Eye Injuries: Blunt, Penetrating, Chemical Burns and Emergency Care

Eye trauma ranges from a small corneal abrasion to an open-globe wound, orbital compartment syndrome or chemical burn that can destroy vision within minutes. The first emergency task is to find the injuries that need action now while avoiding pressure on an eye that may be ruptured. This guide covers blunt, sharp/penetrating, foreign-body, chemical and thermal/UV injuries, with a structured assessment and current referral priorities for emergency-medicine students.

Learning objectives

• Classify ocular trauma as closed-globe or open-globe injury and explain the difference between rupture, laceration, penetrating injury, perforating injury and an intraocular foreign body.
• Recognize time-critical open globe, chemical burn, hyphema with raised pressure, orbital compartment syndrome, retinal detachment and traumatic optic neuropathy.
• Take a mechanism-focused history and perform a safe, reproducible eye assessment, including visual acuity, pupils, motility, fluorescein and fundoscopy when appropriate.
• Describe the emergency management of blunt, sharp, chemical, thermal/UV and foreign-body injuries, including what must not be done before ophthalmology review.
• Understand acute and delayed complications involving the orbit, lids, cornea, anterior chamber, iris, lens, vitreous, choroid, retina, optic nerve and pressure system.
• Correct unsafe historical recommendations in the supplied deck, especially chemical neutralization, pressure patching of serious injury, unsupervised corneal procedures and prophylactic eye removal.

1. Start with life-threatening trauma, then protect sight

In a major road crash, fall, assault or explosion, use the trauma primary survey first. Manage airway, breathing, circulation, cervical spine and associated head/facial injuries before a detailed ocular examination. An eye finding must not distract from intracranial injury, facial fracture, airway compromise or haemorrhage. At the same time, chemical exposure and orbital compartment syndrome have time-sensitive eye-specific actions that may need to occur before a complete history or imaging.

Ask where, when, how and with what the eye was injured. Clarify high-velocity mechanisms such as hammering metal-on-metal, grinding, drilling, explosions, firearms, shattered glass or a sharp object; whether a chemical is acid, alkali or another product; contact-lens use; prior eye surgery or corneal transplant; and the first aid already given. Ask about immediate and delayed pain, photophobia, blur, diplopia, field loss, flashes/floaters, nausea, headache, bleeding and loss of consciousness. Bring the chemical container or safety data sheet when relevant without delaying irrigation.

A practical eye-trauma assessment sequence

1. Check scene safety and contamination: protect staff from chemicals, blood or embedded material; remove contaminated clothing and use appropriate gloves. Brush dry lime/particulate from surrounding skin before it enters the eye, then irrigate the eye if open globe is not suspected.
2. Record visual acuity early when feasible: each eye separately, with habitual correction and pinhole if appropriate. If the patient cannot read a chart, record counting fingers, hand movements, light perception or no light perception. Do not delay irrigation for acuity in an active chemical burn.
3. Inspect without pressure: observe facial asymmetry, lid wounds, proptosis, enophthalmos, bruising, laceration, foreign body, pupil shape, corneal clarity and anterior-chamber depth. Do not force the lids open or palpate a possibly ruptured globe.
4. Compare pupils and ocular function: check direct/consensual responses, relative afferent pupillary defect, eye movements and diplopia if safe. A new RAPD or marked acuity loss suggests optic-nerve, retinal or severe globe injury.
5. Decide whether open globe is possible before using instruments or drops: mechanism and signs such as uveal prolapse, peaked pupil, abnormal chamber depth, visible wound, soft/deformed globe, extensive subconjunctival haemorrhage or positive Seidel test raise concern. Do not measure IOP or place pressure on the eye when open globe is suspected.
6. Only after globe integrity is reasonably established: use slit lamp and fluorescein to assess epithelial defects, lacerations, foreign bodies and leakage; evert lids when safe and trained; examine the anterior chamber and dilate/fundus examine if the injury permits.
7. Image and refer selectively: thin-slice noncontrast CT of the orbits is useful for suspected fracture, orbital foreign body or open globe, but a negative CT cannot exclude every globe wound. Avoid MRI until a ferromagnetic foreign body has been excluded. Contact ophthalmology early for serious or uncertain injury.

