A 31-year-old woman presented to the emergency department (ED) after suffering multiple lacerations during an assault. The patient stated it was unclear what weapon the assailant had used, but she thought it was a sharp blade of some kind. She had two linear lacerations on her right arm that were superficial and did not require suturing.
She also had a 3 cm linear laceration over her right eyelid. She denied any pain in the eye or vision changes. On examination, her pupillary response and ocular movements were intact. The ED provider did not formally check her visual acuity but asked her to close each eye separately and asked her if she noted any change in her vision (which she did not). The ED provider everted the lid (turned it up to see underneath) and the laceration did not appear to extend through the eyelid. He performed a fluorescence examination and did not note any corneal abrasion or evidence of injury to the globe. The eyelid laceration was sutured without complication. An ophthalmologist was not consulted.
The patient presented to a different hospital 10 days later complaining of eye pain. At that time, she reported to providers that her vision had been poor in the right eye since the attack. She was referred to an ophthalmologist and found to have a ruptured globe. She was taken to the operating room for repair and found to have a 4 mm cut in the cornea that extended 7 mm into the sclera (globe of the eye). This laceration was directly beneath the laceration in her eyelid. The defects in the cornea and sclera were repaired, but she had some residual pain and mild visual deficits after the procedure.
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Table. Ocular Disease and Injury: Recommendations for Emergency Department Ophthalmologist Consultation
IMMEDIATE CONSULTATION WITH OPHTHALMOLOGIST: |
Trauma |
• Retrobulbar hemorrhage
• Severe chemical and thermal burns
• Traumatic hyphema
• Traumatic iridodialysis
• Lens subluxation or dislocation
• Scleral (globe) rupture
• Traumatic and atraumatic vitreous hemorrhage
• Acute retinal injury
• Optic nerve injury
• Complicated eyelid lacerations, such as lid margins, involvement of canalicular system, levator
or canthal tendons, orbital septum, and tissue loss
• Conjunctival, scleral, and corneal lacerations
• Orbital and intraocular foreign bodies
• Posttraumatic corneal ulcers
• Retinal tears and detachment
|
Infection |
• Endophthalmitis
• Corneal ulcers and infiltrates
• Herpes simplex and zoster
• Orbital cellulitis
|
Glaucoma |
• Acute narrow angle glaucoma
|
Vascular |
• Central retinal artery ccclusion
• Central retinal vein occlusion
|
Neuro-Ophthalmology |
• Neuro-ophthalmic visual loss including all diseases affecting prechiasmal, chiasmal,
and postchiasmal tissues
• Acute extraocular movement deficit
• Acute Horner syndrome
• Papilledema
|
Miscellaneous |
• Sympathetic ophthalmia
• Posterior vitreous detachment
|
OUTPATIENT FOLLOW UP WITH OPHTHALMOLOGIST: |
Trauma |
• Uncomplicated orbital wall fractures
• Postcorneal foreign body removal
• Corneal abrasions if symptoms persist > 24 hours
• Uncomplicated traumatic iridocyclitis
|
Corneal Disease |
• Ultraviolet keratitis if symptoms persist > 24 hours
• Superficial punctate keratitis
|
Miscellaneous |
• Pterygium and pinguecula
• Age-related macular degeneration
• Adie's tonic pupil
|
NO OPHTHALMOLOGIST REQUIRED: |
Trauma |
• Periorbital contusion
• Postconjunctival foreign body removal
• Subconjunctival hemorrhage
• Biologic ocular exposures
|
Infection |
• Uncomplicated conjunctivitis (nongonococcal)
• Uncomplicated dacryocystitis
|
Anatomic |
• Hordeolum and chalazion
• Blepharitis
|
Neuro-Ophthalmology |
• Pharmacologic mydriasis
• Physiologic anisocoria
|