the thick protective cornea. Blunt force or penetrating trauma, foreign bodies, chemical splashes, abrasions, or perforations can damage the cornea as well as the anterior and posterior ocular structures. Injuries to the cornea and deeper structures can result in pain and vision loss. Some injuries require emergent referral whereas others can be managed with close outpatient follow-up.
Figure 1.: Eye anatomy. Illustration from Anatomy and Physiology, by Connexions (http://cnx.org/content/col11496/1.6/) and Search media, by Wikimedia Commons (https://commons.wikimedia.org/w/index.php?search=human+eye+anatomy&title=Special:MediaSearch&go=Go&type=image). Creative Commons Attribution 3.0.Bony Structures
Figure 2 shows the orbital bony structures that surround the eye. The orbital bony ridge is composed of the frontal and the thin, fragile maxillary, ethmoidal, sphenoid, lacrimal, palatine, and zygomatic bones. Blunt force trauma can fracture the delicate bones that make up the orbital floor entrapping the inferior rectus and inferior oblique muscles limiting movements and causing diplopia.
Figure 2.: EYE EXAMINATION
This section discusses the approach to the eye examination including the external, internal, and slit lamp examinations. Table 1 lists the basic steps in the eye examination.
Table 1. - Components of an eye examination Explain the examination to the patient because eye complaints are anxiety provoking and may be painfulNote. Created by D. Evans.
Obtain visual acuity first unless the patient had a biological or chemical splash, has an abnormal pupil, history of a penetrating eye injury, or if exposed to riot control agents (tear gas). If the provider is unable to obtain visual acuity, perform a gross estimate of the patient's vision. See Table 2.
Table 2. - Gross estimate of vision Description Abbreviation Definition Counting fingers CF Ability to count fingers at a given distance Hand motion HM Ability to distinguish a hand whether it is moving or not in front of the patient's face Light perception LP Ability to perceive any light No light perception NLP Inability to see any light—total blindnessNote. Created by K. Hoyt.
Examine the external and adnexal eye structures. This includes pupillary response, extraocular movements, visual fields, eyelids, conjunctiva, and cornea. Evert the lid to inspect for possible foreign bodies. Gently palpate the bony orbit if you suspect a fracture. Palpation of the closed eye with comparison to the unaffected eye can be used as a gross assessment of intraocular pressure (IOP) if tonometry is unavailable. Examine extraocular movements especially in patients complaining of visual disturbances.
To differentiate between optic and neurologic causes of vision loss, perform the swinging flashlight test used to assess for optic nerve neuropathy. To perform this test, examine the patient's pupils in ambient lighting. They should be equal in size. Next, darken the room and begin alternately shining a light into the patient's right and left eyes. Normally, the light will cause constriction in the stimulated eye along with consensual constriction in the other eye; however, if the optic nerve is damaged, direct light stimulation will cause dilation rather than constriction (Graves & Galetta, 2012). This abnormal pupillary response is referred to as a Marcus Gunn pupil.
Visual field testing is also an important aspect of checking optic nerve function, lesions in the brainstem or cerebellum, or paralysis or palsy of cranial nerves III, VI, and IV in patients complaining of visual disturbances or vision loss. If the damage is limited to one optic nerve, vision loss will be unilateral. If the damage occurs in the optic chiasm where the two optic nerves meet, vision loss will affect the outer peripheral visual fields of both eyes. If the visual pathway is damaged between the optic chiasm and the visual cortex of the occipital lobe, vision loss will affect the same visual fields in both eyes. For example, if the damage is in the right visual cortex, the patient will have vision loss in the left visual fields of both eyes.
Internal ExaminationExamine the posterior chamber structures including the retina and optic disc with the ophthalmoscope. Check the red reflex and retinal vessels for nicking and pulsations. Note any abnormalities such as cotton wool spots or hemorrhages on the retina.
Slit Lamp ExaminationAfter directly inspecting the external and internal eye structures, the cornea should be stained with fluorescein to check for defects. Do not apply fluorescein if suspicion of a penetrating foreign body, which can also cause an abnormal pupillary response. If after instilling fluorescein stain a Seidel sign, or leakage of aqueous fluid from the cornea, is noted, obtain an emergent computerized tomography (CT) scan of the orbits to assess for a penetrating foreign body that has torn through the cornea into the anterior or posterior chamber.
