1. 25: Eye Injuries

2. 1.List the main anatomical features of the eye. 2.Describe the principal functions of the eye. 3.Describe the signs and symptoms of eye injuries. 4.List the steps to assess eye injuries. 5. Describe the steps for managing foreign objects in the eye. 6.Describe the steps for managing puncture wounds to the eye. Cognitive Objectives (1 of 2)

3. 7.Describe how to manage burns to the eye. 8.Describe how to remove contact lenses from the eye. 9.Recognize abnormalities of the eyes that may indicate underlying head injury. 10. Recognize and manage a patient with an artificial eye. There are no affective objectives for this chapter. Cognitive Objectives (2 of 2)

4. Psychomotor Objectives 11. Demonstrate the use of irrigation to flush out foreign bodies lying on the surface of the eye. 12. Demonstrate the care of the patient with chemical burns to the eye. 13. Demonstrate the steps in the emergency care of the patient with lacerations of the eyelids. All of the objectives in this chapter are noncurriculum objectives.

5. Anatomy of the Eye

6. Eye Injuries Can produce severe complications Examine pupil for shape and reaction.

7. Appearance of Eye In a normal, uninjured eye, the entire circle of the iris should be visible. Pupils should be round, equal in size, react equally when exposed to light. Both eyes should move in same direction when following a finger. Always note patient’s signs and symptoms including severity and duration.

8. You are the provider You and your EMT-B partner are dispatched for an injured person at Frank’s Auto Repair. You discover a patient with a large metal fragment in his right eye. Bystanders tell you that he was working with a piece of machinery that exploded in his face.

9. You are the provider continued (1 of 2) You take BSI precautions and ask the patient what happened. He tells you that the machine “blew apart” and he felt something hit his right eye. He did not fall, never lost consciousness, and is alert and oriented.

10. You are the provider continued (2 of 2) What precautions would you take on this scene? What was the mechanism of injury?

11. Scene Size-up Observe for hazards. Request additional help early.

12. You are the provider continued (1 of 2) Your patient has a patent airway and is breathing. You observe moderate bleeding from his right eye. You perform a rapid assessment and determine the only injury present is a large metal fragment in the sclera of the right eye.

13. You are the provider continued (2 of 2) What are some considerations for your initial assessment of this patient? At what point in the assessment would you control bleeding? How would you control the bleeding to the right eye?

14. Initial Assessment Eye injuries can cause permanent disability. Can create great anxiety Approach patient calmly.

15. Airway and Breathing Consider immobilization. Eye injuries can affect airway. Check for clear, symmetric breath sounds. Provide high-flow oxygen. Palpate chest for DCAP-BTLS.

16. Circulation Quickly assess pulse rate and quality. Control bleeding. Do not put pressure on eye. Wounds around eye bleed freely. Are not usually life threatening Usually easy to control

17. Transport Decision Eye injuries are serious. Transport quickly and safely. Surgery/restoration of circulation to eye may need to be achieved in 30 minutes. Do not delay transport.

18. You are the provider continued (1 of 3) The patient is an A on the AVPU scale. No noted airway abnormalities. Breathing is normal. DCAP-BTLS is unremarkable. Pulse and skin are unremarkable. You scan the body for bleeding and note bleeding at the right eye. You control bleeding by placing a sterile moist dressing gently on the eye. You decide patient is medium transport due to eye injury.

19. You are the provider continued (2 of 3) You take a SAMPLE history and learn that the patient wears contact lenses. You observe that the left eye is uninjured; the pupil is round and reactive to light, and the contact lens is in place.

20. You are the provider continued (3 of 3) Would you remove the contact lenses? How would you treat this patient? Do you bandage one or both eyes? How would you deal with the emotional well-being of the patient during treatment and transportation?

21. Focused History and Physical Exam Rapid physical exam –In bleeding cases, do not focus just on bleeding. –Quickly assess entire patient from head to toe.

22. Focused History and Physical Exam continued Focused physical exam –Begin with eyes and face. –Assess eyes for equal gaze. –Check pupil shape and response to light. –Assess globe for bleeding. –If eye is swollen shut, do not attempt to open.

23. Baseline Vital Signs/SAMPLE History Baseline vital signs –Monitor for shock. SAMPLE history –Perform as usual; obtain from responsive patient or family/bystanders.

24. Interventions Provide complete spinal immobilization. Be cautious in bandaging.

25. You are the provider continued You leave both contact lenses in place. You place a cup over the dressing and bandage both eyes to minimize movement of the object. Patient is likely to be upset that both eyes are covered. Explain everything that you are doing and keep reassuring patient.

