Your ocular physical exam should include:

• Visual field/acuity:

  • • • confrontational visual field test

      • visual acuity testing (Snellen chart)

• Periocular exam:

  • • • visual inspection of orbit and lid

      • evaluation of lid function

      • eyelid and periocular sensation, palpation of orbital rim

• Ocular exam:

  • • • examination for relative afferent pupillary defect (rAPD)

      • extraocular movement testing

      • Slit lamp

      • Funduscopy

      • intraocular pressure with tonometry (only if no suspected globe rupture!)

      • fluorescein staining

• Imaging:

  • • • Ocular U/S can be used to detect retinal detachment, vitreous hemorrhage, and lens dislocation (see https://sites.google.com/view/foamocularultrasound/home)!

      • Orbital CT (if likely open globe, foreign body, orbital fracture, orbital compartment syndrome)

• acids / alkalis from cleaning products, fertilizer, bleach

• necrosis of conjunctival and corneal epithelium

Findings:

• • • corneal opacity

    • blurring of pupillary outline

    • blanching of conjunctival and scleral vessels

Management:

• remove offending agent, foreign particles

• immediate copious irrigation with Morgan's lens + NS until pH 7.0, as tested by pH strip

Hyphema is defined as a collection of blood in the anterior chamber of the eye. It can occur after blunt injury, high energy blows to the eye, as well as penetrating injuries. The blood is from tearing of vessels of the ciliary body or iris. Sickle cell disease patients, and those on anticoagulation are especially prone to hyphema.

Findings:

• photophobia

• decreased visual acuity

• anisocoria

• iridodialysis

• increased IOP

Management:

• eye shield

• elevate head of bed

• dilate pupil

• Antiemetics (ondansetron) to decrease IOP increase from emesis

• control IOP with topical beta blockers, alpha-adrenergic agonists, or carbonic anhydrase inhibotrs

• cycloplegia with cyclopentolate 1% (but contraindicated in open globe injury)

Vitreous hemorrhage may indicate retinal tear or detachment. It is often found in pediatric patients (infants and young children) with abusive head trauma.

Findings:

• hazy vision, black spots, cob webs in visual field

• optic disc, retina may be obscured on opthalmoscopy

• if large, red reflex may be absent

Management:

• CT of head in patients with head trauma

Findings:

• light flashes, floaters, spots

• "curtain being pulled down"

• visual field defect

• U/S shows detached retinal flap, is 97% sensitive, 92% specific

Management:

• • may involve ophthalmologic surgical management

Direct: usually from traumatic laceration to orbit

Indirect: contusion of nerve (blow to temple / brow)

Findings:

• decreased vision with desaturation of red color or decreased color vision

• rAPD

Management:

• Emergent CT of orbit!