Next, assess the eye with a slit lamp, an ophthalmologic biomicroscope, to further examine the external eye structures, cornea, anterior chamber, and posterior chamber structures including the retina. Slit lamp assessment is the gold standard for examining eye complaints in the ED (DelMonte et al., 2023). Use of a slit lamp is a core clinical competency for ED clinicians but requires specialized training and practice for accurate assessment of eye trauma and disease (American Academy of Emergency Nurse Practitioners & Emergency Nurses Association, 2021). For an excellent resource on using the slit lamp and what to look for, refer to Dr. Timothy Root's book and video lecture series (Root, n.d.). If a slit lamp is not available, use a Wood's lamp to examine the cornea for defects after instilling fluorescein stain. Figure 3 shows a Wood's lamp and Figure 4 shows a slit lamp.
Figure 3.: The Wood's lamp. Photograph taken by Dian Evans.
Figure 4.: Slit lamp. Photograph taken by Dian Evans.
Intraocular Pressure MeasurementObtaining IOP measurements using tonometry is indicated in patients presenting with blunt eye trauma, a hyphema, or if a red eye associated with pain to rule out acute narrow-angle glaucoma. There are two types of tonometers used in the ED, the iCare (iCare Finland Oy, Vantaa, Finland) device and the Tono-Pen (Reichart, Inc, Depew, New York). Figures 5 and 6 show these different devices.
Figure 5.: iCare tonometer. Photograph taken by Dian Evans.
Figure 6.: Tono-Pen. Photograph taken by Dian Evans.
The iCare instrument uses a lightweight magnetic probe that lightly taps the cornea to obtain a rebound measure of IOP. This allows for a painless assessment that does not require anesthetizing the eye prior to the examination. In contrast, eye anesthetization is required when using a Tono-Pen because the probe of the device is placed directly on the cornea to obtain pressure readings. Both devices are easy to use, correlate well, but require practice to ensure accurate readings (Lee et al., 2019). Table 3 reviews the steps in using a tonometer to obtain IOP readings with indications for emergent and urgent ophthalmologic referral.
Table 3. - How to obtain intraocular pressure with a tonometer When using the Tono-Pen, calibrate the device, apply a disposable cover to the tipNote. Created by D. Evans.
The next section covers eye trauma including the etiology of eye trauma across the lifespan, external structure injuries, corneal injuries, ocular burns, blunt eye trauma, and penetrating foreign bodies. Red eye and vision loss are also discussed.
Eye TraumaTable 4 summarizes the history questions to include when assessing a patient with a traumatic eye injury.
Table 4. - History questions for orbital/ocular trauma Obtain a complete medical history and review of systemsNote. Created by D. Evans.
Table 5 lists the trauma-related eye examination steps. Traumatic eye injuries can be classified according to where they occur within the eye or surrounding structures.
Table 5. - Eye examination components for orbital/ocular trauma Wash hands and apply glovesNote. Created by D. Evans.
Table 6 depicts injury type by eye structure and urgency of referral to ophthalmology for definitive care. Patients with ocular trauma require tetanus prophylaxis if their immunization status is not up to date.
Table 6. - Types of eye injuries and selected management Injury condition/location Signs and symptoms Management Referral/complications Eye adnexa (eyelids, conjunctival sac, lacrimal gland, and drainage system)Note. CT = computerized tomography; FB = foreign body; HOB = head of bed; IV = intravenous; NS = normal saline; PMD, primary medical doctor; V/A = visual acuity. Created by D. Evans and K. Hoyt.
Superficial injury of the cornea is the most common traumatic diagnosis across age groups, and males sustain most of the injuries (Kim et al., 2022; Miller et al., 2018; Ramirez et al., 2018). Other traumatic diagnoses include ocular contusions, anterior and posterior segment injuries, orbital fractures, and open globe injuries (Cheung et al., 2014).