26. Detailed Physical Exam Perform if patient is stable and time allows.

27. Ongoing Assessment With serious injuries, make sure bandage covers both eyes and is not putting pressure on eyeball. Communication and documentation –Inform hospital in case eye specialists are available. –Document the patient’s vision or changes in vision.

28. Foreign Objects in the Eye For small foreign objects lying on the surface of the eye, irrigate with saline. Flush from the nose outward.

29. Removing a Foreign Object from Under the Eyelid (1 of 2) Never attempt to remove an object on the cornea. Have the patient look down. Place a cotton-tipped applicator on the outer surface of the upper lid.

30. Removing a Foreign Object from Under the Eyelid (2 of 2) Pull the lid upward and forward. Gently remove the foreign object from the eyelid with a moistened, sterile applicator.

31. Foreign Objects Impaled in the Eye (1 of 2) If there is an object impaled in the eye, do not remove it. Immobilize the object in place. Prepare a doughnut ring by wrapping a 2” piece of gauze around your fingers and thumb. Remove the gauze from your hand and wrap remainder of gauze around ring.

32. Foreign Objects Impaled in the Eye (2 of 2) Carefully place the ring over the eye and impaled object, without bumping the object. Stabilize the object with roller gauze. Cover the injured and uninjured eye.

33. Chemical Burns Chemicals, heat, and light rays can burn the eye. For chemicals, flush eye with saline solution or clean water. You may have to force eye open to get enough irrigation to eye. With an alkali or strong acid burn, irrigate eye for about 20 minutes. Bandage eye with dry dressing.

34. Irrigating the Eye

35. Thermal Burns For thermal burns, cover both eyes with a moist, sterile dressing. Transport patient to a burn center.

36. Light Burns Infrared rays, eclipse light, direct sunlight, and laser burns can damage the eye. Cover each eye with a sterile pad and eye shield. Transport the patient in a supine position.

37. Lacerations Lacerations to the eyes require very careful repair. Never exert pressure on or manipulate the eye. If part of the eyeball is exposed, apply a moist, sterile dressing. Cover the injured eye with a protective metal eye shield.

38. Blunt Trauma Blunt trauma can cause a number of serious injuries. –A fracture of the orbit (blowout fracture) –Retinal detachment May range from a black eye to a severely damaged globe

39. Hyphema Bleeding in the anterior chamber of the eye May seriously impair vision

40. Blowout Fracture May occur from blunt trauma caused by a fracture of the orbit Bone fragments may entrap muscles that control eye movement, causing double vision.

41. Retinal Detachment Often seen in sports injuries Produces flashing lights, specks, or floaters in field of vision Needs prompt medical attention

42. Eye Injuries Following a Head Injury One pupil larger than the other Eyes not moving together or pointing in different directions Failure of the eyes to follow equally –Bleeding under the conjunctiva –Protrusion or bulging of one eye

43. Pupil Size and Head Injury Variation in pupil size may indicate a head injury.

44. Contact Lenses and Artificial Eyes Contact lenses should be kept in the eyes unless there is a chemical burn. Do not attempt to remove a lens from an injured eye. Notify the hospital if the patient has contact lenses. If there is no function in an eye, ask if the patient has an artificial eye.

45. Contact Lens Removal (1 of 2) If absolutely necessary, remove a hard contact lens with a small suction cup, moistening the end with saline.

46. Contact Lens Removal (2 of 2) To remove a soft contact lens: –Place two drops of normal saline in eye. –Gently pinch it between your gloved thumb and index finger. –Lift it off surface of eye.

47. Review 1.The globe of the eye is also called the: A. lens. B. orbit. C. retina. D. eyeball.

48. Review Answer: D Rationale: The globe the eye is also called the eyeball. The lens, which sits behind the iris, focuses images on the retina—the light-sensitive area at the back of the globe. The globe is located within a bony socket in the skull called the orbit.

49. Review 1.The globe of the eye is also called the: A.lens. Rationale: The lens sits behind the iris and focuses images on the light-sensitive area at the back of the globe. B. orbit. Rationale: The orbit forms the base of the floor of the cranial cavity and contains the eye. C. retina. Rationale: The retina is the light-sensitive area at the back of the globe. D. eyeball. Rationale: Correct answer

50. Review 2. While assessing a 20-year-old man with a penetrating eye injury, you note the leakage of a gel-like substance from the eyeball. It is important to remember that this substance: A. cannot be replaced when it is lost. B. will be replaced gradually over time. C. is vitreous humor from the front of the lens. D. is aqueous humor from within the eyeball.

51. Review Answer: A Rationale: The clear, gel-like substance that maintains the shape of the eyeball (globe) is called vitreous humor. If the eyeball is ruptured or lacerated, vitreous humor may be lost and cannot be replaced. If this occurs, permanent vision loss in the affected eye is likely.