2. Classify the injury correctly

The eyewall is the cornea and sclera. In a closed-globe injury, there is no full-thickness break in the eyewall; contusion and lamellar laceration are examples. In an open-globe injury, a full-thickness wound communicates with the inside of the eye. A sharp object may make a laceration, while blunt force can cause an inside-out rupture, often at a weakened area or prior surgical wound. “Penetrating” usually describes a single entry wound without an exit wound; “perforating” describes both entry and exit. An intraocular foreign body can accompany either a penetrating or perforating wound. This classification helps anticipate risk; it does not replace an examination or an ophthalmologist’s assessment.

Potential open-globe signs include an obvious corneal/scleral wound, peaked or teardrop pupil pointing toward a wound, uveal/vitreous prolapse, shallow or unusually deep anterior chamber, hyphema, irregular globe contour, low-pressure/deformed appearance, dense 360-degree subconjunctival haemorrhage, positive Seidel leakage, lens disruption or intraocular air. Some small posterior wounds are hidden under conjunctiva or lids. A normal-looking front of the eye does not exclude a posterior rupture after a high-energy mechanism.

3. Blunt trauma: injury may be hidden behind a “black eye”

A fist, ball, stick, fall, road crash or blunt projectile compresses the globe front-to-back and expands it sideways. The same force can injure the orbit, eyelids, conjunctiva, cornea, sclera, anterior chamber, iris, ciliary body, lens, vitreous, choroid, retina, optic nerve, lacrimal passages and extraocular muscles. Symptoms can be modest despite severe injury; bruising does not prove that the globe is intact. Some consequences—angle-recession glaucoma, retinal tear/detachment, traumatic cataract and macular damage—appear days, months or years later.

Orbit and orbital compartment syndrome

Orbital wall fractures may cause diplopia, restricted eye movement, numbness in the cheek or upper lip, enophthalmos or orbital emphysema. A floor or medial-wall blowout can trap an extraocular muscle or soft tissue. Children may have a deceptively subtle “white-eyed” trapdoor fracture with severe motility restriction, nausea/vomiting, bradycardia or pain on eye movement due to the oculocardiac reflex. Entrapment, vision loss, open globe, retrobulbar haemorrhage or optic-nerve compression requires urgent specialist review. Advise against nose blowing or forceful Valsalva when an orbital fracture/emphysema is suspected; sneezing with the mouth open and antiemetics can reduce pressure spikes.

Retrobulbar haemorrhage or rapidly expanding orbital swelling can produce orbital compartment syndrome: proptosis, a tense orbit, tight lids, reduced vision or colour vision, RAPD, restricted motility and raised IOP. It is a clinical emergency. If globe rupture is not suspected, a trained, credentialed clinician may need to perform immediate lateral canthotomy with inferior cantholysis; do not wait for CT when the diagnosis is clinically evident. If open globe may coexist, get immediate ophthalmology/trauma assistance to decide the safest decompression pathway. Medical pressure-lowering measures do not replace decompression when compartment syndrome is present.

Delayed pulsatile proptosis, chemosis, orbital bruit, cranial-nerve palsy or elevated pressure after head trauma can suggest a carotid-cavernous fistula. Fever, progressive pain, redness and swelling can indicate infection or orbital cellulitis, though post-traumatic emphysema and haemorrhage are also possible. These require imaging and urgent specialist assessment. Do not label pulsating exophthalmos as a routine black eye.

Eyelids, lacrimal drainage and conjunctiva

Periorbital ecchymosis, swelling, traumatic ptosis and subcutaneous emphysema are common. Ptosis may be mechanical from swelling, due to levator injury or associated with a third-nerve injury. A lid laceration that crosses the lid margin, medial canthus/canaliculus, levator, tarsal plate or full eyelid thickness needs specialist repair; poor alignment can cause notching, exposure, tearing, lid malposition or visual-axis obstruction. A medial eyelid cut can injure the canaliculus even when small. Do not close a complex lid wound blindly before checking for globe injury, retained material and lacrimal involvement.