Lacerations and contusions to the eyelids can typically be managed without the need for ophthalmology referral unless they involve the lacrimal gland and structures, which require prophylactic antibiotic medication and surgical repair with stent placement within 48 hr (Ducasse et al., 2016). Open globe injuries and eyeball lacerations require immediate ophthalmologic referral with repair within 6 hr (Ducasse et al., 2016). Patients experiencing these injuries will require analgesics and often antiemetic medications.
If there is bruising and abnormal extraocular movements, suspect a fracture, order an orbital and facial CT, provide prophylactic antibiotics, and consult an ophthalmologist or facial plastic surgeon emergently (Koenen & Waseem, 2022). Anterior and posterior segment injuries such as hyphema or retinal detachment also require emergent evaluation by an ophthalmologist.
Etiology of Eye Trauma Across the LifespanPediatric eye injuries are typically nonemergent and include corneal abrasions, conjunctivitis, and foreign bodies (Miller et al., 2018). The most common pediatric eye emergencies include eyebrow and eyelid lacerations, contusions of the eye area, eye pain, and visual disturbances (Miller et al., 2018). Because eye injuries may result from child maltreatment, maintain a high degree of suspicion when assessing children with ocular injuries (Christian & Binenbaum, 2022).
Sports-related injury is a frequent etiology in pediatric eye trauma among children aged 10–17 (Kim et al., 2022; Miller et al., 2018; Patel et al., 2023). In a cross-sectional analysis of sports-related ocular trauma obtained from the U.S. Consumer Product Safety National Electronic Injury Surveillance System All Injury Program dataset, Patel et al. (2023) found that basketball (37.8%), baseball (12.8%), and football (12.3%) accounted for most sports-related ocular injuries. Corneal/scleral abrasions were more common with basketball injuries, contusions with baseball, and major anterior and posterior ocular injuries occurring more often from nonpowder guns (paintball, BB, and pellet) and soccer. Although the frequency of eye trauma is more common in boys, dance, gymnastics, and cheerleading are the sports activities associated with most eye injuries in girls (Miller et al., 2018).
In adults, use of workshop tools accounts for most cases of product-related ocular trauma in those older than 20 years whereas sports activities account for most cases of ocular trauma in those younger than 20 years (Go et al., 2022). Injury from falling on home furniture causes most ocular injuries in adults older than 80 years (Go et al., 2022).
Corneal InjuriesMinor anterior chamber/segment injuries include corneal/scleral abrasions and foreign bodies that can be managed with oral or topical analgesic medication, such as ketorolac drops, topical antibiotic drops, and ophthalmology reevaluation within 24 hr (Fusco et al., 2019). Patients with corneal abrasions from contact lens should be seen the next day and be treated with fluoroquinolone topical antibiotics (Gilani et al., 2017).
Providing patients with topical anesthetics for pain relief at discharge, such as tetracaine, is controversial. One systematic review found that brief use of topical anesthetics does not impair corneal healing if used for 24 hours or less (Puls et al., 2015). However, another review cited this practice is not without risks because use may mask a worsening condition that could lead to possible permanent visual impairment (Fraser et al., 2019). Use of prophylactic topical antibiotics is also controversial for management of corneal/scleral abrasions. One systematic review found that topical antibiotics did not reduce infection or accelerate healing when compared with a placebo (Algarni et al., 2022). Eye patches for corneal abrasions are not recommended because they have not been found to improve corneal healing or reduce pain (Lim et al., 2016).
Ocular BurnsOcular exposure to chemical or biologic agents requires rapid decontamination with copious irrigation using water, saline, or lactated Ringer's (LR) until the normal eye pH returns (approximately 7.5) (Slovin, 2015). LR is the preferred irrigation solution because it is closest to the pH of the eye and is less likely to cause corneal edema and endothelial damage than either tap water or normal saline (Rihawl et al., 2006). However, if rapid irrigation is needed, use whatever solution is available.
Patients who have been exposed to riot control substances (tear gas) will need body decontamination before entering the clinical area for eye irrigation. Although referred to as tear gas, riot control agents are aerosolized dry particles that burn and irritate the eye and respiratory mucosa. These particles adhere to clothing as well as the skin. To avoid provider exposure and contamination, patients exposed to these agents should carefully remove clothing outside of the care setting and wash the skin before being evaluated because the particles will continue to aerosolize if decontamination is not performed (Rothenberg et al., 2016). Visual acuity should be obtained following decontamination and eye irrigation.