52. Review 2. While assessing a 20-year-old man with a penetrating eye injury, you note the leakage of a gel-like substance from the eyeball. It is important to remember that this substance: A.cannot be replaced when it is lost. Rationale: Correct answer B. will be replaced gradually over time. Rationale: This substance cannot be replaced or reproduced. C. is vitreous humor from the front of the lens. Rationale: Vitreous humor is fluid near the back of the eye and maintains the shape of the globe. D. is aqueous humor from within the eyeball. Rationale: Aqueous humor is watery fluid found in front of the lens which may leak out, but given time and treatment, the body can reproduce it.

53. Review 3. When a person is looking at an object up close, the pupils should: A. dilate. B. constrict. C. remain the same size. D. dilate, and then constrict.

54. Review Answer: B Rationale: The pupils, which allow light to move to the back of the eye, constrict in bright light and dilate in dim light. The pupils should also constrict when looking at an object up close and dilate when looking at an object farther away; this is called pupillary accommodation. These pupillary adjustments occur almost instantaneously.

55. Review 3. When a person is looking at an object up close, the pupils should: A.dilate. Rationale: The pupils will dilate when looking at objects far away. B. constrict. Rationale: Correct answer C. remain the same size. Rationale: The pupils will constrict when looking at objects that are close. D. dilate, and then constrict. Rationale: The pupils will constrict first when looking at close objects.

56. Review 4. You are treating a patient with a ballpoint pen impaled in the left eye. After properly stabilizing the pen, you should: A. leave the other eye alone. B. cover the unaffected eye. C. irrigate the unaffected eye. D. assess movement of the other eye.

57. Review Answer: B Rationale: After properly stabilizing an impaled object in the eye, you should cover the unaffected eye. Do not irrigate the unaffected eye or assess its movement; doing so will also cause the affected eye to move and could potentially worsen the injury. Remember, both eyes normally move in unison (sympathetic eye movement).

58. Review 4. You are treating a patient with a ballpoint pen impaled in the left eye. After properly stabilizing the pen, you should: A.leave the other eye alone. Rationale: Cover the unaffected eye to prevent or minimize the movement of both eyes. B. cover the unaffected eye. Rationale: Correct answer C. irrigate the unaffected eye. Rationale: Irrigation may cause the effected eye to move. D. assess movement of the other eye. Rationale: Movement of the unaffected eye will cause the injured eye to move in unison and potentially increase damage.

59. Review 5. When caring for a chemical burn to the eye, the EMT-B should: A. prevent contamination of the opposite eye. B. immediately cover the injured eye with a sterile dressing. C. avoid irrigating the eye as this may cause further injury. D. irrigate both eyes simultaneously, even if only one eye is injured.

60. Review Answer: A Rationale: When irrigating a chemical burn to the eye, it is important to direct the stream away from the uninjured eye. If you do not, you will likely flush the chemical into the unaffected eye. After irrigating the eye for the appropriate amount of time, cover both eyes with a sterile dressing.

61. Review 5. When caring for a chemical burn to the eye, the EMT-B should: A.prevent contamination of the opposite eye. Rationale: Correct answer B. immediately cover the injured eye with a sterile dressing. Rationale: Irrigation of the eye must take place first. C. avoid irrigating the eye as this may cause further injury. Rationale: Irrigation of the effected eye must take place. Direct the stream away from the uninjured eye. D. irrigate both eyes simultaneously, even if only one eye is injured. Rationale: Both eyes must be irrigated. Direct the stream of the contaminated eye away from the unaffected eye.

62. Review 6. While assessing a patient who experienced blunt trauma to the face, you note the presence of hyphema. This indicates that: A. an orbital skull fracture is present. B. bleeding is likely occurring in the brain. C. the globe was exposed to direct trauma. D. bleeding is occurring in the posterior eye chamber.

63. Review Answer: C Rationale: Hyphema, or bleeding into the anterior chamber of the eye, obscures part or all of the iris. The presence of hyphema indicates direct blunt trauma to the globe (eyeball); as a result, serious vision impairment may occur.

64. Review 6. While assessing a patient who experienced blunt trauma to the face, you note the presence of hyphema. This indicates that: A.an orbital skull fracture is present. Rationale: An orbital skull fracture is possible due to blunt trauma, but will present with ecchymosis and swelling to the eye orbit. B. bleeding is likely occurring in the brain. Rationale: Bleeding in the brain can only be confirmed at a medical facility. C. the globe was exposed to direct trauma. Rationale: Correct answer D. bleeding is occurring in the posterior eye chamber. Rationale: Bleeding is occurring in the anterior chamber of the eye.

65. Review 7. Which of the following signs is LEAST indicative of a head injury? A. Asymmetrical pupils B. