History
Although the ophthalmologist usually is not called to the emergency room until life-threatening injuries are stabilized, ophthalmologists should still take a thorough history and carefully review the notes of the other trauma physicians. Record standard information, such as the last oral intake, allergies, and tetanus status.
Ascertaining the mechanism of injury is important, as this may indicate associated injuries (eg, cervical trauma), the depth of the ocular adnexal injury, and possibly a foreign body. [1]
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Windshield-related accidents may be associated with a foreign body and tissue loss.
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Bite wounds may implicate infection (eg, rabies) and tissue loss. In human bite wounds, determine the assailant's HIV and hepatitis status.
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In patients with small penetrating lid lacerations, maintain a high index of suspicion for underlying globe trauma.
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Document prior visual function, the time of the injury, use of safety glasses, and accident witnesses.
In some cases, pertinent history may not be revealed to the clinician.
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Patients who are inebriated or under the influence of recreational drugs may not be good historians. Confirmation with family members or acquaintances may be required.
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Children might conceal the details of their injury for fear of parental rebuke or implicating a playmate who caused the injury. Be especially wary of underlying foreign bodies in children.
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Consider spousal or parental abuse.
Physical
The patient's airway, breathing, circulation, and cervical spine should be cleared before addressing ocular adnexal trauma. Perform a quick gestalt of the patient, and review the vital signs. Precede lid repair with a thorough eye examination to exclude globe rupture.
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If no globe rupture is present, evert the lids and flush the fornices, if needed. If the lids are markedly edematous, Desmarres retractors will aid in ocular examination. (If a Desmarres retractor is unavailable, a bent paper clip may be used.) Palpate and examine the lids for foreign bodies, including contact lenses.
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Hyphema, orbital fractures, and other ocular adnexal trauma often occur with lid trauma.
Exclude injury to the levator, medial canthal tendon, lateral canthal tendon, canaliculi, and supraorbital nerve.
The presence of orbital fat indicates disruption of the septum and possible injury to the levator. In conscious patients, test levator function by splinting the brow and asking the patient to look up and down.
Displacement or rounding of the canthal angles suggests canthal ligament injury.
If the puncta are displaced or lacerations medial to the puncta are present, gently probe the canaliculi.
In patients with superonasal lacerations near the orbital rim, test for supraorbital anesthesia prior to anesthetic injection.
Diagram and measure lid lesions. Photograph the lid lesion, if appropriate. Patients may not realize the extent of their injury, and photography may aid in later compensation issues.
If occult foreign body is suspected, obtain neuroimaging studies.
The patient and family members should be given specific preoperative counseling regarding the possibilities for vision loss, lid malposition, cutaneous scarring, and possible need for further surgery. Patients should understand that some degree of scarring will result even with meticulous oculoplastic repair.
In patients with glass or windshield injuries, occult, embedded glass may chronically extrude. Inform patients of this possibility.
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Extramarginal upper lid laceration from blunt trauma in an infant. Such lacerations tend to follow relaxed skin tension lines.
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Penetrating lid trauma with extensive periorbital ecchymosis. A ringlike projectile was ejected from a pipe fitting under high pressure. The patient also experienced choroidal rupture and traumatic optic neuropathy.
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Preoperative. This child had a dog bite injury with a double lower lid margin laceration, dehiscence of the lateral canthal tendon, and disruption of the inferior canaliculus.
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Postoperative. The inferior canaliculus was repaired with bicanalicular stenting. Lateral canthus reattachment and repair of lid margin lacerations was performed.