Conjunctival lacerations can conceal scleral wounds or foreign bodies. A small superficial cut may need lubrication and follow-up, but a large wound, exposed sclera, prolapse, retained material or suspected open globe needs urgent ophthalmology. Traumatic subconjunctival haemorrhage is often harmless after globe injury has been excluded. However, a 360-degree haemorrhage or one with no visible posterior margin can hide a scleral rupture. The deck’s colour, triangular shape and timing rules do not reliably distinguish local haemorrhage from skull-base injury. Use the full trauma history, neurologic status, examination and imaging indications; unexplained bilateral periorbital bruising after head trauma raises concern for a basilar skull fracture.

Cornea and sclera

A corneal abrasion causes pain, foreign-body sensation, tearing, photophobia and blepharospasm. After ruling out open globe and embedded foreign body, fluorescein highlights the epithelial defect; lid eversion may reveal a subtarsal foreign body that produces vertical scratches. A small uncomplicated abrasion often heals, but central/large defects, reduced acuity, contact-lens wear, contamination, immunosuppression, chemical injury, recurrent erosion, an only-seeing eye or uncertain diagnosis needs prompt review. Avoid routine pressure patching. Do not prescribe topical anaesthetic for home use; repeated use can damage the epithelium and mask deterioration. Antibiotic prophylaxis and cycloplegia are selected according to abrasion features and local guidance; cycloplegics may help severe ciliary spasm/photophobia but are not automatic for every scratch.

Corneal oedema, Descemet membrane folds or rupture can follow contusion and blur vision. Corneal blood staining is an uncommon but serious result of severe hyphema with sustained high IOP; it may clear slowly and can permanently impair vision. Corneal/scleral rupture is a full-thickness open-globe emergency, not an abrasion to patch or suture in the ED.

Hyphema: blood in the anterior chamber

Hyphema is blood between the cornea and iris, often from injured iris/ciliary vessels. It may form a visible horizontal level or be microscopic. Blunt trauma may also injure the angle, lens, retina or optic nerve. Rebleeding commonly occurs in the first several days and can cause pressure elevation, optic-nerve injury or corneal blood staining. Check visual acuity, pupils and the anterior chamber when safe; do not measure pressure before excluding open globe.

Arrange urgent ophthalmology review for traumatic hyphema. A rigid shield, head elevation, limited activity and close follow-up are common initial measures under eye-service direction. Avoid aspirin and NSAIDs if possible because they can increase bleeding risk; use safer analgesia when appropriate. Ask about sickle cell disease/trait and bleeding disorders; where sickle haemoglobin is prevalent, testing may be indicated. Even a small hyphema can produce dangerous pressure elevation in sickle cell disease/trait, and pressure-lowering drug choices differ. Steroid drops, cycloplegics, aqueous suppressants, admission, antifibrinolytics or surgical washout are ophthalmology decisions based on grade, IOP, rebleeding, sickle status, age and follow-up reliability. Do not routinely use complete bed rest, patch the eye tightly, perform paracentesis or prescribe acetazolamide without specialist advice.

Iris, ciliary body, lens and pressure system

Blunt trauma can cause a briefly small pupil (traumatic miosis), a persistently enlarged pupil from sphincter tears (traumatic mydriasis), photophobia, glare, poor near focus, iris tears or iridodialysis where the iris root separates from the ciliary body. A D-shaped pupil, peripheral dark crescent, monocular diplopia or an irregular pupil suggests structural injury. Severe injury can produce traumatic aniridia. Cycloplegic drops or surgical iris repair may be considered for painful inflammation, disabling glare or diplopia, but treatment depends on associated injuries and should be directed by ophthalmology.

Ciliary-body injury may cause accommodation spasm or paralysis, low aqueous production with hypotony, hyphema, inflammation or angle recession. Post-traumatic iridocyclitis can present later with pain, photophobia and cells/flare. Angle recession is a tear between layers of the ciliary body; it may lead to glaucoma months or years later. A patient with significant blunt trauma needs documented follow-up and later pressure/angle assessment even if initial symptoms settle.

A Vossius ring is pigment on the anterior lens capsule after iris contact; it is a clue to impact rather than proof of a harmless injury. Traumatic cataract may develop immediately or later. Zonular damage may cause phacodonesis/iridodonesis, lens subluxation or dislocation into the anterior chamber or vitreous. An anteriorly displaced lens can block aqueous outflow and cause acute glaucoma; sudden blur, a shallow chamber, corneal oedema or severe pain needs urgent review. Lens surgery timing is planned by an ophthalmologist after globe integrity, inflammation and capsule status are assessed.

