Overview of eye injuries in the emergency department

INTRODUCTION — This topic provides an overview of eye injuries. The approach to diagnosis and initial treatment of eye injuries and emergency evaluation and management of open globe injuries are discussed separately:

●(See "Approach to diagnosis and initial treatment of eye injuries in the emergency department".)

●(See "Open globe injuries: Emergency evaluation and initial management".)

EPIDEMIOLOGY — The World Health Organization’s (WHO) Blindness Data Bank notes that approximately 55 million eye injuries occur worldwide annually resulting in about 23 million individuals with at least unilaterally poor vision and 750,000 hospitalizations [1]. Over 70 percent of all injuries and 95 percent of occupational injuries occur in males [2-5]. The average age of eye injury patients in the United States is 29 years [6]; thus, these injuries may affect the vision of individuals for many of their remaining years.

Ocular and orbital injuries have diverse mechanisms, including:

●Unintentional injuries while metal drilling, welding, hammering, and nailing [4,5]

●Gunshot wounds, including BB, pellet, and paintball guns [7-17]

●Being struck by objects such as fingernails, scissors, curling irons, curtain rods, or branches from trees or other vegetation

●Use of fireworks and other explosives

●Sports-related blunt injuries from balls and pucks, sports equipment, or inadvertent contact (eg, elbow to the eye) [18-26]

●Other blunt mechanisms such as assault with a fist or other object [27], airbag deployment during motor vehicle collisions [28-36], falls [37-39], or bungee cord recoil [40]

Significant eye injuries often lead to permanent visual impairment. As an example, in an observational study of serious injuries in over 11,000 eyes, 27 percent had less than 20/200 vision in the injured eye, a level of vision that is defined as legal blindness in many jurisdictions [41]. In this study, definitive ophthalmologic treatment was associated with visual improvement in 61 percent of victims. Thus, rapid recognition of serious eye injury and early involvement of an ophthalmologist are critical to ensuring the best possible visual outcome.

Proper use of eye protection during high risk activities has the potential to prevent up to 90 percent of eye injuries [6].

ANATOMY

Ocular — The anatomy of the eye is clinically useful in triaging the severity of the injury and in communicating the nature of the injury to sub-specialists. The eye is composed of three layers (figure 1) [42]:

●The external fibrous layer (cornea and sclera)

●The middle vascular layer (chorioid, ciliary body, and iris)

●The internal layer (retina)

The sclera and cornea form the outer wall of the eye (figure 1). The junction of the cornea and sclera is known as the limbus. The epithelial surfaces of the conjunctiva and cornea are critical structures in preventing infection and providing a barrier to the external world. The sub-conjunctival space is located between the bulbar conjunctiva and the sclera (figure 2).

The lens demarcates the anterior structures (iris, anterior chamber, and cornea) from the posterior structures (vitreous, retina, choroid, and optic nerve) (figure 1) [42].

Periocular

●Eyelids – The eyelid margin is shaped by the underlying tarsal plate which gives the lids strength and helps them to hug the ocular surface [42]. The canalicular system is essential for draining tears from the ocular surface into the nasopharynx (figure 3). The orbital septum divides the pre- and post-septal regions (figure 4); this anatomic separation is important because trauma penetrating into the orbital (post-septal) space can involve vital structures.

●Bony orbit – The bony orbit is composed of seven bones but can be simplified clinically into the orbital roof, floor, medial wall, and lateral wall (figure 5). The medial wall is very thin and commonly fractured, often in conjunction with the floor. Associated orbital structures by bony region are noted in the table (table 1).

●Orbital compartment – Besides the eye, the orbital compartment houses the following structures [42]:

•Extraocular muscles

•The retro-orbital fat

•The ophthalmic artery (which gives rise to the central retinal artery)

•The superior and inferior orbital veins

•The optic nerve

With its surrounding bony walls, the orbit is a confined space such that trauma and hemorrhage can cause an orbital compartment syndrome (OCS). In this case, the elevated intraorbital pressure is transmitted to the eye, optic nerve, and retina causing ischemia.

