Blunt Ocular Trauma

Blunt trauma is the most common cause of eye injuries seen in the general eye doctor’s office.  Annually over 2.5 million Americans suffer eye trauma and over 10% will have permanent vision loss.  While vision loss is often acute, it may occur months or years later.  Blunt ocular trauma is also responsible for a large percentage of medical-legal cases associated with emergency patient visits.   Here are some guidelines for the evaluation, management and referral of these patients.

What is Blunt Trauma?

Don’t be caught off-guard by a history of a mild bump on the head or an eye that appears completely quiet.  While classic cases of blunt trauma are associated with ptosis, chemosis, hyphema or a blown pupil, some of the most severe cases of vision loss may present with no findings at all.  If a patient reports any vision change or any history of trauma with or without vision change, a careful work-up is mandatory. 

Diagnosis, Management and Referral

Obvious complications of blunt trauma include traumatic iritis, traumatic mydriasis, and hyphema.  A careful slit lamp exam will reveal these conditions and management normally includes anti-inflammatory drops (NSAIDS and steroids) and cycloplegics for a week or two.  A course of oral steroids will facilitate resorption of a hyphema.  Signs of occult trauma include deepening of the anterior chamber (angle recession, iridodialysis, lens subluxation), hemorrhagic chemosis and hypotony (possible occult rupture), APD (optic neuropathy, traumatic maculopathy) and pigment cells in the anterior vitreous (retinal dialysis or tear).  In the setting of macular changes prompt referral is mandatory.  Urgent treatments include pneumatic displacement of a subretinal hemorrhage, surgical repair of traumatic macular hole and treatment of secondary choroidal neovascularization (CNV) with anti-VEGF therapy (eg, Avastin). 

When to Bring Patients Back

Complications of trauma can go from mild to severe in a hurry.  Patients with any inflammation, hyphema, pain or vision loss should be checked daily at first and promptly referred for any unexplained vision loss or treatable complication.  Even in the setting of normal vision, every patient with blunt trauma should undergo a sclera depressed exam to rule out a retinal dialysis both in the days after trauma and every 2-4 mo thereafter for the first year.  A screening visual field should always be performed on presentation to document vision loss and at 2-4 mo intervals to pick up late onset optic neuropathy or retinal detachments.  Peripheral imaging with the OPTOS can pick up occult peripheral tears, ruptures and detachments and can supplement the ophthalmoscopic exam. 

Counseling Your Patients

Most medical-legal problems arise from late-onset complications that catch the patient (and practitioner) by surprise.  While many changes are acute, some changes occur much later and you need to counsel your patients and schedule follow-up appointments accordingly.  Send all of your patients home with an Amsler grid and instruct them on monitoring their peripheral vision as well as any difference in color perception (especially red) between the two eyes.  Bring them back for gonioscopy and visual field testing at least once a year.  Traumatic optic neuropathy may develop slowly and optic disc pallor will result – obtain disc photos when the view allows and annually thereafter.  Gradual cataract formation can cause myopic shifts and decreased acuity mandating periodic refractions.  Late onset retinal detachment can be missed on conventional ophthalmoscopy and OPTOS imaging, visual field testing and/or sclera depressed exams should be done yearly.    

Summary

Be on the look-out for both acute and late onset complications associated with ocular trauma.  More frequent exams and documentation of your discussions with the patient regarding the short and long term risks and what to look for will reduce medical-legal problems.  Referral for occult retinal disease should be considered in the majority of cases, particularly when any central or peripheral vision loss is present.  Working together we can reduce the incidence and degree of vision loss in these complicated cases.  

Ron P. Gallemore, M.D, Ph.D.

Founder and Director

Retina Macula Institute and the

Retina Macula Research Center

South Bay 310-944-9393

Los Angeles 310-466-9393