Ophthalmology​ - Management and Emergencies

Audience

Medics

Nursing Staff

Forward Surgical Teams

Ophthalmologists

Initial Assessment & Management

Eye injuries are common in warfare.

During Op HERRICK and Op TELIC 10-15% of combat-related trauma involved the eye.

  • Significant numbers of potentially serious eye conditions can arise in non-battle environments.
  • Many serious and/or blinding eye injuries can be prevented by wearing approved combat eye protection.  The eye is extremely intolerant of injury
  • Significant eye trauma requires prompt evaluation and treatment by an eye surgeon, however, the foundation for successful treatment and preservation of vision is most often laid in the initial phases by forward medical providers at all echelons of care
  • Ophthalmic resources are deployed increasingly sparingly in select locations.

If direct access to an eye surgeon is impossible:

  1. Initiate Telemedicine consultation with eye surgeon as soon as possible using Pando or Proximie / Artemis .
  2. Evacuate all vision-threatening injuries to see an eye surgeon within 12- 24 hours if possible.

Factors such as combat operations, aircraft availability, weather, proximity to port, transport safety and security can affect the timing of transfer and definitive treatment.

  • If evacuation is delayed beyond 24 hours:
    • see the Prolonged Casualty Care notes on individuals condition pages.

Initial Eye Exam

Vision

  1. Assess and document visual acuity for each eye if possible.
  2. Presenting vision may be the best predictor of final visual outcome.

Intraocular Pressure (IOP)

  1. Do NOT put pressure on eye with suspected open globe injury.
  2. If orbital compartment syndrome is suspected, palpate eyelids to see if one eye has increased firmness and resistance compared with the opposite eye (“rock hard” eyelids).
  3. Do not attempt to check IOP unless experienced with this technique.

Pupils

  1. Test for relative afferent pupillary defect (RAPD) using swinging light test.
  2. Check for normal pupil reactions to light – note any abnormal findings such as dilated pupil, failure to react, misshapen pupil or the presence of blood on the iris/in the anterior chamber.

Eye Movements

If patient can follow commands, ask to follow your finger/light without moving the head. Record any restrictions to movement.

Record any double vision and in what position of gaze it occurs

Examinations

  1. Examine for critical findings. Perform focused eye exam “outside to inside.”
  2. External Exam – face, bony orbit, eyelids.
  3. Eye – conjunctiva, cornea, anterior chamber, iris, lens.
  4. Unless experienced, do not attempt fundus/posterior segment examination at Role 1 or 2.

Do Not Harm

  • DO NOT let a suspected eye injury leave your level of care without rigid eye protection.
  • DO NOT patch. It puts pressure on eye. (DO shield but DO NOT patch.)
  • DO NOT wrap. It puts pressure on eye.
  • DO NOT place anything under an eye shield, including gauze (except in confirmed isolated lid injury with no open globe injury)
  • DO NOT put pressure on eye with suspected open globe injury; it may
    increase the risk of extrusion of intraocular contents.
  • DO NOT check intraocular pressure at a Role 1 or 2. (Eye surgeon will check at Role 3 or 4.)
  • DO NOT attempt ultrasound of the eye. It places pressure on the eye.
  • DO NOT remove impaled or resistant foreign bodies.
  • DO NOT attempt to repair the eye.
  • DO NOT enucleate or eviscerate or debride tissue, even if eye is severely traumatised.

General Considerations For R1-R2/R2A

  • Treat life-threatening injuries first
  • Initiate telemedicine consultation ASAP
  • Utilise advice in this Initial Assessment & Management for initial management of eye injury

Expectations of care in R1-R2:

  1. Maintain high index of suspicion for eye injury in trauma
  2. Assess and document visual acuity, pupil responses and eye movements. Conduct an
    examination of the external eye.
  3. Recognise and treat chemical injury and orbital compartment syndrome as per R1 CGO
  4. Follow SHIELD AND SHIP protocol for sight-threatening injuries:
    • Place an eye shield or other rigid covering over the injured globe. Do not pad.
    • Provide adequate analgesia and antiemesis
    • Initiate systemic antibiotic cover with fluoroquinolone (e.g. moxifloxacin 400mg) for good ocular penetration and cover against gram negative organisms.
  5. Initiate remote consultation with service ophthalmologist ASAP for advice
  6. EVACUATE ALL VISION THREATENING INJURIES TO RECEIVE TREATMENT BY AN OPHTHALMOLOGIST WITHIN 24 HOURS WHEN POSSIBLE.

