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Managing common ocular injuries at primary health care level

Accreditation Number: ODO 003/42/10/2019

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Abstract

Eye injuries are very common and can lead to severe visual impairment and blindness. They are most likely to occur in a work place, sports or as a result of assault. Studies show that males have a high incidence of eye injuries compared to females. Millions of people in the world have gone blind as a result of ocular injuries, therefore health care providers (in primary level) both public and private sector should have clear knowledge and skills on how to manage ocular injuries. This article briefly outlines the classification of ocular injuries, epidemiology and how to manage ocular injuries at primary level of health care.

Ocular Injuries

The eye is the third most common organ affected by trauma after hands and feet1. Ocular structures are vulnerable to injury and the injury site depends on the cause and the mechanism of the injury.  Ocular trauma is one of the most significant public health concerns, and a preventable cause of visual impairment. According to the World Health Organization (WHO), the global incidence of ocular trauma was estimated at 55 million annually, and 1.6 million people worldwide were found with severe visual impairment and have gone blind due to ocular trauma2

Allied health medical professionals with little to no training often find themselves in a position where they are tasked with the recognition, assessment and management of ocular trauma2.  In such situations having no clear instructions or guidance that can support in decision making with regards to the management of the patient could be a serious challenge2.  Ocular trauma is one of the main causes of monocular blindness and has a significant impact on the individual and their family2. If a patient presents with a case of ocular trauma, the outcome and prognosis highly depend on the initial management. Therefore, it is very important for health care providers to have a clear understanding on how to identify eye injuries (including the structures involved), and to properly manage these injuries according to their severity2.

Ocular structures

The eye is classified according to anterior and posterior segments.

The anterior segment includes:

  • the cornea
  • conjunctiva
  • trabecular meshwork
  • anterior chamber
  • Iris
  • Crystalline lens

While the posterior segment includes:

  • The retina
  • Choroid
  • Optic nerve

The anterior segment is commonly vulnerable to direct trauma. When both the anterior and posterior segments are injured in combination, there is a possibility of significant vision loss2.

Classification of Ocular injuries

Ocular injuries can be classified according to open globe and closed globe injuries (which account for most sports related injuries). Sometimes there is an overlap in classification of these injuries depending on their cause2. An open globe injury is a full thickness wound involving penetration of the corneoscleral wall, usually caused by blunt trauma or an object penetrating the eye.  Some common open globe injuries include lacerations, which are further classified as penetrating injuries, perforating injuries and presence of intraocular foreign bodies2.

Unlike open globe injuries, closed globe injuries are commonly due to trauma without penetration or laceration of the corneoscleral wall (resulting in a partial thickness corneal wound), nevertheless, intraocular damage may occur2.

Closed globe injuries are categorized into burns, contusions (from blunt trauma) and lamellar lacerations2. Blunt objects can cause ruptures/tears resulting in an actual wound. If the inflicting object is blunt, it can result in a contusion or rupture, hence an open globe injury2.

The most frequently observed morbidities of ocular trauma include corneal tear, lens damage and scleral tear. These are followed by lid, canalicular laceration, uveal prolapse, anterior chamber abnormality, retinal detachment and optic nerve avulsion. However, the prognosis of the injury can also rely on how soon after the injury the individual seeks medical attention2. A study by Alem et al., (2019) showed that patients who present to the hospital or clinic within 24 hours of eye injury occurrence showed much better visual outcome compared to those who present later than 24 hours1.  

Epidemiology overview

The epidemiology of ocular injuries varies according to age groups and geographic location, also depending on different factors such as one’s lifestyle, socioeconomic status, whether they play sports (including the kind of sport they play), creative activities and the type of work done for a living. According to Dagwood (2014), about half a million of people in the world have gone blind as a result of ocular injuries, and about 30%-40% of monocular blindness is due to eye injuries3.

The major risk factors found in many countries are age, gender, socioeconomic status and lifestyles. High rates of ocular trauma are known to frequently occur in males compared to females (within the ages of 18-45 years), this is related to work, sports, and assaults (predominating cause in developing countries). The less common causes are gunshot wounds, which can lead to severe visual damage, war-related ocular injuries and fireworks (mostly in children) 3

Due to the wide spread of contact lens use, there’s a correlation between contact lens-induced keratitis and decreased vision3. Microbial keratitis is a corneal infection caused by bacteria, fungi or parasites. Keratitis can be related to several ocular abnormalities including corneal ulceration, can also be related to ocular trauma, ocular surgery and ocular surface disease. Albeit, microbial keratitis is known to be rare, however, it has a potential to result in significant ocular morbidity, hence, it requires prompt diagnosis and treatment to prevent severe visual impairment and possibly vision loss3.

