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Eye trauma – Written by Adjunct Professor Marlon Maus, M.D., MPH, DrPH, FACS.

What is ocular trauma?

Ocular (eye) trauma encompasses a great range of injuries from very mild, such as a scratch to the cornea (the clear surface at the front of the eye), to more serious, such as a penetrating wound that can result in the loss of an eye or a chemical burn that can result in blindness.

Ocular trauma can also involve not just the eye itself, but also the structures surrounding it, such as the eye lids, the bones of the orbit (the facial bones that house and protect the eye), and even the optic nerve (cable that sends signals to the brain, allowing vision). Understanding the different types of ocular trauma and their causes can help us take measures to prevent them, as well as know when to seek medical treatment.

The following sections will briefly outline the global problem of the condition, the main causes and different types of ocular trauma, as well as some insights into its prevention strategies.

The global problem of ocular trauma

Ocular trauma injuries are a major avoidable cause of vision loss worldwide. Almost 2 million Americans suffer eye injuries every year, and worldwide 55 million eye injuries that restrict activities for more than one day occur annually [1]. While most eye injuries are treated in emergency departments or private physicians’ offices, some require treatment in hospital clinics or even admission to inpatient facilities. Worldwide, 750,000 cases require hospitalization each year [2].

Who gets affected by ocular trauma?

Ocular trauma can happen in people of any age, but it is seen to a greater extent among adults in their 20s, followed by those more than 70 years old. Trauma is more common in males. Young adults suffer trauma mainly from sports or work-related activities, while in older adults it is usually the result of falls, mainly at home [3].

Causes of ocular trauma

Ocular trauma can occur from superficial wounds, penetrating wounds or burns to the eye.

1. Superficial wounds of the eye

   Superficial wounds include abrasions and foreign objects in the eye.

   • Abrasions

     An abrasion can occur when the surface of the eye is “scratched” by an external object (such as a poke in the eye) or by rubbing it when there is a foreign object, also called a “foreign body,” on the surface of the eye, such as dust or sand. A tree branch, pets, and children, such as a baby’s fingernail, are examples of common causes of abrasions.

     The symptoms can start right away, or they may start hours after the injury and then become worse. The abrasion can occur on either the conjunctiva (the clear layer covering the white of the eye), the sclera (the white of the eye itself), or the cornea (the clear surface covering the eye). The cornea has one of the highest concentrations of pain nerve endings in the body, and as a result, even a very small corneal abrasion can be extremely painful.

     Symptoms of abrasions

     The symptoms of a conjunctival abrasion include tearing, pain, and the sensation of a foreign object in the eye. A conjunctival abrasion can cause a small haemorrhage (blood loss from a damaged blood vessel) or visible scratch. If the blood spreads under the conjunctiva, it can expand and cover a large portion of the eye within a few hours. These sub-conjunctival haemorrhages can have a striking appearance, with the sclera bright red, but they are usually not as serious as they appear. If the abrasion goes deeper, through the conjunctiva, it can affect the sclera and could also cause serious problems to the internal structures of the eye.

     The symptoms of a corneal abrasion include eye pain, a sensation that there is something in the eye, blurry vision, light sensitivity, or headache. A corneal abrasion can cause a scar that could affect eyesight permanently if it is in the line of vision.

     Treatment of abrasions

     In most cases, conjunctival or corneal abrasions are minor and will heal on their own in a few days. Any time, however, that an abrasion causes severe pain or a decrease in vision, or if there are any questions about how serious it is, you should see an eye health professional or go to the emergency department.

     Abrasions can make an eye susceptible to infections from bacteria or fungus, especially if they were caused by a dirty object. The eye health professional may treat an abrasion with antibiotic eye drops or ointment to prevent an infection. You may be given prescription steroid eye drops to reduce inflammation and the possibility of scarring. Artificial tears, or lubricating drops, can be very helpful in making you more comfortable. Do not use any other eye drops without first consulting your eye health professional. Wearing sunglasses can also make you more comfortable while you heal, especially when experiencing light sensitivity.

     It is important to avoid rubbing your eye, which could worsen the abrasion. If there is any possibility that there could be a foreign object, do not try to remove it yourself because this could cause even more harm. Contact lenses should be removed and not worn until the surface of the eye is completely healed. Wearing contacts can worsen the abrasion or can result in a serious infection.

