Eye Contusions and Lacerations

Eyelid contusions (which result in black eyes) are more cosmetically than clinically significant, although more serious injuries may sometimes accompany them and should not be overlooked. Uncomplicated contusions are treated with ice packs to inhibit swelling during the first 24 to 48 hours.

Eyelid Contusion (Black Eye)

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Minor lid lacerations not involving the lid margin or tarsal plate may be repaired with nylon or polypropylene (or, in some populations such as children, absorbable suture such as plain gut) 6-0 or 7-0 sutures. Lacerations of the lid margin are best repaired by an ophthalmic surgeon to ensure accurate apposition and to avoid a notch in the contour. Complicated lid lacerations, which include those of the medial portion of the lower or upper eyelid (possibly involving the lacrimal canaliculus), through-and-through lacerations, those in which the patient has ptosis, and those that expose orbital fat or involve the tarsal plate, should also be repaired by an ophthalmic surgeon.

Trauma may cause the following:

• Conjunctival, anterior chamber, and vitreous hemorrhage

• Retinal hemorrhage, edema, or retinal detachment

• Laceration of the iris

• Cataract

• Dislocated lens

• Glaucoma

• Globe rupture (laceration)

Evaluation can be difficult when massive lid edema or laceration is present. Even so, unless the need for immediate eye surgery is obvious (necessitating evaluation by an ophthalmologist as soon as possible), the lid is opened, taking care not to exert pressure on the globe, and as complete an examination as possible is conducted. At a minimum, the following are noted:

How To Do Lateral Canthotomy

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• Visual acuity

• Pupil shape and pupillary responses

• Extraocular movements

• Anterior chamber depth or hemorrhage

• Presence of red reflex

An analgesic or, after obtaining any surgical consent, an anxiolytic may be given to facilitate examination. Gentle and careful use of eyelid retractors or an eyelid speculum makes it possible to open the lids. If a commercial instrument is not available, the eyelids can be separated with makeshift retractors fashioned by opening a paperclip to an S shape, then bending the U-shaped ends to 180°. Globe laceration should be suspected with any of the following:

• A corneal or scleral laceration is visible.

• Aqueous humor is leaking (positive Seidel sign).

• The anterior chamber is very shallow (eg, making the cornea appear to have folds) or very deep (due to rupture posterior to the lens).

• The pupil is irregular (possibly indicating herniation of the iris).

• The red reflex is absent (possibly indicating vitreous hemorrhage, or retinal injury).

If globe laceration is suspected, measures that can be taken before an ophthalmologist is available consist of applying a protective shield and combating possible infection with systemic antimicrobials as for intraocular foreign bodies. A CT scan should be done to look for a foreign body and other injuries, such as fractures. Topical antibiotics are avoided. Vomiting, which can increase intraocular pressure (IOP) and contribute to extravasation of ocular contents, is suppressed using antiemetics as needed. Because fungal contamination of open wounds is dangerous, corticosteroids are contraindicated until after wounds are closed surgically. Tetanus prophylaxis is indicated for open globe injuries.

Very rarely, after laceration of the globe, the uninjured, contralateral eye becomes inflamed (sympathetic ophthalmia) and may lose vision to the point of blindness unless treated. The mechanism is an autoimmune reaction; corticosteroid drops can prevent the process and may be prescribed by an ophthalmologist.

Hyphema may be followed by recurrent bleeding, intraocular pressure (IOP) abnormalities, and/or blood staining of the cornea, any of which may result in permanent vision loss. Symptoms are of associated injuries unless the hyphema is large enough to obstruct vision. Direct inspection typically reveals layering of blood or the presence of clot or both in the anterior chamber. Layering is seen as a meniscus-like blood level in the dependent (usually inferior) part of the anterior chamber. Microhyphema, a less severe form, may be detectable by direct inspection as haziness in the anterior chamber by slit-lamp examination with visualization of suspended red blood cells.

An ophthalmologist should attend to the patient as soon as possible. The patient is placed on bed rest with the head elevated 30 to 45° and is given an eye shield to protect the eye from further trauma (see Corneal Abrasions and Foreign Bodies). Patients who are at high risk of recurrent bleeding (eg, those with large hyphemas, bleeding diatheses, anticoagulant use, or sickle cell disease), who have IOP that is difficult to control, or who are likely to be nonadherent to recommended treatment may be hospitalized. Testing for bleeding abnormalities should be considered if the cause of the hyphema is not known. Oral and topical nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated because they may contribute to recurrent bleeding.

Anterior Chamber Hemorrhage (Hyphema)

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Blowout fracture occurs when blunt trauma forces the orbital contents through one of the most fragile portions of the orbital wall, typically the floor. Medial and roof fractures also can occur. Orbital hemorrhage can cause complications such as entrapment of the infraorbital nerve, lid edema, and ecchymosis. Patients may have facial or orbital pain, diplopia, enophthalmos, hypesthesia of the cheek and upper lip (due to infraorbital nerve entrapment or injury), epistaxis, and/or subcutaneous emphysema. Other facial fractures or injuries must also be ruled out.

Diagnosis is best made using CT with thin cuts through the facial bones. If ocular motility is impaired (eg, causing diplopia), extraocular muscles should be assessed for signs of entrapment.

If there is diplopia or cosmetically unacceptable enophthalmos, surgical repair may be indicated. Patients should be told to avoid blowing the nose to prevent orbital compartment syndrome from air reflux. Using a topical vasoconstrictor for 2 to 3 days may alleviate epistaxis. Oral antibiotics could be used if patients have sinusitis.

Orbital compartment syndrome (OCS) is an ophthalmic emergency. OCS occurs when orbital pressure increases suddenly, usually due to trauma that causes orbital hemorrhage. Anything that increases orbital volume (air, blood, or pus in the orbit) can lead to an OCS. Symptoms can include sudden vision loss, as well as diplopia, eye pain, and lid swelling.

Physical examination findings may include decreased vision, chemosis, ecchymosis, limited and/or painful eye motility, afferent pupillary defect, proptosis, ophthalmoplegia, and elevated intraocular pressure (IOP). Diagnosis is clinical and treatment should not be delayed for imaging.

Treatment is immediate lateral canthotomy and cantholysis (surgical exposure of the lateral canthal tendon with incision of its inferior branch) followed by:

• Monitoring with possible inpatient hospitalization with elevation of the head of the bed to 45°

• Treatment of elevated IOP as in acute angle-closure glaucoma

• Reversal of any coagulopathy

• Prevention of further increasing intraorbital pressure (preventing or minimizing pain, nausea, cough, straining, severe hypertension)

• Application of ice or cool compresses

• Consultation with ophthalmology for consideration of surgery and/or other indicated speciality-specific treatments