Advanced Assessment & Management

Open Globe Injury

Manage initially as per R1 CGO with SHIELD AND SHIP principles

Initial ophthalmic assessment to include all elements of Ocular Trauma Score (OTS) and OTS Calculation (see Appendix 1):

  • Visual acuity
  • presence or absence of RAPD
  • open globe
  • perforating injury
  • endophthalmitis
  • retinal detachment

Antibiotic prophylaxis should ensure adequate gram positive and gram negative cover.

Suggested regimes include either:

  • Levofloxacin (750mg IV/PO OD) or
  • Ciprofloxacin (750mg PO BD/400mg IV 8hrly) AND Vancomycin (15-20mg/kg IV every 8-12 hours).
  • If Moxifloxacin (400mg IV/PO OD) is available, it can generally be used as monotherapy due to its superior gram positive cover.
  • However, if MRSA is suspected, Vancomycin must also be given.

Management

  1. Place a rigid shield
  2. Make patient nil by mouth
  3. Bed rest at 30-45 degrees
  4. Avoid movements that increase IOP or eye movement
  5. Manage pain, nausea/vomiting (ondansetron 4-8mg IV or Promethazine 50mg IV)
  6. Give Tetanus prophylaxis
  7. Liaise with anaesthetics/medical team to ensure adequate analgesia/sedation
  8. Obtain CT of orbits with thin cuts if available. Facial XR may be of value for metal/glass FBs if no CT available.
  • An ophthalmologist should perform primary repair of open globe injury within 24 hours.
  • Have high index of suspicion for open globe injury with significant areas of subconjunctival haemorrhage.
  • EUA +/- full peritomy and temporary extraocular muscle disinsertion may be necessary to exclude occult injury.
  • Urgent globe repair will have to be performed in close coordination with colleagues when dealing with unstable/polytrauma casualties.

For Ophthalmologists ONLY

Surgical Management

  • Prep with 5% betadine.
  • Do not disinsert more than 3 rectus muscles.
  • Consider using limbal traction sutures placed at 90 degrees from the wound (e.g. if wound at 3 o’clock, place traction sutures at 12 and 6) to avoid direct pressure on the wounded area.
  • Recommended sutures are 10-0 for cornea, 8-0 or 9-0 for limbus and 8-0 for sclera (all nylon with spatulated needle).
  • Muscles can be slung on 6-0 Vicryl double-ended spatulated suture for reattachment later.
  • Attempted closure of wounds beyond the equator may cause further extrusion or damage optic nerve/macula.

Ophthalmic surgeons should proceed as far as they are able (using 6-0 vicryl is an (non-preferred) option to provide adequate tensile strength for scleral injuries in an absorbable alternative) without causing further injury.

Consider intracameral antibiotics (for Zone 1 injury or if retinal detachment present) or intravitreal antibiotics (zone 2 or 3 injury, no RD).

Give:

  • Vancomycin 1mg in 0.1ml AND Ceftazidime 2mg in 0.1ml.

Vitreous/Uveal prolapse

  • Perform sponge/scissors vitrectomy as far as required for closure.
  • Do not debride tissue unnecessarily.
  • Use of glue – For use on small corneal wounds or large complex wounds that cannot achieve adequate closure with sutures alone.
    • Note that glue applied to sutured areas will adhere for significantly longer than to clear cornea.
  • If further procedures are needed (e.g. pars plana vitrectomy, phacoemulsification), consider the impact on visualisation before closing the cornea with sutures and glue in combination.
  • Dry the area to be glued thoroughly before application.
  • Use the least amount of glue possible.
  • Patches may be made from clear eye drape or tegaderm.
  • These can be cut with skin punches for a neat circular patch.
  • Place a BCL at conclusion.

Temporary Patch Grafts

  • Scleral patch grafts, glycerin preserved cornea (soak for 15 mins in BSS prior to grafting) or tutoplast may be used for closing defects with 10-0 nylon sutures.
  • Small corneal defects can be closed with the autologous double-tectonic patch technique or with an autologous tenons patch.
  • Place a BCL.