     Your eye health professional will tell you what to expect and for how long to use any treatment prescribed. If there is any worsening of the symptoms, get in touch with your eye health professional to find out what to do next.

   • Superficial foreign objects

     A foreign object, also called a foreign body, is something lodged in the eye, such as dust, dirt, debris, sawdust, shattered glass, or other substance. Very often, foreign objects get into the eye because of work that produces flying particles. Contact lenses can also act as a foreign object when kept in the eye too long.

     Symptoms of superficial foreign objects

     Foreign objects are usually felt immediately when they touch the eye. They cause irritation that can get worse the longer they remain in place. Some foreign objects can get lodged under the lid, which can cause painful scratches on the cornea when you blink. Most often, the presence of a foreign object results in significant tearing, which is a mechanism for the body to try to remove the object. The area can also become red from irritation.

     Treatment of superficial foreign objects

     In most cases, a natural particle in the eye, such as dirt, sand or dust, is not an emergency and will resolve on its own through tearing and blinking. If the foreign object is a piece of wood, or glass, metal, or other artificial material, the results can be more serious. When such objects become embedded in the surface of the eye, they can cause ongoing irritation and even permanent damage.

     It is very important not to rub the eye when you feel a foreign object. It is recommended to try flushing the object out of the eye with a gentle stream of clean warm water. Flushing can also be done using an eyewash with a small clean cup. Always remove contact lenses if they are present. If you are unable to remove the foreign object — or if you feel as though it is still present 24 hours after removal – you should see your eye health professional or go to the emergency department as soon as possible.

     Whenever the foreign object is a piece of metal, such as flecks from hammering a nail, there is a possibility that it could penetrate the eye. In such cases, it is important to go immediately to the emergency department because of the risks of infection, retinal detachment, or blindness. In addition, a small piece of metal can cause a rust ring to form in the cornea, and this rust may need to be removed by the eye health professional.

2. Penetrating wounds

   When the cornea suffers a deeper cut than an abrasion it is called a corneal laceration. A laceration can cut partially or fully through the cornea. When the laceration cuts completely through the cornea, it is a very serious injury that requires immediate medical attention to avoid severe vision loss. Lacerations can occur from a sharp object flying into the eye, such as a piece of glass, or from something striking the eye with significant force, such as a screwdriver or a knife. It can also happen from sharp rapidly moving objects like a fishhook.

   If your eye has been injured, it is best to place a protective shield over the eye and seek medical help. The shield can be made from a small piece of cardboard, such as the cutout bottom of paper cup, taped around the eye. Under no circumstances try to remove a large object embedded in the eye. Do not rub or apply pressure. Do not rinse with water.

   If the object hits the eye with sufficient force, it can go through the cornea into the lens of the eye. This can result in a cataract and severe inflammation if it is not removed surgically. If the object enters the back of the eye, it can damage the retina, which is the light sensitive lining inside the eye, and can result in decreased vision or blindness. These wounds are very serious emergencies that should be treated immediately by an eye health professional.

3. Burns to the eye

   Burns may be chemical or thermal. Chemical burns occur when a solid, liquid, or gas chemical comes in contact with the eye. They are common, occurring mostly in people 18 to 64 years of age in work settings or at home. Chemical burns can be very serious depending on the type of chemical involved.

   The pH is a measure of how alkaline or acidic a chemical may be. A pH of 7 is neutral, with alkaline substances having a pH higher than 7 and acids below 7. Natural tears are close to neutral, with a pH of 7.5. The severity of the burn depends on the chemical’s alkalinity or acidity, how much comes in contact with the eye, and how long it remains in contact.

   In general, alkaline burns are more serious than acid ones. Alkaline chemicals are strong enough to penetrate the eye and can cause damage to the internal structures. They can lead to conditions like cataracts and glaucoma and result in vision loss or blindness. Examples of alkaline chemicals include ammonia, lye, lime, drain and oven cleaners, cement, and fertilizers.

   Acid burns are less serious but can still cause significant damage. Acids don’t tend to penetrate the eye, but they can damage the cornea and cause vision loss. Examples of acids include cleaning acids, vinegar, battery acid, and nail polish remover (acetic acid).

   Other substances can cause severe irritation without causing burns. Examples include household detergents and pepper spray.

   • Treatment for burns of the eye

     The most important treatment for a chemical burn is immediate irrigation with copious amounts of water or saline solution in order to get the chemical out of the eye (there are often special irrigation stations in industrial work settings). Flush out the eye with cold water for at least 15 minutes. Try to hold the eyelids open as wide as possible and roll your eyes so that the fluid rinses as much of the surface as possible. If contact lenses are present, they should be removed. Never try to neutralize the chemical with another substance because it could cause even more harm. Then seek immediate medical attention. If possible, continue flushing until you reach the emergency department; otherwise, call emergency services for transportation. Be ready to tell the eye health professional what chemical was involved.

     

     The eye health professional will determine when it is safe to stop irrigation, and then do a full exam of the eye and surrounding structures such as the lids and tear system in order to evaluate the extent of damage. Treatment may include a prescription for topical antibiotic ointment, dilating drops, pain medications, and possibly topical steroids. Close follow up by the ophthalmologist is a must since it can take several days to recognize the extent of damage to the eye.

     Thermal burns to the eye are much less common and can occur from splatters of cooking oil, e-cigarette explosions, electric soldering arc, and flash burns. Fireworks have the potential to cause both thermal and chemical burns. Thermal burns tend to affect the eyelids because of the blink response to the heat. Treatment can include oral and topical antibiotics, dilating drops, and pain medication.

Types of ocular trauma

The four main types of ocular trauma are lid trauma, blunt trauma, orbital fractures, and traumatic optic neuropathy.

1. Lid trauma

   Trauma to the lids can occur from many of the mechanisms we have already discussed. It can be the result of foreign bodies, sharp objects causing lacerations, or chemical or thermal burns. The first thing to be determined is whether the trauma involves just the lid or also the eye itself.

   If the trauma is confined to the lid and only involves the skin, it can be managed as a common skin abrasion or laceration. This could involve topical antibiotics or, if deep enough, stitches. If the margin of the lid is involved, it must be repaired surgically to avoid uneven scarring, which could affect the cornea when blinking. Only someone with experience in this type of surgery should attempt the repair. If the trauma results in a dirty wound, such as from a dog or human bite, or if there is evidence of an infection, it may need to be treated with oral antibiotics. (pic6)

   The lids serve not only to protect the eye, but also to contain important structures like glands and part of the tear system. The opening to the drainage ducts for tears is located on the side closest to the nose of both the upper and lower lids. If the laceration involves the tear ducts and is not repaired correctly, it can result in bothersome chronic or long-term tearing.

2. Blunt trauma

   Blunt trauma can range in severity from bruising around the eye to orbital fractures and traumatic optic neuropathy.

   A very common type of blunt trauma to the eye and surrounding structures is referred to as a black eye. This is commonly caused by a blunt object hitting the area, such as a ball or elbow during sports or a fist during a violent attack. A black eye represents bruising of the soft tissues around the eye when blood and other fluids collect, causing swelling and discoloration. While the black eye itself is often limited to the surrounding tissues, it can be a sign of more serious trauma to the eye itself or the bones surrounding it.

   When the blunt trauma involves the eye, it can cause other conditions. One is bleeding within the eye, called a hyphema. It is important that the doctor diagnose this condition because it can result in damage to the cornea or high pressure inside the eye, glaucoma.

   If the trauma causes inflammation of the iris, it is called traumatic iritis. (Other causes of iritis include immune diseases or genetic predisposition.) Traumatic iritis is often the result of blunt trauma to the eye caused by firecrackers, pellet gun projectiles, and automobile accidents. The symptoms include eye redness, discomfort or achiness in the affected eye, sensitivity to light, and decreased vision.

   If the blunt trauma is severe, the bones around the eye can be fractured.

   • Symptoms of blunt trauma

     Swelling and bruising following blunt trauma are common, and they often get worse some hours after the initial injury. The discoloration of the skin around the eye may be initially red but turns darker, progressing to purple, yellow, green, or black. Pain is also present.

     If there are signs of a more serious head injury, you should seek medical attention. Some of these signs include loss of vision, inability to move the eye, severe or constant headaches, fainting or loss of consciousness, and blood or fluid coming from the ears or the nose. If the doctor suspects that the blunt trauma has resulted in a fracture or a foreign object inside the eye or around it, then an x-ray or CT scan may be ordered.

