Though conditions like age-related macular degeneration and glaucoma are scourges upon patients and doctors, nothing robs patients of vision as suddenly or shockingly as ocular trauma. To make matters worse, trauma cases often have to be evaluated under duress, sometimes with a tight time window in order to avoid further damage. In this article, experts outline how to deal with these cases.
A Range of Injuries
Ocular trauma is relatively common. According to Thomas John, MD, who is in practice in Chicago, there are more than 2.4 million eye injuries in the United States annually. “Ninety percent of these are preventable, and more than 20,000 eye injuries occur in the workplace,” he says.
Kevin M. Miller, MD, who is in practice in Los Angeles, says that he sees bungee cord injuries more than any other injury. “They are incredibly common,” he says. “One of my patients had taken his boat out of the water and put it on a trailer. He and another person were securing a tarp over the boat, when a bungee cord came loose. The cord came flying under the boat and around to the side where he was standing. The metal hook portion went through his lower eyelid, through his eyeball, and through his upper eyelid all in one millisecond. Another guy was exercising at a gym using a bungee cord apparatus. He was sitting in the rowing position, holding the two rubber straps away from the wall apparatus, and somehow both bungee cord hooks came loose at exactly the same time. They hit him in both of his eyes simultaneously. He went from a high-functioning executive to being basically blind in both eyes.”
Blunt trauma is also common. Injuries include fist injuries, racquetball injuries or just getting hit in the eye with a cabinet door or table edge.
There are also projectile injuries, such as flying glass during automobile accidents, and gunshot wounds. “A lot of people try to kill themselves by putting a gun up to the side of their temple,” Dr. Miller says. “When they pull the trigger, the bullet goes through both eyes, but doesn’t kill them. There are quite a variety of injuries.”
He says that people who suffer ocular injuries rarely lose their sight or their eye. “In the majority of open globe injuries, people retain vision,” Dr. Miller says. “It may not be the greatest vision, however. It depends on how badly damaged the retina is. They might end up going through a couple of years of reconstructing the anterior segment of the eye. The surgeon might have to do a corneal transplant, implant a glaucoma tube device, and/or implant an artificial iris. But, if the retina comes through okay, they can actually maintain pretty good vision."
Assessing the Injury
The first step with any type of ocular injury is to determine the mechanism of injury, if possible. “Sometimes, the patient knows exactly what happened,” says Darren Gregory, MD, who is in practice in Aurora, Colorado. “Sometimes, it’s the middle of the night, the patient’s drunk, and you can’t get a good story. They know they were beaten up, but they don’t know what they were hit with.”
The next step is to evaluate the extent of the injury. A computed tomography scan can be performed very quickly in the ER. “This can show you details about what’s going on in the eye,” explains Uday Devgan, MD, who is in practice in Los Angeles and teaches UCLA ophthalmology residents at Olive View-UCLA Medical Center. “You can have a ruptured globe and the lids are so swollen and the [patient’s eye] so tender, it’s hard to examine him or her. But a CT scan will tell you if any of the orbital bones are broken. It can tell you if there’s a posterior rupture. The eye is like a round ball, but if somebody hits the front of the eye really bluntly, like with a knuckle, it may blow out the back of the globe. So, you can have a posterior rupture, which can easily be seen on a CT scan. A CT scan can also show you if there is a retained intraocular foreign body.”
It’s important to get both an axial scan and a direct coronal scan. “Make sure the slices are thin enough. If you only get scans every 5 mm, you’ll miss a lot of details. You want somewhere in the 1 to 2 mm range for the slices,” Dr. Devgan says.
After the CT scans, the patient can be examined clinically. Dr. Devgan recommends first checking a patient’s vision. “Then, you can examine the front of the eye and the lid to make sure there are no significant issues or lacerations there,” he says. “A slit-lamp microscope can be used to look at the front of the eye. It’s important to know where the eye typically ruptures and look there. For example, one of the places is where the extraocular muscles attach to the sclera. The sclera tends to be a little thinner there and can rip in those areas. If the patient has had cataract surgery, the eye can rupture at the site of the phaco incisions, even if it’s 10 or more years later.”
Dr. Devgan also recommends examining the iris, which has the ability to plug up a leak. “Much like when you have a stab wound or a bullet wound in your abdomen and the omentum plugs up the leak, the iris can plug up an anterior segment leak or rupture,” he says. “If the eye has a rupture, the iris will be peaked and pointed toward the area of the rupture. If possible, get a view of the back of the eye. If the eye is full of blood, a B scan ultrasound can be used to look back there, as well.”
Dr. Miller adds that it can often be difficult to assess a patient’s ocular trauma immediately after an accident because he or she may have injuries to other parts of the body that are also being evaluated.
An Intact Globe
Treatment can typically be delayed if the patient has an intact globe. “It often doesn’t require immediate surgery that day or night,” Dr. Devgan explains. “With anterior segment trauma that’s not rupturing, you’ll typically see damage to the iris and lens. Posterior trauma can include damage to the retina, the choroid, and the other layers of the posterior segment, as well. Those usually can be fixed a little bit later; [the repair] doesn’t have to happen right away.”
A Ruptured Globe
A ruptured globe is a severe injury. It’s sight-threatening, and there is the potential that the patient could lose the eye. “Patients with ruptured globes, such as those who have been in a car crash, may also have severe head and/or brain trauma,” Dr. Devgan says. “When you’re called to the ER to see a patient with a ruptured globe, you must determine the extent of the trauma. Is it limited to the eye and the orbit, or does it also involve other body parts? With the brain particularly, it can be life-threatening.”