Intraocular Foreign Body

  • Continue systemic antibiotics as per Open Globe guidelines above.
  • Early telemedicine discussion with Vitreoretinal consultant.
  • Do not attempt removal of IOFB in austere environment without vitrectomy capability.
  • Evacuate to vitreoretinal service R4.

Lens Capsule Violation

  • Generally manage conservatively during primary repair.
  • Monitor IOP and inflammation.
  • Treat raised IOP with topical treatments.
  • Consider acetazolamide second line if no haemodynamic/renal concerns.
  • Treat inflammation with mydriatics and intensive topical steroids.
  • Lensectomy only recommended in R2/R3 if IOP not controllable.

Prolonged Casualty Care

Delayed/Prolonged/Unknown evacuation

  • As above then following primary closure start topical antibiotics, steroids and mydriatics.
  • Continue systemic antibiotics.
  • Daily monitoring of VA, IOP and wound.
  • Monitor for endophthalmitis.
  • B-Scan if no fundal view.

Evacuation Timelines for Eye Injuries

The following document will define evacuation timelines and necessary management as follows:

  • Rapid Evacuation – Within 24-48 hours
  • Delayed Evacuation – 48-96 hours
  • Prolonged/Unknown - >96 hours

Aeromedical Evacuation Considerations for Eye Injuries

  • Telemedicine consultation recommended prior to fixed wing evacuation.
  • CT orbits if available can identify air trapped in the globe which can expand at altitude and cause extrusion of contents.
  • Casualties with open globe injury should be evacuated with a cabin pressure between sea level and 2500 feet, which will keep gas expansion minimal.
  • Liaise with the aircraft commander to allow a safe transit altitude for the required cabin pressure.
  • No limitations on rotary wing evacuation other than to recommend that altitude remains below 2500 feet in transit.
  • No prior discussion required with ophthalmologist prior to rotary wing transport of an open globe injury casualty.
  • Consider the need for decongestants, anti-emetics and adequate analgesia prior to and during flight.
  • In-flight valsalva may be dangerous for ophthalmic casualties.
  • Increased risk for motion-related nausea if vision-impaired.
  • Consider the need for prophylactic lateral canthotomy/cantholysis.
  • Casualties with poor vision may be at risk during flight due to their inability to safely navigate around the aircraft.
  • Consider transport on a stretcher or nominating a non-medical assistant for the casualty.

Eye Trauma Emergencies

Recognise and Treat immediately sight threatening conditions:

  • Chemical injury – Irrigate copiously and manually remove contaminant source if possible. DO NOT irrigate or touch the eye if open globe injury is present.
  • In cases of orbital compartment syndrome (normally caused by retrobulbar haemorrhage) trained personnel should perform emergency lateral canthotomy and cantholysis (LCC) using the 'full thickness cantholysis' technique.
  • Shield and Ship casualties with eye injuries
  • Prevent further damage.
  • Protect injured eyes (known or potential injuries) with a rigid eye shield immediately (e.g. “Eyepro” or “Fox shield” or locally improvised substitute, e,g. gallipot, cutdown plastic cup etc).
  • Maintain patient comfort, providing pain control and prophylactic antiemesis.
  • DO NOT put pressure on eye with suspected open globe injury. DO NOT pad the eye.
  • Prevent Valsalva which can increase the risk of extrusion of intraocular contents.
  • Treat nausea and vomiting aggressively (Promethazine 50 mg IV or Ondansetron 4-8 mg IV).
  • Avoid strenuous movements.
  • Bed rest with head elevated 30 degrees if possible.
  • Initiate TELMEDICINE consultation with an eye surgeon at Role 3 or Role 4 as soon as possible.

Evacuate all vision-threatening injuries so that they are able to receive treatment by an eye surgeon within 12-24 hours when possible.

Open Globe Injury or Intraocular Foreign Body

Mechanism – Penetrating injury or blunt/blast trauma (globe rupture)

Signs:

  • Collapsed or severely distorted eye.
  • Open wound, full-thickness corneal or scleral laceration.
  • Shallow anterior chamber.
  • Peaked or irregular pupil.
  • Prolapse of intraocular contents outside the eye. Dark tissue is iris or uveal tissue.
  • Subconjunctival haemorrhage (SCH), especially if 360 degrees.