   • Treatment of blunt trauma

     When the black eye is confined to the area around the eye, it can usually be treated at home. An ice pack applied to the area for 15-to-20 minutes once each hour helps reduce swelling pain during the first 24 hours. Bags of frozen peas or ice cubes in a plastic bag wrapped in a cloth are good alternatives to an ice pack. You should avoid direct contact of the skin with ice cubes to prevent ice burns. The area should be kept clean, and strenuous physical activity such as sports should be avoided for a few days.

3. Orbital fractures

   

   The orbit is formed by the bones that surround the eyeball, also called the eye socket. The bones of the orbit help protect the eye and other structures like the muscles that move the eye, and nerves and blood vessels. There are seven bones that form the orbit; some are very solid but others are among the thinnest bones in the body. If the blunt trauma is significant enough, it can fracture one or more of these bones.

   There are different types of fractures depending on which bones are involved and the type of trauma. A blowout fracture usually occurs from blunt trauma directly to the front of the eye. This results in the eye pushing back forcefully, increasing the pressure inside the orbit, causing the thin bones that form the walls of the orbit to break. Common causes include being hit with a fist, being kicked, or hit by a bat, baseball, hockey stick, or puck. One complication of a blowout fracture is that the muscles and other tissues around the eye may become stuck in the break. This results in the inability of the eye to move normally, causing double vision.

   An orbital rim fracture results when the thicker bones forming the rim of the orbit break because of being hit with a great deal of force, such as in a car accident, and a visible face deformity can result. Because this type of trauma is much more forceful, it is important to make sure that there are no injuries to the brain, the optic nerve, or other facial bones. If the bones adjacent to the jaw are broken, there may be difficulties chewing.

   The orbital floor is composed of the bones around the bottom of the eye socket, which support the eye and surrounding tissue. An orbital floor fracture results from significant eye trauma that causes the orbital rim bone to push back, causing the floor and surrounding structures to cave downward into the sinus below. This type of fracture can restrict eye movements and cause the eye to sink into the orbit.

4. Traumatic optic neuropathy

   The optic nerve carries the visual information from the retina to the brain. When it is damaged from trauma it is unable to transmit information, resulting in loss of vision. Depending on the extent of the damage the loss can vary from a very slight loss of color perception to complete blindness.

   The main cause of traumatic optic neuropathy is when the force of the impact to the eye, or surrounding structures, is transmitted directly to the area in the back of the eye where the optic nerve connects with the light-sensing cells of the retina. It can also be damaged indirectly if the impact affects the narrow optic nerve canal in the orbital bones. Initially the optic nerve appears normal but becomes pale and atrophied 3-to-6 weeks after the trauma. Vision loss begins almost immediately. With treatment, some improvement in vision can occur but most often there is some permanent loss.

Can ocular trauma be prevented?

Simply wearing protective eyewear can reduce the risk for eye injury by 90 percent. It is unfortunate, then, that only about three out of 10 people wear protective eyewear during home projects that could result in harm to the eyes.

The recommended protective eyewear in the US is “ANSI-approved,” meaning that the protective eyewear is made to meet safety standards of the American National Standards Institute. ANSI currently works in tandem with over 150 countries around the world, helping in the development of national standards.

Being aware of the different causes and manifestations of ocular trauma can help us understand how it can be prevented, and when it does occur, how the rates of blindness and visual disability can be reduced through correct and timely treatment.

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References

1. D. Tubert., “Eye Injury Prevention”, April 2021, Accessed on 11 Nov 2021. Available: https://www.aao.org/eye-health/tips-prevention/preventing-injuries
2. C. J. MacEwen, “Ocular injuries,” Journal of the Royal College of Surgeons of Edinburgh, vol. 44, no. 5, pp. 317-23, 1999.
3. G. McGwin, A. Xie and C. Owsley, “Rate of eye injury in the United States”. Archives of Ophthalmology, vol. 123, no. 7, pp. 970-6, 2005.
4. A. D. Négrel and B. Thylefors, “The global impact of eye injuries,” Ophthalmic epidemiology, vol. 5, no. 3, pp. 143-69, 1998, doi:10.1076/opep.5.3.143.8364.
5. B. Thylefors, “Epidemiological patterns of ocular trauma,” Australian and New Zealand journal of ophthalmology, vol. 20, no. 2, pp. 95-8, 1992.
6. J.M Tielsch, L. Parver and B. Shankar, “Time Trends in the Incidence of Hospitalized Ocular Trauma,” Archives of Ophthalmology, vol. 107, no. 4, pp. 519-23, 1983, doi:10.1001/archopht.1989.01070010533025.