What should be done to ensure that non-ophthalmologist medical personnel are properly trained to recognize and treat ocular traumatic injuries? How much treatment should they administer?

Prompt care from all medical personnel needed for best results

Allen B. Thach

Ideally, our colleagues in the emergency room should be able to recognize severe, sight-threatening eye trauma and know when to refer to an ophthalmologist and how to stabilize the patient to avoid additional injury to the eye. Teaching emergency personnel to recognize some common injuries will potentially save the sight of many trauma victims.

All responsive patients should have their vision evaluated. If unable to read a chart or newspaper print they should have an urgent referral to an ophthalmologist.

The eyeball structure should be evaluated. If there is blood or pus in the eye or if there is any suspicion of disruption of the integrity of the eye, a metal shield or rigid device should be vaulted over the orbit to ensure that no pressure is placed on the eye itself, and the patient should be promptly referred to an ophthalmologist. Additionally, patients with a suspected open globe should be treated with broad-spectrum intravenous antibiotics.

Upon checking the pupils, if they are poorly reactive or there is an afferent pupillary defect, then additional ophthalmic or neurologic evaluation should occur. Double vision or restriction of eye movements should alert the emergency personnel to a severe ocular or orbital injury. Proptosis can be a sign of severe retrobulbar hemorrhage, and without relieving the pressure, the vision may be lost permanently. Emergency personnel may be trained to do a lateral canthotomy and cantholysis. Even if it is not done in a nice cosmetic fashion, the lids may be repaired secondarily with a good functional result.

Prompt recognition, treatment and referral of severely injured patients may result in preservation of the eye and vision.

Allen B. Thach, MD, is an ophthalmologist at Retina Consultants of Nevada.

Distinction needed between urgent and emergent eye injuries

Charles B. Slonim

The vast majority of non-ophthalmologist medical personnel already feel uncomfortable dealing with traumatic eye injuries. The goal of any educational program designed to improve their comfort level should be to teach non-ophthalmologist medical personnel how to recognize emergent (refer immediately) vs. urgent (refer within 24 hours) eye injuries. This education can take place at the podium at their local, regional or national meetings or in print in their journals, newsletters or texts. Direct educational programs for non-ophthalmologist medical personnel in their own emergency departments can also benefit the ophthalmologist who will eventually receive the referrals. Recognition of ocular injuries should be a part of their basic curriculum.

Eyelid contusions and orbital soft tissue trauma in the absence of ocular injuries and vision changes can be treated by those who feel comfortable doing so. Most are capable of removing low-velocity, superficial conjunctival foreign bodies. Ocular traumatic injuries with any vision complaints should be referred immediately.

The amount of treatment administered by the non-ophthalmologist medical personnel should be directly proportional to their degree of comfort and level of experience.

Charles B. Slonim, MD, FACS, is an OSN Oculoplastic and Reconstructive Surgery Section Board Member.