Most cases of eye injuries are preventable, and even though preventative measures such as protective eye wear is sometimes made available in some of the work places, sports and leisure facilities, they are not always readily available for use nor comfortable to wear during the related activity3.   Hence the continued increase in traumatic eye injuries, and it is important to always know how to respond and treat ocular injuries whether in primary health care (community clinic, hospital) or in private practice3.

A thorough systematic examination is important to make sure that sight-threatening injuries are identified and managed accordingly3.

Approaching the patient

A clear, detailed history concerning the conditions under which the injury occurred (including time and place of injury and previous ocular history if there is any) must be taken to accurately determine the nature and severity of the injury. As previously stated, many injuries are known to occur in the workplace, it is important to understand how the injury occurred, objects involved and whether protective eye wear was used. The object involved will enlighten on the nature of the tissue damage that may be involved (e.g. blunt objects lead to contusions and depending on severity, they may cause globe rupture, while one might expect lacerations and penetrating injuries to result from sharp objects)5.

Employ a systematic anterior to posterior examination approach while keeping in mind that any anatomical structure of the eye may be involved.  One may use local anaesthetic drops for a basic examination (with lid swelling to pry swollen lids apart) 5.

Getting a quick description on the nature and cause of the injury is important.

  • For a suspected chemical injury – immediate irrigation is required
  • Active bleeding – Arrest bleeding and pad eye
  • Severe pain, especially in children – analgesics can be given (more practical in a public sector setting where doctors and nurses can be immediately involved) 5.
  • If an open globe injury is suspected, it can be made worse by examining which can lead to increased prolapse of the ocular content, rather refer the patient to specialist for examination under anaesthesia5.

Required professional behaviour

  • Firstly, your priority should be to manage the anxiety and pain of the patient, reassure them that you will do your very best to help them5.
  • Children with eye injuries should be examined in the presence of their caregiver5.
  • Even when the injury looks bad, avoid giving that indication at the very beginning either verbally or non-verbally (body language) 5.
  • Treat every patient with common courtesy and respect, no matter the cause of the injury (even if they were involved in a fight) 5.

Ocular examination

  • Obtain history (current and previous medical and ocular history)
  • Asses both eyes (even if the injury is unilateral) 5.
  • Measure and document visual acuity (VA), to determine current visual function, it is a prognostic feature in severe ocular trauma, however do not assume that 6/6 VA excludes severe complications in the eye5.
  • Assess ocular motilities (Should not be done on a patient suspected of having an open globe injury as this may cause prolapse of the intra-ocular contents) 5.
  • Use confrontation test to assess visual fields
  • Examine all anatomical structures of the eye using a slit-lamp (if unavailable, assess with the aid of a good light source- asses upper and lower fornix) 5.
  • Perform external examination (lids defects such as ptosis or laceration), internal examination (cornea, sclera, conjunctiva etc.) if abrasions are suspected, use fluorescein staining to confirm your diagnosis5.
  • Assess the size of the eyeball, if both lids can open, check if they are the same size. A smaller one could mean blow-out fracture while a larger one could suggest orbital bleeding5.
  • Check pupillary responses, note presence or absence or relative afferent pupillary defect5.
  • Use ophthalmoscopy to check for red reflex.
  • Prevent secondary infections by using sterile dressing to cover the eye when indicated5.
  • Irrigate chemical injuries4
  • Do not pull out a protruding foreign body (stabilize and refer patient to specialist urgently) 5
  • Advice patient to avoid using traditional medicines4.
  • Further assessments can be done upon referral to appropriate health care providers (such as orbital or skull X-rays, computed tomography (CT) scan especially for patients who sustain penetrating injuries) 5.

It is important to differentiate between minor and severe injuries in order to appropriately manage. Most minor injuries can be managed at a primary health care level while severe injuries must be referred to a specialist for further management5.

Basic principles involved in managing some common eye injuries

Prophylaxis for tetanus infection can be given to patients presenting with lacerations, especially if dirty6.

Corneal abrasions

Most corneal abrasions are a result of scratching from a finger, resulting in a painful eye. To examine the eye, topical anaesthetic can be instilled, use fluorescein to indicate epithelial defect. Manage with an antibiotic and pad eye for one day. Corneal abrasion recovery is rapid, and management basically involves pain relief and preventing infection6.

When welding without protective goggles, corneal damage may occur. When stained with fluorescein, diffuse punctate staining covering the cornea becomes visible, symptoms are like those of corneal abrasion, and management is the same as for corneal abrasion6.

Corneal foreign bodies can be removed with a cotton bud after the application of topical anaesthesia under magnification and a light source. However, if the foreign body persists, then the patient must be referred to an ophthalmologist6.

Eyelid lacerations

These injuries may or may not involve the lid margin, they can be caused by sharp objects or by a blunt object.  Chronic watery eyes may result in cases of unrepaired lacerations involving medial canthal region and the nasolacrimal apparatus. Lacerations resulting in full-thickness injury should be referred to an ophthalmologist, including those involving the margin or the medial canthal area for canalicular repair6.

Simple lacerations can be sutured, septic ones should be cleaned and treated with systematic antibiotics6.

Open globe injury (penetrating injury)

As previously stated, any open globe injury must be urgently referred to an ophthalmologist. The eye must be shielded but eye pads must not be used to avoid exerting any pressure on the eye. A globe ruptured by blunt trauma (e.g. blow out fist) must be treated like the penetrating injury, even if the rupture injury is sub-conjunctival6.

Haemorrhage

Sub-conjunctival haemorrhages are common after ocular trauma and easily managed. However, occasionally they suggest a ruptured globe that may be associated with low intra-ocular pressure (IOP) and abnormally deep anterior chamber. A hyphaemia may be present from a blunt injury and tearing of iris, pupil may be dilated. Most hyphaemia’s may clear within five to six days with conservative treatment, surgical washout is rarely indicated and carries risks. It’s better to refer patient to an ophthalmologist for management6.

Damage to the lens

A single episode of blunt trauma or repeated, may result in a dislocated subluxated lens. The IOP may increase in the acute phase which may indicate lens extraction. Penetrating and blunt trauma injuries may lead to cataracts which may require extraction, sometimes very soon after injury if it causes complications otherwise it can be done later when the patient has recovered from the injury6.

Eye Burns

Ocular burns may involve the conjunctiva, cornea and eyelids. Cornea must be kept moist and not exposed. In case of a burn, antibiotic ointment can be applied all over the conjunctiva, eyelid or cornea. Do not place eye pad over the eye as it may ulcerate cornea. In case of severe burns, a skin graft may be indicated for the eyelids6.

Chemical injuries

Immediate and generous irrigation with clean water (after anaesthetic drops have been instilled) must be done immediately after the eye is exposed to the chemical6. Patient must lie flat for fifteen minutes during irrigation, after which fluorescein staining can be applied to examine the eye for any ulceration in the cornea. Topical antibiotics should be given and padding of the eye should be done. Acid chemical injuries usually have good prognosis as they usually involve the superficial layers of the cornea. Alkali burns are rare however more severe, hence they should be immediately referred to an ophthalmologist, as they require intensive topical steroids6.

Microbial Keratitis

Antibiotics are the best treatment for keratitis, the patient must be referred to an ophthalmologist for immediate treatment to avoid severe visual complications. It is also important to constantly educate them on the importance of hygiene with contact lens wear, proper leans cleaning and to avoid wearing their contact lenses overnight6.

Penetrating injuries

Penetrating injuries are a major threat to vision be it in a workplace, at home, during sports or school. It can also leave patients with profound emotional trauma, including their families6. Treatment is usually expensive and time consuming, but there is usually a grave prognosis.  Penetrating injuries need first aid and immediate referral to an ophthalmologist especially if there is a foreign body. Therefore prompt diagnosis, referral and removal of foreign body including surgical repair with help to preserve the VA and the anatomy of the globe6.

Conclusion

Eye injuries are very common and affect most of the world’s population. It is very important to have the knowledge and the skillset to treat them as best as possible to prevent further sight-threatening complications from occurring. Eye injuries, even minor ones may result in significant economic burdens to families due to time lost from work, school and expensive hospitalization and treatment6. Some complications result from patients delaying in seeking help, it is therefore important to advice patients on the importance of seeking medical attention as soon as possible to better their chances and minimize complications that may lead to severe visual impairment6.

References

  1. Alem, K. D., Arega, D. D., Weldegiorgis, S. T., Agaje, B. G., & Tigneh, E. G. (2019). Profile of ocular trauma in patients presenting to the department of ophthalmology at Hawassa University: Retrospective study. PloS one14(3), e0213893. 1-10.
  2. Sukati, V. N. (2012). Ocular injuries-a review. African Vision and Eye Health71(2), 86-94.
  3. Aghadoost, D. (2014). Ocular Trauma: An Overview. Archives of trauma research 3(2), 2013–2014. https://doi.org/10.5812/atr.21639
  4. Mustak, H., & Du Toit, N. (2014). Ocular trauma. South African Family Practice56(2), 88-94.
  5. Mutie, D., & Mwangi, N. (2015). Assessing an eye injury patient. Community eye health28(91), 46.
  6. Lecuona, K. (2005). Assessing and managing eye injuries. Community Eye Health Journal18(55), 101-104.

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