Chapter 24 Damage Control Management of Eye Injuries

Priorities in the care of an injured patient are life, limb, and then eyesight. Eye injuries are usually evaluated in the secondary survey. This chapter will review a rapid approach to assessment for eye injury, essential interventions to protect the injured eye, and pitfalls in the management of eye injury.

Learning Objectives

By the end of the ASSET course, participants should be able to do the following:

1. Describe the rapid assessment and management of eye injuries.
2. Describe the common findings and symptoms of orbital compartment syndrome and retrobulbar hematoma.
3. Discuss indications for performing eye irrigation, eye shielding, and lateral canthotomy and cantholysis (LCC).
4. Demonstrate the steps required for performing LCC.
5. Explain potential pitfalls in the management of eye injuries.

General Considerations

• Vision is the vital sign of the eye in conscious patients and is the best indicator of eventual visual prognosis after injury. It also gives an indication of urgency; the worse the vision, the more urgent the condition. Vision is evaluated by simple initial assessment of each eye (with the contralateral eye closed or blocked):
  • Can you read any print or type? Identify any images?
  • How many fingers do you see? (counts fingers, CF)
  • Do you see a hand moving? (hand motion, HM)
  • Do you see light? (light perception, LP; no light perception, NLP)
• The vision of the uninjured eye can provide a useful comparison for vision assessment. A pocket Snellen chart is not necessary for accurate vision assessment in the trauma bay. Readily available and simple alternatives, such as typeface of name badges and newspapers are acceptable substitutes for documenting this important information.
• The periorbital soft tissues, upper and lower eyelids, and bony orbit protect the globe. The medial and lateral canthi serve as attachment points for the upper and lower eyelids. Regardless of consciousness, all protective structures should be inspected for lacerations and swelling as indicators of potential open globe injury.
• In a conscious patient without contralateral eye injury, eye movement can be assessed quickly for evidence of extraocular muscle entrapment from orbital floor fractures. With muscle entrapment, elevation of the eye(s) is usually restricted, and the patient will often complain of double vision with both eyes open.
• The globe is briefly evaluated for redness, foreign bodies, and lacerations. An irregular pupil, externalized iris tissue, or gelatinous eminence from the eye indicates a possible globe rupture or other penetrating globe injury. Other findings of globe injury are hyphema, bullous subconjunctival hemorrhage, enophthalmos, and/or conjunctival tear.
• Ocular proptosis (protrusion of the eye from its socket) with diffuse subconjunctival hemorrhage and swelling (hemorrhagic chemosis) suggests increased retro-orbital pressure with possible retrobulbar hemorrhage and is an eye emergency.
• There are two true eye injury emergencies requiring immediate intervention: orbital compartment syndrome (OCS, usually from retrobulbar or retro-orbital hematoma) and acid/alkali splash burns to the eye. In both conditions, minutes matter and treatment cannot be delayed for the arrival of an opthalmologist.
• OCS typically results from hemorrhage in the orbit (Figure 1). This can compress the globe, vessels, and optic nerve, putting the nerve on tension compromising blood flow to the retina. The resultant retinal and optic nerve ischemia may result in blindness within 60-90 minutes if not addressed.
• OCS is not always associated with an orbital fracture, as the fracture permits decompression of hemorrhage into the adjacent sinuses. The retro-orbital space must be decompressed rapidly with urgent LCC.
• Acid/alkali splash burns to the eye are managed immediately with copious water directly on the eye for at least 30 minutes. There is no need for further testing—history alone guides the need for immediate irrigation. Alkali exposure can cause corneal melting and ocular ischemia and is more serious than acid exposure.
• Open globe injuries are best managed initially with placement of a rigid periorbital eye (Fox) shield (convex shape) over the socket (Figure 2).
• It is vital to avoid any pressure on the eye if an open globe injury is suspected. Avoid maneuvers that might induce nausea, vomiting, or retching, and administer antiemetics and analgesics.
• In adults, intravenous antibiotics (4th generation fluoroquinolone or Cefazolin) should be administered as soon as possible and urgent ophthalmological consultation obtained.
• If a retrobulbar hematoma is present in the setting of a ruptured globe, the injury should be managed with a Fox shield and immediate ophthalmological consultation.
• Almost all eye injuries are best managed initially with placement of a Fox shield (not a patch) including corneal, conjunctival, intraocular foreign bodies, hyphema, lid lacerations, and severe corneal abrasions.
• Other than the two true surgical emergencies listed above, most eye injuries are best left to the care of an eye specialist and can be addressed in a more delayed fashion. General principles for the initial management of such nonemergency injuries are as follows:
  • Perform a rapid check of visual acuity
  • Limit manipulation of the eye to a minimum
  • Leave foreign bodies in place
  • Do not suture wounds unless evacuation is delayed
  • Do not employ topical treatment
  • Correctly apply an eye shield (Figure 2)
  • Administer antibiotics, antiemetics, and analgesics

Orbital Compartment Syndrome (Retrobulbar Hematoma)

• OCS, commonly caused by a retrobulbar hematoma, is an eyesight-threatening condition that requires prompt recognition and treatment.
• Irreversible vision loss can occur in as little as 60–90 minutes; therefore, expedient diagnosis and treatment are needed to prevent blindness.
• The keys to recognition of OCS are severe eye pain, tense proptosis, vision loss, afferent pupillary defect, and decreased eye movement.

