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Referral and warning signs
When to refer
IMMEDIATE, URGENT referral to an Ophthalmologist / Eye Hospital is mandatory for ALL suspected or confirmed penetrating eye injuries. Time is critical for surgical repair and prevention of endophthalmitis.
Red flags
- Any sign suggestive of globe perforation:
- - Visible laceration of cornea/sclera
- - Prolapse of intraocular contents (dark tissue - iris/uvea)
- - Peaked or irregular pupil
- - Positive Seidel test (aqueous leak)
- - Very low vision (LP/NLP)
- - History of penetrating mechanism (sharp object, projectile)
Signs and symptoms
- History of injury with sharp object or high-velocity projectile.
- Severe eye pain.
- Significant decrease in visual acuity (may be light perception only or no light perception).
- Visible laceration/defect in cornea or sclera.
- Irregularly shaped pupil (often 'tear-drop' or peaked, pointing towards the perforation).
- Shallow anterior chamber.
- Hyphema (blood in anterior chamber).
- Extrusion of intraocular contents (uveal tissue - iris/ciliary body/choroid, vitreous, lens matter).
- Positive Seidel test (leakage of aqueous humor seen with fluorescein staining - streaming fluid).
- Low intraocular pressure (usually, but can be normal/high).
- Subconjunctival hemorrhage.
- Lid laceration may be associated.
Risk factors
- Workplace accidents (metal work, construction).
- Assaults (stabbing).
- Accidents involving sharp objects (tools, glass).
- Falls onto sharp objects.
- Explosions / Blast injuries (high velocity projectiles).
- Not wearing eye protection during high-risk activities.
Diagnosis
Clinical assessment
High index of suspicion based on mechanism of injury (sharp object, projectile). Clinical signs are key: - Grossly reduced visual acuity. - Visible corneal or scleral laceration. - Peaked or irregular pupil. - Shallow anterior chamber. - Visible iris/uveal tissue prolapse. - Positive Seidel test. Avoid any pressure on the globe during examination.
Investigations
- Visual acuity test (may be very poor).
- Gentle inspection (AVOID pressure). Document findings.
- Seidel test with fluorescein (confirms full-thickness leak).
- Orbital CT Scan: To rule out intraocular foreign body (IOFB) and assess extent of injury. Thin cuts needed.
- B-scan Ultrasound: May help visualize posterior segment damage or IOFB, but use cautiously to avoid pressure on ruptured globe.
- Intraocular Pressure (IOP) measurement is CONTRAINDICATED if open globe suspected.
Diagnostic criteria
Clinical signs suggestive of violation of globe integrity (laceration, prolapse, Seidel test, peaked pupil) following penetrating trauma mechanism.
Management
Non-pharmacological management
- Immediate Action:
- - STOP all examination/manipulation causing pressure on the eye.
- - Place a rigid protective eye shield (e.g., Fox shield, base of paper cup) over the eye. Tape securely to forehead and cheek. DO NOT PATCH the eye (patch applies pressure).
- - Keep patient NPO (nil per os) in anticipation of surgery.
- - Bed rest with head slightly elevated.
- - Provide antiemetics to prevent vomiting (increases IOP).
- - URGENT referral/transfer to an Ophthalmologist/Eye Hospital.
Pharmacological treatment
- Analgesia: Systemic pain relief (e.g., IV Morphine) as needed. Avoid NSAIDs.
- Antiemetics: (e.g., Ondansetron IV) to prevent vomiting/straining.
- Tetanus Prophylaxis: Update tetanus immunization status (give TT booster +/- TIG).
- Systemic Antibiotics: Broad-spectrum IV antibiotics are crucial to prevent endophthalmitis (severe intraocular infection). Start ASAP pre-transfer/pre-operatively. Common choices: Vancomycin PLUS Ceftazidime OR Ciprofloxacin.
- Topical medications: Generally AVOIDED in the field to prevent substances entering the eye, unless specifically directed by ophthalmologist.
Monitoring
Monitor vital signs. Monitor for worsening pain, signs of infection. Reassess vision only if possible without disturbing shield/eye. Prepare for urgent surgery.
Complications
- Endophthalmitis (severe intraocular infection) -> Blindness, Loss of eye.
- Retinal detachment.
- Vitreous hemorrhage.
- Traumatic cataract.
- Secondary glaucoma.
- Sympathetic ophthalmia (rare autoimmune inflammation in the fellow, uninjured eye).
- Phthisis bulbi (shrunken, non-functional eye).
- Permanent vision loss / Blindness.
- Loss of the eye (enucleation/evisceration).
Prevention
- Consistent use of appropriate eye protection (safety glasses, goggles, face shields) in high-risk occupations and activities.
- Workplace safety regulations and training.
- Careful handling of sharp tools and objects.
- Violence prevention.
Patient education
- Explain the seriousness of the injury and the need for urgent surgery.
- Emphasize the importance of keeping the eye shield in place and avoiding any pressure on the eye.
- Instruct patient to remain NPO.
- Provide reassurance while stressing urgency.
- Discuss potential visual prognosis cautiously (often guarded).
Uganda-specific notes
These are devastating injuries often leading to blindness if not managed promptly and expertly. Access to ophthalmologists and facilities equipped for microsurgical repair is limited. Immediate shielding, systemic antibiotics, tetanus prophylaxis, and rapid transfer to the nearest capable center (likely RRH or NRH) are the critical steps at lower levels.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 20, Section 20.3.2.2