Vitreous, choroid, retina and optic nerve

Vitreous haemorrhage causes haze, cobwebs, floaters or reduced vision and may obscure the retina; it can accompany retinal tears, detachment or open globe. Sudden flashes, a shower of floaters, a curtain/field defect or loss of vision after trauma requires urgent dilated retinal assessment. Choroidal rupture can be subtle but may scar near the macula and permanently reduce central vision. Choroidal haemorrhage, inflammation or detachment can also occur and require ophthalmology assessment.

Commotio retinae (Berlin oedema) is retinal whitening after blunt impact, often at the posterior pole; macular involvement can cause significant blur or a central scotoma. The retina may improve, but visual recovery is not guaranteed, and delayed macular/retinal complications need follow-up. Retinal haemorrhage may be superficial, deep or preretinal. Retinal dialysis/tears can lead to rhegmatogenous detachment, particularly in an eye with pre-existing peripheral retinal degeneration. A normal initial external appearance does not exclude posterior injury.

Traumatic optic neuropathy may follow direct nerve injury or force transmitted through the optic canal. Findings include reduced acuity, colour desaturation, visual-field defect, RAPD and a normal early optic disc in some indirect injuries; avulsion or disc swelling may be visible. It is a sight-threatening diagnosis that can coexist with orbital fractures or head injury. Urgent ophthalmology/neuro-ophthalmology and trauma evaluation are required; routine high-dose steroid or optic-canal decompression is not an automatic evidence-based ED treatment.

Trauma can also injure the lacrimal gland, canaliculi, extraocular muscles and pressure-control structures. Tearing after a medial eyelid cut may reflect canalicular damage; diplopia or strabismus may reflect muscle entrapment, palsy or orbital injury. Traumatic glaucoma and hypotony may occur early or late. Document these associated injuries and ensure follow-up rather than treating each sign in isolation.

4. Open-globe and penetrating injuries

Sharp instruments (knives, scissors, needles, nails, glass), high-velocity fragments and projectiles may lacerate eyelid, conjunctiva, cornea or sclera. A small corneal entry wound may be self-sealed yet associated with iris incarceration, anterior synechiae, lens injury, endophthalmitis or a retained IOFB. A scleral wound can extend posteriorly beyond what is visible. Blunt impact can rupture the globe from inside out, often at a previous surgical or structurally weak site. Mechanism matters: an apparently tiny entry mark after metal-on-metal work may represent a high-speed intraocular projectile.

For all suspected open globe injuries, do not apply pressure, tonometry, topical anaesthetic, fluorescein, eye drops, ultrasound probe or a pressure dressing. Never pull out an embedded or protruding object: stabilize it without pushing it deeper, shield the eye and transport urgently. A rigid eye shield can be made from a clean protective cup if a commercial shield is unavailable; secure it without compressing the globe. Keep the patient nil by mouth in case surgery is needed, control pain/nausea, review tetanus status and arrange prompt specialist transfer. Systemic antibiotic prophylaxis, antiemetic, imaging and timing of repair are set by local trauma/ophthalmology protocol. Do not let an investigation delay urgent globe closure when it will not change immediate surgery.

The ophthalmologist plans primary repair, assesses whether an IOFB is present, and decides whether vitreous/uveal tissue can be repositioned, excised or repaired. The old deck’s instruction to excise all prolapsed tissue is too broad; tissue management requires microsurgical judgement. Similarly, routine enucleation of a severely damaged eye “to prevent sympathetic ophthalmia” is no longer appropriate. Current guidance favors repair when technically feasible; primary eye removal is considered when repair cannot be performed, for example with irreparable tissue loss. Even an eye with very poor initial vision may retain salvage potential. Prognosis is discussed by the surgeon after a complete assessment.

