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Referral and warning signs
When to refer
Refer URGENTLY to Eye Specialist (Ophthalmologist) / HC4 with eye care capacity if: Decreased visual acuity. Presence of hyphema. Diplopia or restricted eye movements. Suspected orbital fracture. Irregular pupil shape or poor reaction. Severe pain. Suspected globe rupture. Any significant concern about intraocular injury.
Red flags
- Decreased visual acuity
- Hyphema (blood visible in anterior chamber)
- Double vision (Diplopia)
- Restricted eye movements
- Irregular or non-reactive pupil
- Severe eye pain
- Proptosis or Enophthalmos
- Palpable orbital rim defect
Signs and symptoms
- Periorbital edema (swelling) and ecchymosis (bruising, 'black eye').
- Pain.
- Blurred or decreased visual acuity (indicates potentially serious internal injury).
- Subconjunctival hemorrhage (blood on white of eye).
- Photophobia.
- Double vision (diplopia) - suggests muscle entrapment or nerve injury (orbital fracture).
- Hyphema (blood in the anterior chamber - visible layer of blood).
- Irregular pupil shape (traumatic mydriasis/miosis, iris tear).
- Pain with eye movement.
- Enophthalmos (sunken eye) or Proptosis (protruding eye) - suggests orbital fracture/hemorrhage.
- Restricted eye movements.
- Palpable step-off or tenderness over orbital rim (fracture).
Risk factors
- Assaults (fist fights).
- Sports injuries (balls, elbows).
- Falls.
- Workplace accidents.
- Motor vehicle accidents.
Diagnosis
Clinical assessment
History of blunt trauma to the eye/orbit. Examination findings: - Visual Acuity assessment (CRITICAL first step). - Inspection for periorbital bruising/swelling, subconjunctival hemorrhage, lacerations. - Check pupillary reactions (size, shape, reactivity - RAPD). - Assess ocular motility (range of motion, pain on movement, diplopia). - Examine anterior chamber for hyphema. - Palpate orbital rims for tenderness/step-off. - Check facial sensation (infraorbital nerve numbness suggests orbital floor fracture). - Fundoscopy (if possible, look for retinal detachment, vitreous hemorrhage - often needs specialist).
Investigations
- Visual acuity test.
- Intraocular pressure measurement (tonometry) - if safe to perform (avoid if globe rupture suspected).
- Slit lamp examination (Specialist): Detailed assessment of anterior segment (cornea, iris, lens, anterior chamber for cells/flare/hyphema).
- Dilated fundus examination (Specialist): Assess retina, optic nerve, vitreous.
- Orbital CT Scan: Indicated if suspected orbital fracture (diplopia, restricted movement, enophthalmos, infraorbital numbness, palpable step-off), significant vision loss, or severe trauma.
- B-scan Ultrasound: May help visualize posterior segment if view obscured by hyphema/vitreous hemorrhage.
Diagnostic criteria
History of blunt trauma with associated signs/symptoms. Severity determined by visual acuity and presence of specific injuries (hyphema, retinal detachment, orbital fracture, etc.).
Management
Non-pharmacological management
- Initial Assessment: Check visual acuity immediately.
- Rule out Globe Rupture: If suspected (severe vision loss, irregular pupil, hyphema, low IOP, extrusion of contents), STOP examination, shield the eye (do not patch), and refer URGENTLY.
- Minor Injury (e.g., simple 'black eye' with normal vision, no diplopia, no hyphema):
- - Cold compresses/ice packs for first 24-48h to reduce swelling.
- - Rest.
- More Severe Injury (Reduced vision, hyphema, suspected fracture, etc.):
- - Apply protective eye shield (NOT a patch).
- - Bed rest with head elevation (esp. for hyphema).
- - Minimize activity, avoid straining.
- - Refer urgently to ophthalmologist.
Pharmacological treatment
- Analgesia: Paracetamol for pain. Avoid NSAIDs initially if hyphema present (risk of re-bleeding).
- Antibiotic Drops/Ointment: (e.g., Chloramphenicol, Gentamicin, Tetracycline ointment - UCG rec) if corneal abrasion present.
- Cycloplegic Drops: (e.g., Atropine, Homatropine) for traumatic iritis or hyphema to reduce pain and prevent posterior synechiae (Specialist guidance).
- Anti-glaucoma medication: If intraocular pressure is elevated (Specialist management).
- Antifibrinolytics (e.g., Tranexamic acid): May be considered for hyphema (Specialist decision).
- Tetanus Prophylaxis: If associated skin break.
Monitoring
Monitor visual acuity. Monitor for increasing pain, worsening vision, development of diplopia. Monitor intraocular pressure if hyphema or glaucoma suspected. Follow-up schedule determined by severity and specific injury.
Complications
- Hyphema (blood in anterior chamber) -> Re-bleeding, Glaucoma, Corneal blood staining.
- Traumatic iritis/uveitis.
- Lens subluxation/dislocation.
- Traumatic cataract.
- Vitreous hemorrhage.
- Retinal detachment or tear.
- Choroidal rupture.
- Commotio retinae (retinal bruising).
- Optic neuropathy.
- Secondary glaucoma.
- Orbital fracture (blowout fracture) -> Muscle entrapment, Diplopia, Enophthalmos.
- Globe rupture (less common with pure blunt trauma unless severe).
Prevention
- Use of protective eyewear during high-risk sports and occupational activities.
- Violence prevention.
- Fall prevention.
Patient education
- Explain the nature of the injury and potential risks.
- Instruct on use of cold compresses, eye shield if needed.
- Advise on activity restrictions (avoid straining, heavy lifting, contact sports).
- Emphasize importance of follow-up appointments.
- Educate on warning signs requiring immediate return (worsening vision, increasing pain, flashing lights, floaters, new diplopia).
Uganda-specific notes
Assault is a common cause. Access to specialist ophthalmological assessment (slit lamp, dilated exam, CT scan) is limited. Careful initial assessment of vision and identification of red flags for referral are crucial. Hyphema and suspected orbital fracture always warrant referral.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 20, Section 20.3.2.1