The superior and inferior ophthalmic veins are important clinically because increased size on imaging implies elevated pressure within the cavernous sinus. The extraocular muscles can be damaged, entrapped by fractures, or disinserted by trauma leading to motility deficits (picture 1). The ophthalmic artery is also susceptible to injury which can cause severe vision loss. (See "Central and branch retinal artery occlusion".)

●Cavernous sinus – Head trauma can affect the cavernous sinus causing carotid-cavernous fistulae. Because the venous system of the eye and orbit drain into the cavernous sinus (figure 6), elevated pressure within this structure leads to ocular and orbital congestion.

INJURY CLASSIFICATION — Ocular injuries are classified as open globe, closed globe, and periocular [43].

Open globe — Open globe injuries have a full thickness break of the eye wall, which is composed of the sclera and the cornea. (See "Open globe injuries: Emergency evaluation and initial management", section on 'Definition'.)

These injuries are further described as follows:

●Open globe rupture – Full thickness eye injury caused by blunt trauma

●Open globe laceration, possible intra-ocular foreign body – Full thickness eye injury caused by sharp objects, which may result in or leave behind an intraocular foreign body

Lacerations are additionally described by type and location of the wound. (See "Open globe injuries: Emergency evaluation and initial management", section on 'Open globe laceration'.)

Closed globe — Closed globe injuries do not have full thickness breaks of the eye wall. They are further divided into lamellar lacerations (partial thickness wound to the eye wall) or contusions (no eye wall wound).

Thus, the following injuries are also lamellar lacerations:

●Conjunctival laceration – Full thickness break of the conjunctiva

●Partial thickness scleral laceration – Incomplete scleral break not to the level of the choroid

●Partial thickness corneal laceration – Incomplete corneal break without loss of aqueous humor

Other closed globe injuries include:

●Conjunctival abrasion – Injury to the epithelium of the conjunctiva

●Corneal abrasion – Injury to the epithelium of the cornea (picture 2)

●Hyphema – Blood in the anterior chamber of the eye (figure 7)

●Traumatic iritis – Inflammation in the anterior chamber resulting from trauma

●Traumatic mydriasis – Chronic pupil dilation usually from iris sphincter damage

●Lens dislocation – Native or artificial lens implant displacement from its original location

●Vitreous hemorrhage – Bleeding into the vitreous cavity (picture 3)

●Commotio retinae – Retinal whitening due to trauma-associated retinal edema

●Retinal detachment – Separation of the retina from the underlying choroid and sclera (picture 4)

Periocular — Periocular injuries are described based upon anatomic considerations. The orbital septum (figure 4) divides the pre-septal tissues (eyelids, meibomian glands, lashes, nasolacrimal system (figure 3), and the orbicularis oculi muscle) from the deeper orbital components (orbital bones, fat, extraocular muscles, intraorbital nerves, and vessels). Frequently, ocular and periocular injuries occur together. Any periocular injury should raise concern for a coexisting ocular injury.

Periocular injuries include:

●Pre-septal:

•Eyelid abrasions – Superficial skin injury not requiring surgical repair

•Eyelid lacerations – Full thickness skin injury usually requiring surgical repair (picture 5)

•Canalicular lacerations – Full thickness eyelid skin injury, which includes the lacrimal drainage system; usually requires nasolacrimal cannulation for repair

•Periocular ecchymoses – Skin bruising, which may indicate more serious underlying injury

●Orbital:

•Eyelid lacerations with fat prolapse – Full thickness eyelid skin injury with likely penetration through orbital septum (picture 6); requires complex repair by ophthalmology

•Eyelid lacerations with levator involvement – Full thickness eyelid skin injury, which may lead to permanent ptosis if not repaired; requires ophthalmology consultation

•Orbital fractures – Fracture of any of the bones making up the socket surrounding the eye (image 1); fracture location leads to specific associated findings and injuries as follows:

-Fractures of the roof can lead to pneumocephalus and/or cerebral-spinal fluid leakage.

-Fractures of the optic canal may injure the optic nerve.