Management

If Open Globe Injury or Intraocular Foreign Body is suspected DO NOT TOUCH THE INJURED EYE. Follow the SHIELD AND SHIP protocol.

Aeromedical evacuation of open globe injuries should ideally be performed in a sea-level pressure cabin to prevent further extrusion of ocular contents. However, if this is not feasible, evacuation should not be unduly delayed.

Administer:

  • CIPROFLOXACIN 500mg BD PO (if tolerated) or 400mg IV BD.
  • Alternatives include Levofloxacin 750mg PO/IV QDS or Moxifloxacin 400mg IV QDS.IF SUPPLY NOT RESTRICTED extra gram-positive cover can be given.
  • Administer CEFTRIAXONE 1g IM STAT (single dose) or CEFUROXIME 500mg BD PO. In restricted supply scenarios, give Ciprofloxacin (or equivalent) alone.

Prolonged Casualty Care

Continue antibiotic regime and maintain good analgesia and anti-emesis. Record visual acuity daily. Do not touch the eye.

Keep area under shield clean as best you can without touching the lids/eye.

If eye contents prolapse onto lids/face, do not touch them.

If you note any changes in appearance, discuss with ophthalmologist.

Chemical Injury

Mechanism – Aerosol or liquid splash of noxious substance

Signs

  • Blistering/blanching around eyes/lids
  • History of exposure to agent
  • Corneal opacification
  • Blanching or redness of conjunctiva
  • Corneal or conjunctival epithelial defect.

Management

  1. BEGIN IRRIGATION IMMEDIATELY unless co-existing open globe injury. Best practice is to use sterile fluid such as normal saline or Hartmann's solution but these may be in limited supply. Potable water is an absolutely acceptable substitute in emergencies requiring high volume irrigation and irrigation should not be delayed looking for particular fluids.
  2. Give at least 2 litres of irrigation fluid. Some chemical injuries will require >10 litres of fluid.
  3. Topical anaesthetic drops can aid compliance with irrigation if it is uncomfortable. DO NOT delay irrigation to apply anaesthetic initially.
  4. Do not attempt to neutralise alkaline or acidic contamination.
  5. Remove any solid contaminants (e.g. plaster, cement etc) with a cotton bud.
  6. Remember to inspect inside the eyelid fornices (under/behind the lids).
  7. Continue irrigation until pH is normal and then recheck pH at 5 and 20 minutes. If pH deteriorates again then repeat steps 1-5, re-examining for retained contaminants.
  8. Once irrigation complete, document visual acuity and perform further eye assessment.
  9. Seek urgent teleophthalmology advice
  10. SHIELD AND SHIP

Prolonged Casualty Care

  1. Oral doxycycline 100mg BD. Topical antibiotic ointment (e.g. Chloramphenicol1% Ointment) every 2 hours.
  2. Most casualties can self administer. If pain worsens significantly, recheck pH and consider restarting irrigation.
  3. If visual acuity drops, discuss with ophthalmologist (note application of ointment may worsen visual acuity).

Orbital Compartment Syndrome

Mechanism: Normally retrobulbar/orbital bleeding secondary to blunt/blast trauma.

Signs

  • Proptosed (bulging out) eye; lids may appear retracted.
  • Restricted eye movements.
  • Eye/lids may feel 'rock hard' due to increased intraocular pressure.
  • Reduced visual acuity/relative afferent pupillary defect indicates immediately sight threatening emergency.

Management

  1. If orbital compartment syndrome is suspected, proceed immediately to full thickness lateral canthotomy and cantholysis. DO NOT attempt imaging or delay intervention.
  2. Assess post-procedure visual acuity and pupil reactions.
  3. Discuss with ophthalmologist at earliest opportunity.
  4. If no response/worsens after LCC consider IV mannitol (0.5–2g) and IV acetazolamide (500mg).
  5. SHIELD AND SHIP

Prolonged Casualty Care

  • Orbital compartment syndrome is usually self-limiting within 2-4 hours.
  • Monitor for re-accumulation of tamponade.
  • Reassess regularly. If available, consider imaging (ideally CT, otherwise XR facial views and orbits).