5. Foreign bodies: surface, lid, orbit or inside the globe

Conjunctival and corneal foreign bodies

Sand, stone, glass, metal, wood, plant material and dust can lodge under an eyelid or in the conjunctiva/cornea. Symptoms include foreign-body sensation, pain, tearing, photophobia and blurred vision. A high-velocity mechanism, central/deep corneal object, irregular pupil, aqueous leakage, hyphema or reduced vision raises concern for open globe/IOFB. First establish that the globe is intact. With safe equipment and training, inspect the fornices and evert the upper lid; a retained subtarsal object often creates vertical fluorescein scratches. Superficial particles may be irrigated or removed by a trained clinician at a slit lamp. Do not use a cotton bud, needle or burr blindly on a central/deep object, suspected open globe or poorly cooperative patient.

Corneal foreign bodies can cause epithelial defects, infection, ulceration, scarring, rust rings and rarely a ring abscess. Iron can rust in corneal tissue; removal and any rust-ring treatment are performed with magnification by someone trained, with attention to residual stromal depth and scarring. Organic/soil material increases concern for bacterial or fungal infection. Reassess vision and fluorescein after removal, prescribe treatment according to local guidance/risk and set definite follow-up. Contact-lens wearers, central defects, reduced acuity, infection, persistent pain or uncertain removal need prompt eye-service care.

Intraocular foreign body (IOFB)

Metal-on-metal hammering, grinding, drilling, explosions and firearms are classic high-risk mechanisms; glass, stone, lead, wood or other fragments may also enter through the cornea or sclera. An entry wound can be tiny. A foreign body can mechanically damage the lens, iris, retina or optic nerve; introduce infection; or chemically injure tissue after remaining in the eye. A retained iron object may cause siderosis bulbi with rusty staining of the lens/iris/retina, cataract, altered pupil or retinal degeneration. Copper may cause chalcosis and a golden/greenish lens change; toxicity varies by composition and location.

When an IOFB is possible, protect the globe and involve ophthalmology urgently. Thin-slice noncontrast orbital CT is generally the first imaging test for metal, glass and orbital fracture. Plain radiography has limited use; a negative CT does not exclude every small or nonmetallic object. MRI must not be used until ferromagnetic metal has been excluded because the magnet can move a metallic fragment and worsen injury. Do not perform B-scan ultrasound if open globe is suspected because probe pressure could extrude ocular contents; after the globe is closed or cleared safe by ophthalmology, ultrasound may help assess posterior structures. IOFB extraction, anterior-segment surgery or pars plana vitrectomy is specialist work. The priority is prompt watertight globe repair; imaging and removal planning should not cause unnecessary delay.

6. Chemical injuries: irrigate first, not neutralize

Chemicals can injure the eyelids, conjunctiva, cornea, limbal stem cells and intraocular structures. Alkalis such as lye, ammonia, cement/lime, sodium or potassium hydroxide can penetrate deeply by liquefactive necrosis and are often more destructive. Acids such as sulphuric or hydrochloric acid usually cause coagulative necrosis that may limit some deeper penetration, but severe acid burns can still blind. Phenols, aniline dyes, iodine, solvents and household/industrial products can also injure the eye. Concentration, volume and—above all—time to irrigation affect severity.

Emergency department irrigation and assessment

1. Use normal saline, lactated Ringer’s/Hartmann’s or another appropriate irrigating fluid if available. Use enough fluid to restore physiological pH; several litres may be necessary. A topical anaesthetic given by a clinician can reduce blepharospasm and help irrigation, but is not a take-home treatment.
2. Remove contact lenses as soon as feasible. Irrigate from the nasal side toward the temporal side and away from the unaffected eye. Let the patient blink and look in all directions as irrigation continues.
3. After initial irrigation, evert the lids and sweep the fornices to remove retained particles, particularly lime/cement. Use appropriate instruments and training; if globe injury is suspected, stop manipulation and obtain urgent specialist assistance.
4. Check ocular surface pH with indicator paper in the lower fornix of both eyes. Continue irrigation until the pH is near physiological (commonly about 7.0–7.4). Pause for several minutes and recheck; a rebound in pH suggests retained chemical or continuing release from particles, so irrigate and sweep again.
5. Only after pH is stable and open globe has been considered, document visual acuity, pupil response, corneal clarity, fluorescein staining, conjunctival epithelial loss, limbal blanching/ischemia and injury to lids/fornices. Measure IOP only when safe and appropriate.
6. Arrange immediate ophthalmology review for significant chemical exposure. Bring the product label/SDS if available; do not delay irrigation to retrieve it.