-Fractures of the orbital floor may cause muscle entrapment, sensory loss in division II of the trigeminal nerve (cranial nerve V) (picture 7), and epistaxis.

•Extraocular muscle entrapment – Prolapse of extraocular muscle(s) into the defect created by a fractured orbital bone; may induce muscle ischemia requiring more urgent repair (picture 8 and image 2)

•Orbital compartment syndrome (OCS) – Elevated intraorbital pressure from infection, bleeding or inflammation causing poor motility and possible ocular ischemia

•Orbital foreign bodies – Any post-septal foreign body present in the eye socket but outside the globe

•Traumatic optic neuropathy – Acute vision loss and afferent pupil defect from trauma-induced optic nerve damage. This injury may occur in the setting of orbit or bony injury without direct globe trauma, from optic canal involvement in the setting of orbital fracture, or from a direct blow to the brow with evidence of orbital fracture.

•Optic nerve avulsion – Acute vision loss and afferent pupil defect from traumatic transection of the optic nerve

•Ophthalmic artery injuries – Ocular ischemia from compression or laceration of the ophthalmic artery

APPROACH — Eye injury includes trauma to the eye (ocular trauma), the orbit (periocular trauma), or both. The initial approach to eye injury, as with any trauma, must involve careful triage. Because the eyes are located near the intracranial space, the cervical spine, and the airway, life-threatening injuries involving these structures need to be treated prior to assessing periocular and ocular damage. (See "Initial management of trauma in adults" and "Trauma management: Approach to the unstable child".)

Once life-threatening injuries are addressed, the emergency clinician should identify threats to vision using a focused history and an organized approach (algorithm 1) to permit the rapid recognition and treatment of vision-threatening conditions including:

●Chemical eye exposures (see 'Ocular chemical burns' below and "Topical chemical burns: Initial evaluation and management", section on 'Patient with eye exposure')

●Orbital compartment syndrome (OCS) (see 'Orbital compartment syndrome' below and "Approach to diagnosis and initial treatment of eye injuries in the emergency department", section on 'Orbital compartment syndrome')

●Open-globe injuries (table 2) (see "Open globe injuries: Emergency evaluation and initial management")

●Traumatic hyphema (table 3) (see "Traumatic hyphema: Clinical features and diagnosis" and "Traumatic hyphema: Management")

In patients with a high likelihood of an open globe based upon mechanism of injury (eg, small projectile at high velocity, metal fragment, or bullet)) or physical findings, the emergency clinician should avoid any further examination procedure that might apply pressure to the eyeball, such as eyelid retraction or intraocular pressure measurement by tonometry and avoid placing any medication (eg, tetracaine) or diagnostic eye drops (eg, fluorescein) into the eye. Any protruding foreign bodies should be left in place. (See "Open globe injuries: Emergency evaluation and initial management", section on 'Primary evaluation and management'.)

VISION-THREATENING CONDITIONS

Ocular chemical burns — Eye contact with an acid or alkali requires emergency evaluation and treatment to prevent permanent vision loss. Burn severity depends upon the agent involved, duration of exposure, and depth of penetration (table 4). Alkaline substances usually cause more severe damage than acids due to increased intraocular penetration.

Patients with chemical eye burns present with decreased vision, moderate to severe eye pain, blepharospasm (inability to open the eyelids), conjunctival redness, and photophobia. In severe cases of alkali exposure, the eye may appear white due to ischemia of the conjunctiva and scleral vessels (picture 9).

With any significant ocular exposure to alkali or acid, continuous irrigation with water or saline is recommended until a neutral pH is achieved in the eye. The author prefers prolonged irrigation using intravenous tubing and manual active irrigation. Polymethylmethacrylate scleral lenses (ie, Morgan lens) (figure 8) are frequently employed rather than active manual irrigation for chemical eye exposures but may not be as effective for irrigation of the fornices, which is particularly important in cases of wet plaster or cement exposure because the retained debris serves as a depot for continued alkali injury. The irrigation technique is described in detail separately. (See "Topical chemical burns: Initial evaluation and management", section on 'Patient with eye exposure'.)