Patients with corneal burns require tetanus prophylaxis, analgesic medication, topical antibiotics, and next-day ophthalmologic follow-up (Soleimani & Naderan, 2020). Although corneal burns are typically mild, all chemical burns require emergent irrigation and ophthalmologic management because alkaline agents can cause devastating damage with complications to internal structures that can even occur following initial treatment (Soleimani & Naderan, 2020).
Most chemical burns result from alkaline agents, such as ammonia, found in fertilizers and household and industrial cleaning agents (Soleimani & Naderan, 2020). Alkaline substances cause liquification necrosis of tissues resulting in severe damage that may require surgery to manage the structural, functional, and cosmetic effects (Soleimani & Naderan, 2020). In contrast, acid burns, such as sulfuric acid found in batteries or industrial agents, cause a coagulation necrosis that, unlike alkaline agents, prevents penetration to deeper structures (Soleimani & Naderan, 2020). The Roper-Hall and Duas Classification systems are used to grade injuries and predict outcomes resulting from chemical burns. The most severe physical examination findings from ocular burns include opacification of the cornea that obscures the iris and pupil. Table 7 shows components of the Roper-Hall Burn Classification system with predicted prognoses based on findings.
Table 7. - Roper-Hall classification for ocular chemical surface burns Grade Cornea Conjunctiva/limbus involvement Prognosis I Some epithelial damage No limbal ischemia Good II Corneal haze, iris details visible Less than one-third limbal ischemia Good III Total epithelial loss, haze, iris details obscured, pupil visible One-third to one-half limbal ischemia Guarded IV Cornea opacity, pupil and iris obscured More than one-half limbal ischemia PoorFireworks-related ocular injuries may cause ocular burns, but they can also result in superficial and penetrating ocular foreign bodies, conjunctival irritation, and globe rupture (Shiuey et al., 2020). Bottle rockets are associated with the most severe injuries, and young White males are most frequently affected (Shiuey et al., 2020). Ocular burns can also occur from welding when protective eye shields are not used properly (Yan et al., 2022).
Blunt Eye Trauma and Penetrating Foreign BodiesPenetrating high-velocity foreign bodies can result from hammering, metal cutting, chiseling, or from firearms. These injuries can often damage the posterior structures of the eye including vitreous detachment, retinal hemorrhage, tears and detachment, or globe rupture resulting in permanent vision loss (Gupta & Tripathy, 2023). A rapidly obtained CT scan of the orbit is needed to accurately evaluate these injuries with emergent ophthalmology referral for management.
Patients with traumatic hyphemas from blunt force trauma also require an orbital CT to evaluate for coexisting bony trauma and tonometry to assess IOP. Patients with hyphemas and increased IOP require emergent ophthalmology referral because they will require medical or possibly surgical treatment to reduce the risk of blindness (Chen & Fasiuddin, 2021). Until seen by ophthalmology, patients with hyphemas should rest with the head of the bed elevated to improve vision and help with resolution (Chen & Fasiuddin, 2021). Steroids and cycloplegic medications are frequently used to improve comfort and reduce inflammation (Chen & Fasiuddin, 2021).
Ocular Trauma Red FlagsIn summary, red flags in orbital/ocular trauma include fractures, acute vision loss, abnormal pupillary response or shape, large hyphemas, globe rupture, enucleation, penetrating foreign bodies, proptosis, and complex lid lacerations. These conditions all require emergent ophthalmology consultation. Proptosis, resulting from blunt force trauma, suggests a retrobulbar hemorrhage or orbital compartment syndrome. Management of this condition requires an emergent lateral canthectomy to prevent blindness (Park et al., 2021). Orbital compartment syndrome may also entrap the eye muscles causing abnormal extraocular movements.
Red EyeThe differential diagnoses of red eye presentations range from infectious etiologies to environmental irritants, trauma, and acute narrow-angle glaucoma. Table 8 summarizes the key history questions for red eye presentations.
Table 8. - History questions for red eye presentations Obtain a complete medical history and review of systems (autoimmune disorders can present with ocular manifestations). Medication history (antihistamines and antipsychotics can increase intraocular pressure)
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