Severity depends on epithelial loss, corneal haze, limbal ischemia and conjunctival involvement. Severe burns can cause corneal melt, infection, limbal stem-cell failure, symblepharon, dry eye, cicatricial entropion/ectropion, corneal scarring/ectasia, secondary glaucoma, cataract, uveitis and phthisis. Drops after irrigation—antibiotic, lubrication, cycloplegic, anti-inflammatory treatment or pressure-lowering therapy—are selected by ophthalmology based on grade and infection risk. Topical corticosteroids may be important early in selected chemical burns, but duration and taper need close eye-service monitoring because of melt/infection risks. Fornix sweeping/adhesion prevention, amniotic membrane, limbal reconstruction or keratoplasty are specialist interventions. Never let medications delay irrigation.

7. Thermal, flash and ultraviolet burns

Flame, hot liquid, molten metal, steam and explosions can burn eyelid skin, conjunctiva and cornea. Assess associated face/airway burns, inhalation injury, blast trauma and open-globe risk. Cool affected facial skin according to burn protocols; do not apply ice directly to the globe or delay eye evaluation. Eyelid swelling can mask corneal exposure or a laceration. Corneal haze, epithelial defect, reduced vision, limbal injury, inability to close the lid or any mixed explosive mechanism requires urgent ophthalmology.

Ultraviolet photokeratitis (“welder’s flash,” arc eye or snow blindness) follows UV exposure, commonly from welding without eye protection or intense reflected light. Symptoms are often delayed for several hours and can include bilateral severe pain, tearing, photophobia and blepharospasm. Slit-lamp examination may show diffuse punctate epithelial staining. Confirm the exposure, exclude a retained foreign body, chemical burn and open globe, assess vision, and provide supportive lubrication and oral analgesia. Most uncomplicated cases re-epithelialize over 24–72 hours, but reduced acuity, unilateral or atypical symptoms, contact-lens wear, retained metal, corneal opacity or worsening pain needs urgent review. Do not prescribe topical anaesthetic for home use or routinely pressure-patch both eyes. Prevention is UV-rated welding goggles/face shield and correctly fitted eye protection.

8. Sympathetic ophthalmia: rare, serious and not a reason for automatic eye removal

Sympathetic ophthalmia is a rare bilateral granulomatous panuveitis that can follow penetrating/open-globe injury or intraocular surgery. It may appear weeks, months or rarely years later; the injured eye is sometimes called the exciting eye and the fellow eye the sympathizing eye. Symptoms can include new photophobia, floaters, blur or redness, often in the fellow eye. Modern understanding involves immune-mediated inflammation after ocular antigen exposure; the deck’s simple “antibodies against pigment” explanation is incomplete.

Preventive priorities are appropriate primary repair, removal of IOFB when indicated, specialist follow-up and prompt evaluation of new fellow-eye symptoms. A patient with prior penetrating trauma should seek care for new photophobia or reduced vision in either eye. Established disease needs urgent uveitis/ophthalmology management, usually corticosteroids and sometimes steroid-sparing immunomodulation under specialist supervision. The historical recommendations to remove every “hopeless” eye or to enucleate at two weeks if inflammation persists are not routine modern practice. Eye removal is considered when primary repair is technically impossible or for specific later indications; it is not guaranteed to prevent sympathetic ophthalmia and should not be performed without specialist counselling.

9. Investigations and disposition

CT should be tailored to the injury (noncontrast thin cuts for globe/orbit/IOFB; facial/head imaging for fracture or associated trauma). CT can show globe contour change, intraocular air, foreign body and fracture but is not perfectly sensitive. Do not use MRI when ferromagnetic metal could be present. B-scan ultrasound, gonioscopy and contact procedures wait until ophthalmology has excluded open globe. If chemical injury is the priority and no open-globe mechanism is present, irrigation comes before imaging. A severe head injury or facial fracture may need neurosurgery/maxillofacial/trauma involvement alongside ophthalmology.

10. Safe treatment principles by injury

Analgesia and antiemetics are not minor details: pain, vomiting and squeezing increase pressure and movement in an injured eye. Provide systemic analgesia and antiemetic treatment as needed, while avoiding medicines that worsen bleeding risk in hyphema or are contraindicated by the patient’s other injuries. Tetanus prophylaxis is considered for penetrating/contaminated wounds according to immunization status and national guidance. Systemic antibiotics for open globe or IOFB and topical antibiotics after surface injury are selected under local protocols and ophthalmology advice; no one regimen fits every injury.

11. Delayed complications and follow-up

Trauma can cause corneal scarring, recurrent erosion, infection, cataract, lens instability, uveitis, angle-recession glaucoma, chronic hypotony, retinal tear/detachment, macular scar, optic atrophy, diplopia, eyelid malposition, canalicular obstruction and sympathetic ophthalmia. Some appear after an initially reassuring emergency visit. Explain return precautions clearly: any reduction in vision, increasing pain/photophobia, flashes/floaters, a curtain/field defect, worsening redness, vomiting, new diplopia, proptosis, discharge or failure to improve requires reassessment.

Follow-up should document visual acuity, corneal healing, pressure when safe, anterior chamber, lens position, pupils, retinal status and function of lids/tear drainage. Patients with angle injury may need long-term IOP monitoring; those with retinal symptoms or poor posterior view need dilated examination and repeat assessment. A contact-lens wearer with an epithelial defect, organic material injury, high-velocity metal exposure, chemical burn, hyphema or open globe should not be discharged without a specific review plan. A written referral or direct clinician-to-clinician handover is safer than “see eye clinic when possible.”

12. Case-based application

Case 1: hammering metal

A 29-year-old was striking a steel chisel when a fragment hit the right eye. He has mild pain, a tiny corneal mark and reduced acuity; the pupil is irregular.

Interpretation: An occult open globe with IOFB is possible despite the small entry mark. Do not evert the lid forcefully, measure IOP, press, instill drops or remove the particle. Rigid shield, NPO, analgesia/antiemetic, urgent ophthalmology and noncontrast thin-slice orbital CT are appropriate under local trauma protocol. No MRI until metal is excluded; do not use ocular ultrasound while globe rupture is possible.

Case 2: lime in the eye

A construction worker reports powdered cement blew into one eye. The eye is red and tightly shut, and a colleague is looking for the bag of cement.

Interpretation: Once scene safety is established and open globe is not suspected, irrigate immediately with clean water or saline. Do not wait for the container or attempt to neutralize the alkali. Remove contact lenses and sweep retained particulate from the fornices after initial irrigation, then check and recheck pH. Arrange immediate ophthalmology review after irrigation.

Case 3: blood in the anterior chamber

A 15-year-old is struck by a ball and has blurred vision. There is a visible hyphema and the pupil is mildly irregular.

Interpretation: Hyphema may coexist with iris, angle, lens, retina or globe injury. Assess acuity and open-globe signs without pressure. Shield the eye, avoid aspirin/NSAIDs, ask about sickle cell disease/trait and bleeding risk, and arrange urgent ophthalmology follow-up with IOP monitoring when safe. Do not discharge after a brief pressure check without a rebleed plan.

Case 4: swelling and proptosis after a punch

A patient develops rapidly increasing proptosis, tight lids, severe pain, reduced acuity and an RAPD after blunt orbital trauma.

Interpretation: Suspect orbital compartment syndrome from retrobulbar haemorrhage. Activate ophthalmology/trauma support. If open globe is not suspected, immediate lateral canthotomy/cantholysis by a trained clinician can save vision; do not wait for CT when signs are clear. Assess the globe and orbit together and image after decompression as clinically indicated.

Case 5: flashes and a curtain after a blow

Several hours after being struck in the eye, a patient notices flashes, new floaters and a dark curtain from the temporal field.

Interpretation: Retinal tear or detachment is an urgent possibility. Arrange same-day dilated retinal assessment; a quiet, minimally painful external eye does not make this safe to observe at home.

Case 6: welding without protection

A metal worker develops bilateral severe pain and photophobia several hours after welding. Visual acuity is largely preserved; fluorescein shows diffuse punctate staining.

Interpretation: Photokeratitis is likely after foreign body, chemical exposure and open globe are excluded. Provide lubricating/supportive care and analgesia according to local protocol, counsel UV protection and review if vision decreases, pain worsens or symptoms fail to improve over 24–72 hours. Do not supply topical anesthetic for home use.

13. Knowledge check

1. What finding separates an open-globe injury from a closed-globe contusion?
2. Why should a clinician avoid tonometry or pressure on a suspected ruptured globe?
3. What is the first action for a chemical splash into the eye when open globe is not suspected?
4. Which types of orbital findings suggest orbital compartment syndrome?
5. Why is a small hyphema potentially dangerous in a patient with sickle cell disease or trait?
6. What imaging is generally first-line for suspected metallic IOFB, and which modality must be avoided until metal is excluded?
7. What symptoms after blunt trauma suggest retinal tear/detachment?
8. Does sympathetic ophthalmia justify routine early enucleation of every severely injured eye?
9. Why can a normal CT not fully exclude open globe?
10. What delayed pressure problem may follow angle recession?

Answers

1. A full-thickness wound through the cornea or sclera communicating with the interior defines open globe; contusion with no full-thickness break is closed globe.
2. Pressure can force intraocular contents through the wound and worsen tissue loss.
3. Start continuous irrigation immediately with clean water or saline; do not wait for product identification or attempt neutralization.
4. Rapid proptosis, tight lids/tense orbit, decreasing vision or colour vision, RAPD, restricted movement and raised IOP after orbital trauma.
5. Sickled red cells can obstruct trabecular outflow and raise IOP even when there is little blood in the anterior chamber.
6. Thin-slice noncontrast CT; avoid MRI until a ferromagnetic foreign body has been excluded.
7. Flashes, new floaters, a curtain/field defect or sudden blur/loss of vision.
8. No. Prompt repair is preferred when feasible; eye removal is reserved for cases where repair is technically impossible or later specific indications arise.
9. CT has imperfect sensitivity and small or self-sealed wounds may be occult; clinical concern needs urgent ophthalmologist assessment.
10. Angle-recession glaucoma, which can develop months or years after injury and requires long-term pressure monitoring.

Key takeaways

• Eye trauma can hide a globe wound, retinal injury or optic-nerve injury behind modest external signs. Measure visual acuity early when it will not delay urgent treatment.
• Open globe means full-thickness eyewall injury: stop pressure/manipulation, place a rigid shield, keep nil by mouth and urgently contact ophthalmology.
• Chemical eye injuries require immediate copious irrigation; do not neutralize the chemical or wait for a complete examination.
• Blunt injury can cause hyphema, angle recession, cataract, vitreous haemorrhage, retinal tear/detachment, orbital fracture or compartment syndrome.
• Do not remove a protruding object or use MRI when metallic IOFB is possible. CT is useful, but a negative scan does not prove the globe is intact.
• Enucleation is not routine prevention for sympathetic ophthalmia. Preserve and repair the eye when technically feasible, with specialist decision-making.
• Every serious injury needs a clear follow-up plan for vision, cornea, pressure, lens, retina, orbit and late complications.

References and further reading

1. Amr Mounir. Eye Injuries. Supplied 52-slide presentation, SlideShare.
2. American Academy of Ophthalmology EyeWiki. Pre-Ophthalmologist Management of Eye Trauma.
3. American Academy of Ophthalmology EyeWiki. Ruptured Globe.
4. Royal College of Ophthalmologists. Open Globe Injury Guidelines. August 2026.
5. American Academy of Ophthalmology EyeWiki. Blunt Ocular Trauma.
6. American Academy of Ophthalmology EyeWiki. Hyphema.
7. American Academy of Ophthalmology EyeWiki. Orbital Compartment Syndrome.
8. American Academy of Ophthalmology EyeWiki. Orbital Floor Fractures.
9. American Academy of Ophthalmology EyeWiki. Intraocular Foreign Bodies.
10. American Academy of Ophthalmology EyeWiki. Chemical (Alkali and Acid) Injury of the Conjunctiva and Cornea.
11. Agency for Clinical Innovation, NSW. Eye Emergency Manual, 3rd ed. December 2023.
12. Royal Children’s Hospital Melbourne. Clinical Practice Guideline: Penetrating Eye Injury.
13. Uganda Ministry of Health. Guidelines for Eye Care.
14. American Academy of Ophthalmology EyeWiki. Photokeratitis.