If a concomitant globe rupture or penetrating injury is suspected or confirmed, a Morgan lens should not be used, and only careful, gentle irrigation is advised to avoid exacerbating the injury. (See "Open globe injuries: Emergency evaluation and initial management" and "Topical chemical burns: Initial evaluation and management", section on 'Patient with eye exposure'.)

Orbital compartment syndrome — The approach to the patient with an open globe injury or intraocular foreign body is summarized in a rapid overview (table 5). With its surrounding bony walls, the orbit is a confined space. Trauma and intraorbital hemorrhage can cause rapidly elevated intraorbital pressure. This pressure is transmitted to the eye and optic nerve causing ischemia and an orbital compartment syndrome (OCS). (See 'Periocular' above.)

OCS is a clinical diagnosis. Patients typically report an acute onset of decreased vision, diplopia, eye pain, and/or periorbital swelling [44].

Key physical findings of OCS include (picture 10) [44-46]:

●Markedly decreased visual acuity

●An afferent pupillary defect (figure 9)

●Proptosis

●Diffuse subconjunctival hemorrhage

●Evidence of increased intraorbital pressure indicated by tight ("rock hard") eyelids and decreased retropulsion (resistance to attempts to push the eye deeper into the orbit sometimes referred to as a "tight orbit")

Other findings consist of periorbital ecchymosis, restricted extraocular movements, chemosis, congestion of conjunctival vessels, vascular attenuation, optic disc edema on funduscopy, increased intraocular pressure, and abnormal color vision (dyschromatopsia) [44,45].

The emergency management of OCS including lateral canthotomy and inferior cantholysis to decompress the orbit is discussed separately and summarized in the rapid overview. (See "Approach to diagnosis and initial treatment of eye injuries in the emergency department", section on 'Orbital compartment syndrome'.).

Open globe injury or intraocular foreign body — The approach to the patient with an open globe injury or intraocular foreign body is summarized in a rapid overview (table 2). Key findings and initial management are also described in the algorithm (algorithm 1). The clinical features, evaluation, and management of patients with open globe injuries are discussed in greater detail separately. (See "Open globe injuries: Emergency evaluation and initial management".)

Physical findings of globe rupture or laceration include (see "Open globe injuries: Emergency evaluation and initial management", section on 'Physical examination'):

●Markedly decreased visual acuity

●Relative afferent pupillary defect (figure 9)

●Eccentric or teardrop pupil (picture 11 and picture 12)

●Increased or decreased anterior chamber depth (picture 13)

●Extrusion of vitreous (picture 14)

●External prolapse of the uvea (iris, ciliary body, or choroid) or other internal ocular structures (picture 15 and picture 16 and picture 17)

●Tenting of the cornea or sclera at the site of globe puncture

●Low intraocular pressure (checked by an ophthalmologist only)

●Seidel sign, fluorescein streaming in a tear drop pattern away from the puncture site (picture 18) (either observed at the time of fluorescein installation by an emergency provider for a presumed corneal abrasion or when specifically performed by an ophthalmologist)

In patients with a high likelihood of an open globe based upon mechanism of injury or physical findings, the following rules are essential:

●Avoid any examination procedure that might apply pressure to the eyeball, such as eyelid retraction or intraocular pressure measurement by tonometry. Gentle irrigation may be carefully performed if chemical eye exposure has occurred. (See "Topical chemical burns: Initial evaluation and management", section on 'Patient with eye exposure'.)

●Avoid placing any medication (eg, tetracaine) or diagnostic eye drops (eg, fluorescein) into the eye.

●Do not remove any protruding foreign bodies.

Traumatic hyphema — A rapid overview summarizes the important clinical features and initial management of traumatic hyphema (table 3). Key finding and initial management are also described in the algorithm (algorithm 1).