Blunt Eye Trauma (No Open Globe) and Orbital Trauma

Signs

  • Hyphaema (blood inside the front of the eye)
  • suspected orbital fracture
  • facial blast injury
  • high energy facial trauma close to eye/orbit (e.g. gunshot)
  • intraorbital foreign body (without globe injury)
  • traumatic optic neuropathy (optic nerve injured, globe intact)
  • dislocated LASIK flap (previous refractive surgery)


Management

  1. Rule out open globe injury – high suspicion in high energy injury.
  2. Wash out/remove any surface foreign bodies if contaminated. DO NOT remove resistant/embedded foreign bodies or debride ANY ocular tissue.
  3. Check pupils for reactions and RAPD
  4. Check visual acuity if possible
  5. Prevent valsalva or nose blowing
  6. Contact ophthalmologist
  7. SHIELD AND SHIP


Prolonged Casualty Care

  • Discuss any changes with ophthalmologist.
  • Monitor ocular movements/restriction and visual acuity.
  • If there is surface injury to the eye:
    • use Chloramphenicol Ointment 1% 4x/day to the ocular surface and lids.
  • If orbital injury/fracture/foreign body is suspected:
    • obtain imaging if available.

NB:  Urgent repair of orbital fractures is required when clinical evidence of extraocular muscle entrapment with non-resolving bradycardia, heart block, nausea, vomiting, or syncope

Eyelid Laceration

Signs

Isolated partial or full thickness injury to the eyelids. Note if the injury involves
the lid margin or the nasolacrimal system (medial eyelid).

Management

  1. Maintain high suspicion for open globe.
  2. Assess and document vision if possible
  3. Seek teleophthalmology consultation with eye surgeon
  4. SHIELD AND SHIP.
  5. Unless experienced, delay definitive repair for laceration involving eyelid margin for surgery by ophthalmologist. Do NOT repair in the presence of an open globe injury.
  6. Do NOT debride or discard tissue, even if the eyelid is severely traumatized.

Prolonged Casualty Care

Gently clean injured tissue, remove any superficial foreign bodies (leave embedded objects). Dress with a paraffin gauze (e.g. Jelonet) and an eye shield over the top.

DO NOT apply pressure to the injured area.

DO NOT pad.

Consider topical (Chloramphenicol Ointment 1% QDS) and/or oral (e.g. CoAmoxiclav/Doxycycline/Clindamycin) antibiotic cover if potential long delays in evacuation.

Thermal Burn

Mechanism

Flash burn, exposure to flame, pyrotechnics (e.g. flares, phosphorous),
blast

Management

  1. Rule out co-existing open globe injury
  2. Assess visual acuity
  3. Assess lid closure
  4. Discuss urgently with ophthalmologist
  5. SHIELD AND SHIP

Prolonged Casualty Care

Protection of the ocular surface is paramount.

Use petroleum jelly or Chloramphenicol ointment to keep a protective layer over the cornea and burned lids.

Oral doxycycline 100mg BD in cases of corneal injury. Dress with jelonet and eye shield.

Reassess lid closure at least weekly in case of contracture.

NB – Aggressive fluid resuscitation in burns patients can precipitate orbital compartment syndrome.

 

Corneal Abrasions, Foreign Bodies and Ulcers

Mechanism

Low energy trauma to cornea, contact lens use, foreign body on cornea

Management

  1. If foreign body injury, rule out open globe injury/corneal leakage
  2. Check visual acuity. Topical anaesthesia may make this easier.
  3. Examine the cornea. A direct ophthalmoscope on +12 makes a useful magnifying lens. Check for any embedded foreign bodies or corneal infiltrates (white patches signifying inflammation or infection).
  4. Apply fluorescein drops and examine under a cobalt blue light (on the ophthalmoscope). Epithelial defects will show up as bright green patches.
  5. Superficial foreign bodies can be removed with a cotton bud or flicked off with a pointed piece of card.

Treatments

CORNEAL ABRASION ONLY (no infiltrates seen)

  • Chloramphenicol Ointment 1% QDS or Chloramphenicol drops 0.5% 6x/day.

CORNEAL FOREIGN BODY

  • If entirely removed, treat as per abrasion.
  • Discuss with ophthalmologist.
  • Be prepared to SHIELD AND SHIP after discussion.

