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Corneal Laceration Clinical Presentation

  • Author: Adedoyin Adesina, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
 
Updated: May 17, 2016
 

History

Document information such as the setting of the injury, changes in vision, or sensation of a foreign body in the eye.[2] Even in the absence of foreign body sensation, evaluate whether there is a possibility of a foreign body entering the eye. Eye penetration may go unnoticed by the patient, particularly when small metal fragments break off and penetrate the eye, such as when metal is struck on metal or when particles are ejected from high-speed machinery. Also, be aware that seemingly blunt objects can still cause lacerations if they contact the cornea in the right orientation. In such cases, the patient may present for care later, after the development of increasing pain, deterioration in vision, or infection.

Obtain the patient's pre-injury vision assessments as well as any history of previous ocular problems or ocular surgery.

Document pertinent medical history, current medications, allergies, and tetanus immunization status.

Determine information regarding the patient's last oral intake if operative intervention is anticipated.

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Physical

Evaluation of visual acuity immediately following the injury is an important examination data point. Test visual acuity in each eye with a Snellen chart. If the patient cannot read a Snellen chart, document the ability of the patient to distinguish number of fingers, movement, or light. This will assist the ophthalmologist in determining what sort of intervention, therapy, and rehabilitation may be required.

If possible, determine visual acuity prior to examination or treatment, and separately test each eye with corrective lenses. This should be compared to the pre-injury visual acuity. Pinhole testing may help differentiate refractive error from uncorrectable vision when spectacles are not available. Use age-appropriate vision testing devices such as the Snellen distance chart or a hand-held vision card.

Ask the patient to identify typed letters, the clock, or objects on the wall if the patient's condition prevents formal (standing upright) testing.

When examining the orbit, care should be taken to avoid putting pressure on the globe. Instead, the examiner should place fingers on the orbital rim when retracting the eyelids. The bulbar conjunctiva will typically be injected with prominent blood vessels.

Direct ophthalmoscopy

Using direct ophthalmoscopy, the lens can be evaluated for dislocation. Ensure that is centered in the pupil. 

Slit lamp examination

Examine the cornea carefully, taking care not to apply additional pressure to the globe. Evaluate the cornea using a slit beam to search for anterior chamber penetration. A shallow anterior chamber, irregularly shaped pupil (teardrop shape), hyphema (blood in the anterior chamber), bubbles in the anterior chamber, or a flat cornea can be signs of corneal perforation.

Aqueous humor leaking from the anterior chamber can be identified by performing a Seidel test. This test is performed by directly applying fluorescein to the suspected corneal lesion. This requires 10% fluorescein. The patient should be informed not to blink so the examining physician can adequately visualize the tear film without it moving. Visualization of diluted or streaming dye under a black light (a positive test) suggests a leak. A negative Seidel test (no dilution of fluorescein) suggests a partial-thickness injury but may be seen in small or spontaneously sealing lesions. One should avoid the temptation to press on the globe to test for a self-sealing injury, as it can extrude globe content and lead to a worse outcome.

Be sure to evaluate for a foreign body in the anterior chamber, especially if the patient’s history suggests that the corneal laceration is from a small, high-speed object (such as from hammering metal).

Full-thickness corneal lacerations

The most common location for corneal laceration is the inferior aspect of the globe. This is due to Bell phenomenon (also known as palpebral oculogyric reflex), the upward and outward reflex rotation of the globe during blinking as a protective mechanism against the entrance of foreign material.[36]

Ophthalmology consultation is required for all types of corneal perforation.

Do not apply pressure to the globe.

Immediately place a protective shield (not a patch) over the affected eye.

Instruct the patient to avoid ocular movement because extraocular muscle contraction can cause extrusion of intraocular contents.

Full-thickness corneal lacerations often result in a loss of aqueous humor producing a shallow or flat anterior chamber.

Prolapse or incarceration of the iris may produce a teardrop distortion of the pupil.

Hyphema, or blood in the anterior chamber, can be another sign of anterior chamber penetration. Hyphema may also be seen with blunt, nonpenetrating trauma. 

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Causes

The causes of corneal lacerations are numerous and include but not limited to flying metal fragments, sharp objects, fingernails, air-bag deployment, fireworks, explosions, blunt force trauma, pellets, and BBs.[3, 4, 5, 6]

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Contributor Information and Disclosures
Author

Adedoyin Adesina, MD Resident Physician, Department of Emergency Medicine, Kings County Hospital Center, State University of New York Downstate Medical Center

Adedoyin Adesina, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Association of Nigerian Physicians in America, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Coauthor(s)

Mark A Silverberg, MD, MMB, FACEP Assistant Professor, Associate Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate Medical Center

Mark A Silverberg, MD, MMB, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Douglas Lavenburg, MD Clinical Professor, Department of Emergency Medicine, Christiana Care Health Systems

Douglas Lavenburg, MD is a member of the following medical societies: American Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

Additional Contributors

William K Chiang, MD Associate Professor, Department of Emergency Medicine, New York University School of Medicine; Chief of Service, Department of Emergency Medicine, Bellevue Hospital Center

William K Chiang, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Andrew A Aronson, MD, FACEP Vice President, Physician Practices, Bravo Health Advanced Care Center; Consulting Staff, Department of Emergency Medicine, Taylor Hospital

Andrew A Aronson, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, Society of Hospital Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Andrew A Aronson, MD, FACEP Vice President, Physician Practices, Bravo Health Advanced Care Center; Consulting Staff, Department of Emergency Medicine, Taylor Hospital

Andrew A Aronson, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, and Society of Hospital Medicine

Disclosure: Nothing to disclose.

Wesley S Grigsby, MD Medical Director, Associate Clinical Professor, Department of Emergency Medicine, Creighton University School of Medicine

Disclosure: Nothing to disclose.

Jerome FX Naradzay, MD, FACEP Medical Director, Consulting Staff, Department of Emergency Medicine, Maria Parham Hospital; Medical Examiner, Vance County, North Carolina

Jerome FX Naradzay, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Nelson M Yang, MD Resident Physician, Department of Emergency Medicine, Allegheny General Hospital

Disclosure: Nothing to disclose.

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