A hyphema appears as a layering of red blood cells in the anterior chamber that may be grossly apparent on visual inspection with a penlight, especially with the patient in a sitting position (picture 19A-C). Slit lamp examination provides the ability to detect microhyphema and to directly measure the millimeter height of the erythrocyte layer in an erect patient. Alternatively, a grading system based on the estimated amount of anterior chamber hemorrhage identifies severity of the hyphema (figure 7).

Other acute findings of traumatic hyphema include:

●Photophobia

●Decreased visual acuity

●Anisocoria

●Iridodialysis (tearing of the iris away from its insertion) (picture 20 and picture 21)

●Increased intraocular pressure

The clinical features, evaluation, and management of traumatic hyphema are discussed in greater detail separately. (See "Traumatic hyphema: Clinical features and diagnosis" and "Traumatic hyphema: Management".)

Vitreous hemorrhage — Traumatic vitreous hemorrhage may indicate a retinal tear or detachment and is also associated with abusive head trauma in infants and young children (picture 22). In addition, there may be subarachnoid or subdural hemorrhage in patients with significant head trauma. (See "Child abuse: Eye findings in children with abusive head trauma (AHT)".)

The patient will report decreased or hazy vision, black spots, or cob webs [47]. On ophthalmoscopy, the optic disc, retina, and vessels may be partially or completely obscured. With a large vitreous hemorrhage, the red reflex (reddish orange reflection of light off of the retina seen through the ophthalmoscope) may be absent. Examination of the red reflex is discussed separately. (See "The pediatric physical examination: HEENT", section on 'Ophthalmoscopic examination'.)

Suspected vitreous hemorrhage is an indication for CT of the head in patients with head trauma. Head CT is also indicated when vitreous hemorrhage is found in young children or infants without a history of head trauma to evaluate for non-accidental injury. (See "Child abuse: Eye findings in children with abusive head trauma (AHT)", section on 'Diagnostic implications of eye findings'.)

Patients with vitreous hemorrhage warrant urgent consultation with an ophthalmologist to guide additional diagnostic testing (eg, ultrasound) to identify the underlying injury and to provide definitive treatment.

Retinal trauma — Traumatic retinal injuries result in loss of vision that may be partial (confined to one part of the visual field) or complete. Retinal hemorrhage, tears, or detachment may be evident on direct ophthalmoscopy. However, urgent examination by an ophthalmologist, including slit lamp evaluation and indirect ophthalmoscopy with scleral depression is essential for full characterization of the retinal injury. Scleral depression is not performed acutely in patients with a concomitant traumatic hyphema or iritis. In patients with vitreous hemorrhage that obscures the fundus but who have a closed globe, orbital ultrasound can identify a retinal detachment (image 3).

Specific retinal injuries and potential interventions include:

●Acute retinal break – The patient may complain of light flashes, floaters, or spots [48]. This full thickness defect is usually seen peripherally and may cause a visual field defect. Laser therapy or cryotherapy within 24 to 72 hours of injury may be indicated.

●Retinal detachment – Retinal detachment may cause light flashes, floaters, visual disruption (shadow or "like a curtain being pulled down"), visual field defect, and loss of peripheral and/or central vision (picture 23) [48]. Patients with acute retinal detachment require bed rest pending urgent surgical repair. The timing of the repair is determined by the location of the detachment. Detachments that threaten the macula and central vision warrant urgent repair.

●Purtscher retinopathy – Purtscher retinopathy presents with sudden decreased vision and superficial retinal hemorrhages or cotton wool spots encircling the optic nerve in patients with traumatic compression of the legs, chest, or head but no direct eye injury [49]. Retinal changes are typically bilateral. Management consists of care of compressive injuries. There is no specific eye treatment. However ophthalmologic consultation is indicated for an initial complete eye examination with a follow-up evaluation in two to four weeks.

●Commotio retinae – Commotio retinae refers to retinal edema after blunt closed globe injury. It may be asymptomatic or cause decreased vision in affected patients [49]. Ophthalmoscopy demonstrates retinal whitening with normal vessels. Retinal hemorrhage may also be seen. This injury typically resolves without intervention. However, ophthalmology consultation is often necessary to identify commotio retinae and to follow for signs of an associated retinal break or detachment.