Anatomy of the Lateral Eyelid Margin

• Proper performance of a lateral canthotomy and inferior cantholysis depends on identification of the lateral canthus and underlying lateral canthal tendon (Figure 3).
• The lateral canthal tendon is a web-like band of connective tissue that originates from the lateral margins of the upper and lower tarsal plates in each eyelid and inserts on the superficial lateral orbital wall. The tendon is formed from the coalescence of the superior and inferior crura.

• The orbit contains the globe, optic nerve, extraocular muscles, blood vessels, nerves, and posterior fat.

Lateral Canthotomy and Cantholysis (LCC)

Indications

• Emergent orbital decompression in tense orbital hemorrhage with compromised ophthalmic blood flow may be achieved with lateral canthotomy, defined as incision of the lateral canthal tendon, and inferior cantholysis, defined as canthotomy combined with release of the inferior crus of the lateral canthal tendon.
• LCC should be performed for retrobulbar hemorrhage with acute loss of visual acuity, afferent pupillary defect, increased intraocular pressure (IOP), and proptosis.
• The relative afferent pupillary defect is also known as the “Marcus Gunn pupil.” The test is positive when pupils constrict less (therefore, appearing to dilate) when a light is shined from the unaffected eye to the affected eye. In the absence of this defect, both pupils constrict the same amount regardless which one is exposed to light.
• In an unconscious or uncooperative patient, a tense orbit with an IOP > 40 mmHg is an indication for a lateral canthotomy (normal IOP is 10–21 mmHg).
• LCC should also be considered in patients with retrobulbar hemorrhage along with any of the following: ophthalmoplegia, cherry-red macula, optic nerve head pallor, and severe eye pain.

Contraindications

• The main contraindication to performing LCC is an actual or potential globe rupture.
• Findings suggestive of a globe rupture include hyphema, irregularly shaped pupil, bullous subconjunctival hemorrhage, enophthalmos, and/or conjunctival tear.

Technique

• All members of the team should use standard precautions to protect against blood and body fluid exposure.
• The instruments required to perform LCC are a straight hemostat, toothed forceps, and small straight or curved blunt-tip scissors (Figure 4).

• The patient should be placed in a supine position. The eye socket should be prepped with standard povidone iodine solution/paint (not detergent/scrub).
• If the patient is conscious, inject 1–2 percent lidocaine (with or without epinephrine) into the lateral canthus, taking care not to injure the globe (Figure 5).
• The lateral canthus is crushed with a straight hemostat, advancing the jaws to the lateral fornix at the orbital rim. Occluding these tissues for one minute facilitates hemostasis and marks the location where the incision is to be made (Figure 6).
• Using straight (or curved) blunt-tip scissors, make a 1 cm long full-thickness horizontal incision of the lateral canthus in the middle of the crush mark.
• Pull the lateral lower eyelid away from the face with toothed forceps to reveal the lateral canthal tendon.
• While maintaining lid traction, sever the inferior portion of the lateral canthal tendon and lateral septum with scissors by keeping the scissors in the sagittal plane of the face, with the tips directed caudally and posteriorly (Figure 7). The inner blade is just anterior to the conjunctiva, and the outer blade is just deep to the skin. When complete, the lower eyelid should pull freely away from the face, decompressing the compartment and releasing pressure on the globe. If the lid does not swing freely, continue dissection until all restricting bands are released.
• If release of the inferior tendon is insufficient (IOP remains > 40 mmHg), the superior portion of the lateral tendon may also be cut. This must be done with great care due to the proximity of the lacrimal gland, and is best deferred to the ophthalmologist.
• Hyperosmotics, such as 3 percent saline, acetazolamide, and mannitol may be used to help decongest the orbit.
• The essential component of this procedure is the cantholysis, not the canthotomy.

• A successful procedure is marked by improvement in visual acuity, softening of the orbit, resolution of a previously described afferent pupillary defect, and decrease in IOP to < 40 mmHg.
• If the intact cornea is exposed (i.e., uncovered by eyelids), apply erythromycin ophthalmic ointment or ophthalmic lubricant ointment to protect the cornea and prevent corneal desiccation or infection.
• Urgent ophthalmic consultation is required.

Pitfalls and Complications

• Not documenting initial vision
• Failure to assess the eye and pupil in an unconscious patient or in the setting of periorbital swelling
• Placing a flat eye patch or dressing rather than a convex rigid shield to protect the eye
• Placing the Fox shield horizontally within the orbit, rather than obliquely to cover all orbital margins
• Placing a dressing under the shield
• Manipulation of the globe when a rupture or penetrating injury is present
• Neglecting antibiotics, antiemetics, or analgesics
• Delaying irrigation of the eye in cases of acid/ alkali splash burns
• Incomplete division of the lateral canthal tendon for decompression of OCS
• Iatrogenic injury to the globe
• Injury to the lacrimal gland and lacrimal artery, which lie superior