Besides car accidents, ruptured globes are typically the result of assault or industrial accidents. “Then, there’s the wild card: Every July 4th, we get patients with combined hand and eye injuries,” Dr. Devgan says. “They light up their firework and if it doesn’t work, they pick it up and look at it, and it goes off in their hand toward their face.”
Ocular trauma with a ruptured globe is less frequently seen in private practice, according to Dr. Devgan. “I’ve been in practice 20 years, and I’ve seen one ruptured globe in my private subspecialty clinic,” he says. “At the county hospital where we do our residency training, we see at least one ruptured globe a week. On July 4th weekend, it will probably be two or three. One year, we had six in one weekend.”
When treating these patients, experts say it’s important to manage patient expectations. If a patient has a ruptured globe, there is a lifetime risk of sympathetic ophthalmia. “Because of the rupture, some of the antigens that are present in the eye, which are normally never seen by the immune system, are now presented to the immune system,” Dr. Devgan says. “The immune system can attack not only the bad eye, but the good eye, months or even years later. Because this is a lifetime risk once you have a ruptured globe, it has to be in the consent form for the procedure to repair the ruptured globe. It’s critical for the patient to know that it’s very difficult to return an eye that has suffered a ruptured globe back to normal. The goal is just to close the globe today, not to restore sight. In fact, this patient may never get useful sight back out of the eye. There’s always the risk that you may lose the whole eye. We must manage expectations and paint a realistic picture before performing surgery.”
Especially if it’s in the middle of the night, the goal is just to close the eye. Dr. Devgan says the surgeon can come back in a few days or weeks and fix the traumatic cataract or retinal detachment. “During the initial surgery, our goal is to remove any intraocular foreign body and close the globe,” he adds. “If we can fix other damage at the same time, we will, but it depends on the severity of the trauma.”
Fifteen percent of eye injuries are a result of burns. “With chemical injuries, alkali is the worst because it can penetrate the ocular structures much faster than acid,” notes Dr. John. “Alkali rapidly disrupts the cell membranes and penetrates into the tissues. Acid is usually less damaging due to the binding and buffering of the acid by the corneal protein. When that happens, the coagulated tissue can act as a barrier and prevent further penetration. The most important thing is to irrigate as soon as possible.”
Chemical ocular injuries can range from very mild to very serious. “In Grade 1, the injury is very superficial,” Dr. John explains. “With such minor injuries, there is little ischemia, and the cornea is completely clear. With Grade 2, there is minor corneal haze and localized focal limbal ischemia. In Grade 3, there is pronounced corneal haze, and the view of the anterior chamber is compromised. There is significant ischemia of the limbus. The worst is Grade 4, where the cornea is opaque and porcelainized. It’s extremely prone to melting in the acute or intermediate time frames after injury. Depending on the extent of the injury, the visual loss can be mild, or there can be total loss of vision.”
Enucleation of the Eye
Surgeons typically don’t perform a primary enucleation of the eye immediately after the injury. “We usually try to let patients come to terms with the severity of their injury,” says Dr. Gregory. “If they have a blind, painful eye or a severely disfigured eye, they may choose to have it removed. However, that’s usually difficult psychologically. And it’s surprising how many cases that look almost hopeless end up with more vision than you initially anticipated.”
He believes that it’s best to close the hole as well as you can to stabilize the eye, “let the dust settle” a little bit, and monitor for signs of infection or problems with the intraocular pressure either being too high or too low. “If the eye begins to stabilize, then you can start looking at repairing the damage that’s occurred inside the eye, whether it’s removal of vitreous hemorrhage and repair of a retinal detachment or replacement of the lens,” Dr. Gregory says. “Especially with ruptures from blunt trauma there’s often prolapse of the lens out of the eye, whether it’s an artificial lens or a natural lens. If it ruptures anteriorly, there’s often damage to the iris and the pupil, which may require some repair at a later date, as well.”
The Million Dollar Eye
When a patient has undergone ocular trauma in one eye, it’s important to turn your attention to the fellow eye. “There is the concept of the million dollar eye and the hundred dollar eye,” Dr. Devgan says. “The eye that’s already severely damaged is the hundred dollar eye, and the better eye is the million dollar eye. You don’t want to lose a good eye, right? So, the million dollar eye should not be neglected. For example, if a patient has a ruptured globe from grinding metal, a little fragment of metal could be in the fellow eye without us knowing it. So, you have to examine what you think is the non-traumatized eye in great detail, as well.”
Dr. Devgan says the number one risk factor for a ruptured globe is a previous ruptured globe, because the patient may continue to do the high-risk activities that caused the injury the first time. “Let’s say you’re a gardener and there are tree branches on the left side of your face, but you’ve lost vision in your left eye and can’t see them,” he says. “You turn your head, and the branches poke you in the good eye. This is why people with a ruptured globe need to be in protective glasses and have monocular precautions for the rest of their lives. If the patient feels that it looks goofy to wear safety goggles every day, we can even place polycarbonate lenses in Ray-Ban frames, so the patient will look cool while being protected.”
Though dealing with an ocular injury demands a lot from the clinician and surgeon, physicians say that moving quickly—but not rushing—and taking a logical approach can often lead to the best possible outcomes. REVIEW
None of the physicians interviewed have any financial interest to disclose.