Optic nerve injury — Optic nerve injury, also known as traumatic optic neuropathy, causes decreased vision, including desaturation of red color or decreased color vision in the affected eye and an afferent pupillary defect. Mechanisms of injury are as follows [49]:

●Direct optic nerve injury usually results from lacerating trauma to the orbit. The nerve may be contused or even avulsed. The optic nerve rarely may be directly injured by a needle puncture during ophthalmic surgery or by hemorrhage within the orbit. (See 'Orbital compartment syndrome' above.)

●Indirect optic nerve injury, much more common than direct injury, results from contusion of the nerve within the optic canal. The usual cause is a forceful blow to the temple or the brow. The concussion is transmitted to the walls of the optic canal where the optic nerve becomes bruised due to shearing forces. Sometimes, avulsion can arise from rapid deceleration of the head or rotation of the globe. Optic canal fractures are sometimes found in these circumstances, but the fracture is typically not the cause of optic nerve injury and does not warrant repair. Although abusive head trauma is a rare cause of optic nerve injury, it is an important consideration in infants who do not have a known history of significant head trauma. (See "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children".)

Further evaluation of optic nerve injury requires emergency imaging (eg, coronal and axial computed tomography [CT] of the orbit with thin sections [1 mm]) through the optic canal and eye examination by an ophthalmologist. Definitive treatment is determined by the underlying etiology [49]. Evidence does not support the use of high-dose corticosteroids for this condition [50].

Periocular injuries that threaten vision — Head trauma can cause a carotid cavernous sinus fistula. In cases such as these, the ocular surface vessels appear tortuous (termed "corkscrew") and dilated with concomitant chemosis (edema of the conjunctiva) (picture 24). Retinal vessel distension and high intraocular pressure is typically present as well.

Patients who have sustained blast injuries or severe facial trauma may have periocular injuries that impair eyelid closure, which could lead to chronic corneal exposure. These individuals should receive lubricant eye ointment four times daily and, once stabilized, undergo ophthalmologic consultation.

COMMON CONDITIONS — Common eye injuries include eyelid lacerations, corneal abrasions and corneal foreign bodies, conjunctival injuries, and orbital fractures. The clinician must carefully evaluate patients with these injuries to identify associated serious conditions such as an open globe, hyphema, or retinal trauma. (See 'Vision-threatening conditions' above.)

Eyelid lacerations — Eyelid lacerations are an important subtype of facial trauma. Ocular injury (eg, open globe, traumatic hyphema, corneal abrasion) may accompany eyelid laceration in up to two-thirds of cases. Proper management and repair of eyelid lacerations requires a basic understanding of the anatomy of the eyelid and its surrounding structures (figure 10) including the nasolacrimal system (figure 11). (See "Eyelid lacerations", section on 'Epidemiology' and "Eyelid lacerations", section on 'Pertinent anatomy'.)

The following injuries warrant prompt consultation with an ophthalmologist or surgeon with special expertise in cosmetic repair of the eyelid (eg, plastic surgeon, oromaxillofacial surgeon) (see "Eyelid lacerations", section on 'Indications for surgical subspecialty consultation or referral'):

●Suspected open globe or intraocular foreign body (table 2)

●Laceration through the full thickness of the eyelid

●Lacerations with orbital fat prolapse (picture 6)

●Lacerations through the lid margin (picture 5)

●Lacerations involving the tear drainage system (figure 11)

●Lacerations with poor alignment and/or avulsion

Evaluation and management of eyelid lacerations is discussed in greater detail separately. (See "Eyelid lacerations", section on 'Primary evaluation and management'.)

Corneal abrasions and foreign bodies — Corneal abrasions and foreign bodies are common eye injuries. Clinical features of these injuries are as follows (see "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis", section on 'Clinical manifestations'):

●Corneal abrasion – Patients with corneal abrasions report severe eye pain and reluctance to open the eye due to photophobia and/or foreign body sensation. Corneal abrasions without other serious eye injuries typically have normal visual acuity and normal pupillary response but a staining defect on fluorescein examination (picture 25). Corneal epithelial defects caused by a retained conjunctival foreign body under the eyelid (picture 26) may have a characteristic appearance of multiple, parallel vertical lines at the upper edge of the cornea.

