Ocular Trauma
On this page
Direct answer
Ocular trauma ranges from blunt contusion and lamellar laceration (closed globe injury) to rupture, penetrating injury, intraocular foreign body and perforating injury (open globe), standardised by the Birmingham Eye Trauma Terminology. Chemical injury is the commonest ophthalmic emergency, and alkali burns are worse than acid because they saponify cell membranes and penetrate deep, so treatment begins with immediate copious irrigation to a neutral pH before any examination. Blunt trauma causes hyphaema, traumatic cataract, vitreous haemorrhage, commotio retinae and retinal dialysis; open globe injuries present with a collapsed shallow anterior chamber, peaked pupil, prolapsed uvea and reduced intraocular pressure, and need urgent surgical repair with tetanus and antibiotic cover. Sympathetic ophthalmia, a rare granulomatous panuveitis of both eyes after a penetrating injury, is the reason for meticulous repair and, in hopeless eyes, careful counselling about enucleation.
What you must remember
- BETT classification: closed globe (contusion or partial-thickness lamellar laceration) versus open globe (full-thickness wound: rupture from blunt force, laceration from sharp objects, further divided into penetrating with or without retained intraocular foreign body, and perforating with entry and exit wounds).
- Chemical burns: alkalis (lime, ammonia, sodium hydroxide) penetrate by saponification and cause worse damage than acids, which coagulate proteins and limit penetration; immediate treatment is copious irrigation with normal saline or Ringer lactate for at least 20 to 30 minutes, with lid eversion and double-everting to remove particulate lime, until the conjunctival pH is neutral; grade by Roper-Hall (corneal clarity and limbal ischaemia extent) or Dua grading by clock hours of limbal stem cell loss.
- Chemical burn management after irrigation: topical corticosteroids and antibiotics, cycloplegics, ascorbate and citrate, preservative-free lubricants; avoid pressure on the globe; severe limbal ischaemia may need amniotic membrane or limbal stem cell transplantation.
- Blunt trauma sequelae: subconjunctival haemorrhage, hyphaema (with rebleeding risk in the first week; sickle cell caution; treatment with shield, cycloplegia, limited activity; surgery for uncontrolled pressure), angle recession (glaucoma later), traumatic cataract with Vossius ring, iris sphincter tears, retinal commotio (Berlin oedema), choroidal rupture, macular hole, vitreous haemorrhage and retinal dialysis (inferotemporal, delayed detachment weeks to months later).
- Open globe signs: pain, visual loss, tense or soft globe, shallow or deep anterior chamber, peaked or irregular pupil, prolapsed black uveal tissue or vitreous, positive Seidel test (aqueous leak highlighted by fluorescein), and low intraocular pressure; never force open lids or press the globe; shield the eye and keep the patient nil by mouth pending examination under anaesthesia and repair.
- Intraocular foreign body: suspect with a history of hammering metal; organic and copper foreign bodies cause severe inflammation; plain radiographs, CT (avoid MRI for ferrous bodies) localise; removal with intravitreal antibiotics; every open globe needs tetanus prophylaxis and systemic plus topical antibiotics, with endophthalmitis and retained-foreign-body vigilance.
- Sympathetic ophthalmia: bilateral diffuse granulomatous uveitis, usually from 2 weeks to months after a penetrating wound involving uveal tissue or surgery; Dalen-Fuchs nodules; treat with high-dose corticosteroids and immunosuppressants; prevention is early meticulous repair of the injured eye, with enucleation of a blind, hopelessly injured eye considered within the first 2 weeks in selected cases.
- Documentation: visual acuity before treatment whenever possible, pupil examination, and precise wound description carry medicolegal importance.
Common confusion
The examinable trap is the sequence in chemical injury: irrigation precedes history-taking, visual acuity and examination; delay for assessment worsens prognosis. The second favourite is acid versus alkali and the reason for the difference (saponification versus coagulation). Students also mix up commotio retinae (grey-white retinal oedema that clears) with choroidal rupture (crescent concentric with the disc, late pigmentation), and confuse hyphaema rebleeding timing; also remember that the Seidel test identifies a leak in a suspected open globe.
Exam-focused takeaway
Expect MCQs on BETT terminology, alkali versus acid burns, the immediate irrigation-first rule and the Roper-Hall or Dua grading, hyphaema management (shield, no aspirin, sickle caution), retinal dialysis after blunt trauma, imaging choices for intraocular foreign bodies (CT, never MRI for ferrous), and the timing and nature of sympathetic ophthalmia. The viva classic is the first-aid management of an injured eye: shield without pressure, nil by mouth, analgesia, antiemetics, tetanus and urgent referral.
Frequently asked questions
Why are alkali burns worse than acid burns?
Alkalis saponify cell membranes and penetrate deeply into the anterior chamber, continuing to damage the cornea, trabecular meshwork and lens after the splash, whereas acids coagulate surface proteins that form a barrier limiting deeper penetration. Hence lime and ammonia injuries carry the worst prognoses.
What is the immediate management of a chemical eye injury?
Begin copious irrigation immediately with saline or clean water for at least 20 to 30 minutes, everting the lids and removing particulate matter, before measuring acuity or taking a detailed history; continue until the conjunctival sac pH is neutral. Then grade the burn and start topical steroids, antibiotics, cycloplegics and supportive therapy.
How are open globe injuries diagnosed and managed?
Suspect open globe with a peaked pupil, shallow chamber, prolapsed uvea, positive Seidel test or a soft painful eye after trauma; the eye is shielded without pressure, the patient kept nil by mouth, and urgent surgical repair under anaesthesia performed with antibiotics and tetanus prophylaxis. CT helps when an intraocular foreign body is possible.
What is the Seidel test?
Fluorescein is instilled and examined with the cobalt blue light; a stream of diluted green dye flowing from a wound or perforation indicates aqueous leakage, confirming a full-thickness (open globe) injury. A negative test does not exclude a self-sealing wound.
What is sympathetic ophthalmia?
It is a rare, bilateral, delayed granulomatous panuveitis that follows penetrating trauma or surgery involving uveal tissue, typically starting from 2 weeks up to months later in the sympathising (previously normal) eye. High-dose steroids with immunosuppressants treat it, and early meticulous repair of the exciting eye, with enucleation of a hopelessly blind eye in selected early cases, prevents it.