CORNEAL ULCER (infiltrate seen in cornea or hypopyon present) or any of the above conditions in a patient who is a CONTACT LENS WEARER

  • Discuss with ophthalmologist.
  • SHIELD AND SHIP if corneal ulcer seen.

Prolonged Field Care

If ophthalmologist review for corneal ulcer not available within 6 hours:

  • commence Ofloxacin 0.3% or
  • Levofloxacin 0.5% 1 drop Hourly.

Do not give regular topical anaesthetic as it delays healing but it can be used to facilitate examination.

Stop contact lens wear.

Laser Injuries

Mechanism

Exposure to high energy photons from LASER equipment. Similar injury may be evident in casualties exposed to flash from nuclear detonation.

Management

  1. Monitor visual acuity
  2. Record incident if occupational exposure
  3. Discuss with ophthalmologist

Cellulitis - Preseptal or Orbital

Mechanism

Upper respiratory tract or superficial soft tissue infections leading to cellulitis. Orbital cellulitis is rapidly progressive and potentially SIGHT AND LIFE THREATENING.

Management

Distinguish if PRESEPTAL (involving superficial facial/lid tissue only) or ORBITAL (involving tissue posterior to the orbital septum/inside the orbit).

RED FLAGS FOR ORBITAL CELLULITIS:

  • Restricted eye movements
  • Proptosis (bulging eye)
  • Injected (red) eye
  • Reduced visual acuity and/or colour vision
  • Presence of RAPD or altered pupil reactions
  • Generally unwell, pyrexic or confused patient. May have other signs of sepsis.
  • PRESEPTAL CELLULITIS patients generally have a white eye, unrestricted/painless eye movements, normal vision/pupil responses and a mild pyrexia only.

If ORBITAL CELLULITIS suspected

  • Obtain urgent imaging (CT) as there may be an abscess requiring drainage.
  • Immediately commence Piperacillin/Tazobactam 4.5mg IV QDS PLUS Vancomycin 15-20mg/kg 12hrly, max 2g/dose.
  • If these are unavailable, broad spectrum cephalosporins (e.g. IV Ceftriaxone) or IV Clindamycin may be used.
  • Discuss urgently with ophthalmologist.
  • Involve ENT services if available.
  • SHIELD AND SHIP

If PRESEPTAL CELLULITIS suspected

  • Start oral antibiotics (Clindamycin 300mg TDS or Co-Amoxiclav 500/125 TDS. Substitute Doxycycline or consider Vancomycin if MRSA suspected).
  • Discuss with Ophthalmologist.
  • SHIELD AND SHIP

Prolonged Casualty Care

  • Give regular antibiotics as recommended and analgesia as required.
  • Monitor for sepsis/signs of deterioration.
  • Monitor visual acuity and pupil responses.
  • Discuss any changes with ophthalmologist.

Acute Glaucoma

Mechanism

In military context, usually precipitated by blunt injury causing hyphaema or damage to normal pressure-controlling structures in the eye.

Management

  1. Palpate eyelids to see if involved eye has increased firmness compared with the opposite eye.
  2. Check for signs of acute glaucoma:
    • Fixed, mid-dilated pupil.
    • Shallow anterior chamber.
    • Corneal oedema (hazy cornea).
    • Conjunctival injection (redness)
    • Severe pain
    •  Assess and document vision if possible.

Once glaucoma suspected, manage as follows:

  1. Lie the patient flat in the supine position. Give analgesia and/or antiemetics if required.
  2. Telemedicine consultation with eye surgeon.
  3. Give Acetazolamide 500mg IV initial dose (can give PO if IV not available), then 250mg PO every 4 hours to a maximum of 1g per 24 hours
  4. Start intra ocular pressure (IOP)-lowering topical medications if available.
  5. Instil 1 drop of timolol, brimonidine, and dorzolamide 5 minutes apart. Repeat for 3 rounds.
  6. SHIELD AND SHIP.

Prolonged Casualty Care

Continue regular topical and systemic IOP-lowering medications as above in discussion with ophthalmologist.

Approved By: DCA Ophthalmology​

Related resources

Local anaesthesia for ophthalmic surgery (Joint guidelines from the Royal College of Anaesthetists
and the Royal College of Ophthalmologists) - 2012