●Corneal foreign body – Patients with a corneal foreign body may or may not recall an episode of material falling or flying into the eye depending upon the type and size of the foreign body. Symptoms of pain and foreign body sensation may not be immediate. Alternatively, the sensation may be immediate, then abate for a while, and then recur. If the foreign body entered the eye at high velocity, as may be the case when using a grinding machine or from metal striking metal, the examiner must consider the possibility of a penetrating eye injury and an intraocular foreign body. Corneal foreign bodies are typically apparent upon careful inspection of the cornea, especially with a slit lamp.

Patients with corneal abrasions or foreign bodies warrant careful evaluation for a penetrating globe injury or traumatic hyphema. Patients who present in a delayed fashion after trauma may have a corneal ulcer (picture 27) or hypopyon warranting urgent ophthalmologic referral (picture 28).

The management of corneal abrasions and foreign bodies are discussed in detail separately. (See "Corneal abrasions and corneal foreign bodies: Management".)

Conjunctival injury — The conjunctiva is a thin, transparent tissue which covers and is adherent to the anterior portion of the sclera and lines the inside of the eyelids (figure 2). Traumatic conjunctival injury includes subconjunctival hemorrhage and conjunctival abrasion, laceration, or foreign body.

Clinical features of these injuries are as follows (see "Conjunctival injury", section on 'Clinical features'):

●Subconjunctival hemorrhage – Most subconjunctival hemorrhages are not associated with intraocular injury. However, in instances of scleral laceration, intraocular blood or fluid can leak through the defect and pool in the subconjunctival space creating a bullous, elevated subconjunctival hemorrhage which may hide the laceration (picture 29).

●Conjunctival lacerations – Patients with conjunctival lacerations warrant careful evaluation for an open globe (table 2) or traumatic hyphema (table 3). Identification of an open globe may require probing of the conjunctival laceration during slit lamp examination, preferably by an ophthalmologist. Computed tomography (CT) of the orbit may also be helpful.

●Conjunctival foreign bodies – Conjunctival foreign bodies typically cause a foreign body sensation and tearing. If the conjunctival foreign body is embedded under the upper lid, it may cause corneal abrasions with associated pain and photophobia. Lid eversion is usually necessary to locate upper lid foreign bodies. (See "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis", section on 'Clinical manifestations'.)

●Conjunctival abrasions – Conjunctival abrasions occur from blunt injuries and mild chemical or thermal burns and present as an irregularity of the epithelial surface of the conjunctiva, best seen using fluorescein stain and a cobalt blue light. Regions of denuded epithelium will appear green. Corneal abrasions are also frequently present. (See "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis".)

Ophthalmologic consultation is indicated for patients with conjunctival injury complicated by an open globe, traumatic hyphema, deeply embedded conjunctival foreign bodies, or conjunctival lacerations >1 cm in length.

Evaluation and management of conjunctival injuries are discussed in greater detail separately. (See "Conjunctival injury".)

Orbital fractures — Common signs and symptoms of orbital fracture include periocular ecchymosis, pain on lateral or vertical gaze, diplopia due to ocular muscle entrapment (picture 8) disconjugate gaze on looking vertically or horizontally, decreased sensation in the distribution of the infraorbital nerve, fracture site tenderness or bony stepoff, and/or crepitus indicating orbital emphysema caused by extension of an orbital fracture into the sinus. Thin cut coronal CT of the orbit is the imaging modality of choice to diagnose orbital fractures (image 2 and image 1). (See "Orbital fractures".)

Patients with orbital fractures may have associated vision-threatening eye injuries [51,52], especially traumatic hyphemas, orbital hematomas with compartment syndrome, or a ruptured globe and warrant careful ocular as well as periocular examination [53]. (See 'Vision-threatening conditions' above.)

The management of orbital fractures is discussed in detail separately. (See "Orbital fractures", section on 'Initial management'.)

