Eye injuries are common, occurring either as isolated injuries or as part of head or facial injuries. Health workers at primary level or in a trauma department should have a good knowledge of the presentation and management of ocular injuries. Health workers must be able to skillfully handle injuries to ocular structures in a way that aims to restore vision and prevent further loss of vision. This article discusses the practical steps that should be taken at first contact with the patient and highlights the level of urgency of referral. Your first priority is to manage the anxiety and pain of the person with an eye injury (see article on page 50). Pain has been suggested as a factor in development of post-traumatic stress disorders (PTSD).1 For the patient with an eye injury:
Mechanical injuries involving the eyeball can be classified using the Birmingham Eye Trauma Terminology System (BETTS), which applies only to mechanical eye injuries. Chemical and thermal injuries are dealt with separately. BETTS is a practical guide to classifying eye injuries. It ensures that all the health workers involved in the care of the same patient have a consistent understanding of the type of injury. Further, it helps to ensure that there is uniformity, which enables comparison of data in future audits and research (see article on page 43). Essential (the basics)
Additional (in an ideal scenario)
The ABCDE approach to the evaluation and treatment of patients with potentially life-threatening injuries should be followed:
Patients with serious non-ocular injuries or unstable vital signs should be managed in a trauma facility. Following stabilisation the specific assessment of ocular injuries can proceed. In the following eye injuries, the health worker needs to get a quick description of what happened, institute immediate measures and obtain a detailed history later.
For all other eye injury patients, a detailed history should betaken, including:
NOTE: If you suspect an open globe injury, stop. You can make it worse by examining it, causing increased prolapse of ocular contents. Refer the patient to theatre for examination under anaesthesia. The patient may be examined in an upright position if it is possible to do so. If it is difficult to open the eyes, lying down may make it easier. Children should generally sit on their parents' laps or lie down if retraction of the lids may be required. If the patient has difficulty opening the eyes, topical anaesthetic drops helps to reduce the pain and allows for examination. Ask the patient to tilt their head backwards or to lie down. Instil a few drops on the medial canthus area of the affected eye (i.e. nearest the nose) and ask the patient to blink briefly. This will allow some of the anaesthetic to seep into the eye and provide relief (Figure 1). Retracting eyelids aids in observation of the rest of the structures and in irrigation. Use lid retractors or a lid speculum. If these are not available, use bent paper clips.
Traumatic enophthalmos (right eye). Everting the upper eyelid using a cotton bud. Sub-conjunctival haemorrhage. For the next steps, use a source of light. Where there is a slit lamp, use it, provided that the patient is comfortable.
Dorothy Mutie, Consultant Ophthalmologist: Jaramogi Oginga Odinga Teaching and Referral Hospital, Kisumu, Kenya. Email: moc.oohay@eitum_d. Nyawira Mwangi, Principal Lecturer: Ophthalmology Programmes, Kenya Medical Training College, Nairobi, Kenya. Email: moc.oohay@ignawmariwayn. Articles from Community Eye Health are provided here courtesy of International Centre for Eye Health |