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Patients with eye injuries need proper diagnosis, management
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According to the United States Eye Injury Registry maintained by the National Eye Institute’s Office of Science, Communications, Public Liaison and Education, about 2.5 million eye injuries occur each year in America, and as many as 50,000 result in some level of permanent vision loss. Males represent 73% of those injured, 44% of injuries occur at home, and 15% are sports related. The typical age of the patient is 18 to 45 years, but many home- and sports-related injuries occur in young children and 90% are preventable by wearing protective eye wear when performing risky tasks such as hammering a nail, using scissors or playing a sport such as hockey, tennis, racquetball, soccer, football and the like. The accompanying cover story is quite comprehensive, so I will make only a few points.
Lid lacerations are common and usually easily repaired. It is important to rule in or out canalicular involvement, and with blunt trauma, a blowout fracture needs to be considered. Chemical injuries require prompt and copious irrigation, and water is fine, ideally done immediately at the site where the injury occurs. In the emergency room, isotonic saline is a reasonable choice.
The classical teaching to pressure patch abrasions and other ocular injuries has been proven to be wrong and even potentially detrimental, especially in the face of abrasions that occur after contact lens wear in which an infection with Pseudomonas is a significant risk. Do not patch injured eyes; instead, place a protective shield, which allows treatment with antibiotic drops. Polytrim (polymyxin B sulfate and trimethoprim ophthalmic solution) is an inexpensive topical antibiotic drop that is effective against a broad spectrum of bacteria, including most MRSA and MRSE.
Many emergency rooms prescribe topical anesthetics for pain control, a practice that is not supported in the ophthalmic literature. Tetanus prophylaxis, which can include both a vaccine booster and tetanus immune globulin, is important to remember.
Looking at ICD-10 coding, the key diagnostic factors include naming the involved tissue, for example conjunctiva, cornea or sclera, ruling out an orbital or blowout fracture, determining if it is a closed globe injury or a penetrating or perforating injury, describing the size and location of any laceration or rupture, determining if there is an extraocular or intraocular foreign body, looking for prolapse of intraocular tissue, and noting the presence or absence of hyphema, vitreous hemorrhage or endophthalmitis.
A severe eye injury is often accompanied by other severe trauma that requires multidisciplinary care. While there are many level 1 trauma centers in the United States, there are only a few well-managed eye emergency centers that are staffed 24/7 by an experienced ophthalmologist. When I was younger and directing the cornea service at the University of Minnesota, it was usually the anterior segment surgeon who dealt with most ocular trauma calls, but these days the vitreoretinal surgeon is more often consulted, especially if there is any evidence of an intraocular foreign body or endophthalmitis. Fortunately, proper diagnosis and management can reduce suffering and preserve or restore vision for most injured patients.