OTHER CONDITIONS — Other conditions that are frequently associated with serious eye injury include lens subluxation or dislocation and choroidal injury.

Lens subluxation or dislocation — Native or implanted lens subluxation or dislocation may occur after blunt trauma to the eye and is frequently associated with traumatic hyphema, iridodialysis, and damage to the posterior structures (vitreous, retina, choroid). In addition, closed angle glaucoma, a vision-threatening condition, may occur. (See "Angle-closure glaucoma".)

Clinical findings include decreased visual acuity, monocular diplopia, iridodonesis (tremulousness of the iris) and a small pupil that is difficult to dilate. If lens dislocation is associated with minor trauma in children, then evaluation for an underlying ocular or systemic condition (eg, simple ectopia lentis, Marfan syndrome, or homocystinuria) is warranted. (See "Ectopia lentis (dislocated lens) in children", section on 'Clinical features' and "Ectopia lentis (dislocated lens) in children", section on 'Etiology'.)

The management of lens subluxation or dislocation in children is discussed in detail separately. (See "Ectopia lentis (dislocated lens) in children", section on 'Management'.)

Choroidal injury — Choroidal rupture with intact sclera from blunt injury causes white or yellow streaks concentric to the optic disc on ophthalmoscopic examination [54]. Chorioretinitis sclopetaria occurs after high-velocity penetrating injury to the orbit (eg, bullet or shrapnel) which spares or lightly grazes the globe [55]. Shock waves from the passing missile cause retinal and/or vitreous hemorrhage and choroidal rupture that appears as white or yellow streaks in a claw-like pattern (picture 30). Choroidal rupture and chorioretinitis sclopetaria warrant prompt consultation or referral to an ophthalmologist.

SUMMARY AND RECOMMENDATIONS

●Injury classification – Eye injury includes trauma to the eye (open- or closed-globe injury), the orbit (periocular trauma), or both. (See 'Injury classification' above.)

●Eye anatomy – A working knowledge of eye anatomy is clinically useful for triaging the severity of the injury and for communicating the nature of the injury to sub-specialists. Figures showing the cross section of the eye (figure 1), conjunctiva (figure 2), lacrimal system (figure 3), eyelid (figure 10 and figure 11), orbital septum (figure 4), orbital bones (figure 5), and orbital venous drainage (figure 6) are presented. (See 'Anatomy' above.)

●Approach – Conditions that pose a threat to vision may be identified using a focused history, initial physical examination, and an organized approach as described in the algorithm (algorithm 1). (See 'Approach' above.)

●Vison-threatening injuries – Rapid recognition and treatment of serious eye injuries such as ocular chemical burns, orbital compartment syndrome (table 5), or open-globe injuries (table 2) are essential to the preservation of vision. Vision-threatening injuries include the following (see 'Vision-threatening conditions' above):

•Ocular chemical burns (see 'Ocular chemical burns' above)

•Orbital compartment syndrome (see 'Orbital compartment syndrome' above)

•Open globe injury or intraocular foreign body (see 'Open globe injury or intraocular foreign body' above)

•Traumatic hyphema (see 'Traumatic hyphema' above)

•Vitreous hemorrhage (see 'Vitreous hemorrhage' above)

•Retinal trauma (see 'Retinal trauma' above)

•Optic nerve injury (see 'Optic nerve injury' above)

•Certain periocular injuries such as carotid cavernous sinus fistula (see 'Periocular injuries that threaten vision' above)

●Common eye injuries – The clinician must carefully evaluate patients with common injuries using a sequential eye examination so that associated serious conditions and vision threatening conditions such as an open globe, hyphema, or retinal trauma are not overlooked. Common eye injuries include the following (see 'Common conditions' above):

•Eyelid lacerations (see 'Eyelid lacerations' above)

•Corneal abrasions and corneal foreign bodies (see 'Corneal abrasions and foreign bodies' above)

•Conjunctival injuries (see 'Conjunctival injury' above)

•Orbital fractures (see 'Orbital fractures' above)