1. Proceed with caution: Assume that any periocular or ocular trauma could include a ruptured globe. Avoid placing undue pressure on the globe until you establish that an open globe injury does not exist.
2. Assess the total patient first: Make sure the emergency department staff thinks the patient is hemodynamically stable before proceeding with your exam. Make sure the patient does not have any concomitant injuries that could prevent him or her from being transported safely to the OR.
3. Make the patient comfortable: If the patient is in significant pain, give analgesics prior to your assessment. Not only will this make him or her more comfortable, but will also make your exam easier. If the patient is nauseated, give anti-emetics. This will reduce the risk of the patient vomiting or straining, which can increase the central venous pressure and potentiate uveal prolapse in an open globe injury.
4. Assess visual acuity and pupils: It can be difficult to obtain a good visual acuity in patients with altered mental status due to the trauma they have just undergone, but this is important, as it can help in formulating a visual prognosis. If a reliable acuity cannot be obtained, carefully assess for an afferent pupillary defect. If the pupil cannot be visualized in the traumatized eye (e.g., secondary to hyphema), check for an afferent pupillary defect in the fellow eye.
5. Assess the adenexal structures: When you get a call about globe trauma, it is easy to jump to skip this part of the exam. However, don’t forget to evaluate for lid or canalicular lacerations. Sometimes this can be difficult to do in the emergency department if there is a lot of dried blood. Therefore, it may need to be determined in the OR, where the area can be more thoroughly cleaned.
6. Visualize the globe: Remember, as the ophthalmologist, your job is to assess the eye. With significant preseptal edema, this can be a difficult task. Use lid speculums or lid retractors if needed (taking care not to press on the eye).
7. Evaluate the fellow eye: Make sure that you conduct a complete exam on the fellow eye for any signs of trauma or changes in visual acuity.
8. Use additional testing and imaging modalities: If hyphema is present, consider checking Sickledex. Consider checking PT/INR if the patient is anti-coagulated. Ask the emergency department to check screening bloodwork and testing, including CBC, Chem 7, CXR and EKG to obtain OR clearance. CT scans may be helpful in confirming globe rupture and assessing for intraorbital or intraocular foreign bodies, as well as orbital wall or other facial fractures.
9. Arrange OR to do the repair: Make sure the patient stays NPO (nil per os, or nothing by mouth) and establish the last time he or she ate. Determine if the patient has had a recent tetanus shot. Place a Fox shield over the traumatized eye. Speak with the surgeons who will be managing the injury, as well as anesthesia and OR staff. Cases are usually performed under general anesthesia.
10. Talk with patient and family: Don’t forget to discuss the surgery and visual prognosis for the eye with the patient and any family members present. Since these patients may have an altered mental status, it is important that the family has a good understanding of the injury and is given a chance to ask questions. Obtain informed consent from the appropriate party. Depending on the extent of the globe injury, it may also be pertinent to discuss the possibility of primary enucleation/evisceration if repair is impossible.
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About the author: David E. Vollman, MD, is a clinical instructor in the department of ophthalmology and visual sciences at the Washington University School of Medicine and a staff ophthalmologist at the John Cochran VA Medical Center in St. Louis, Mo.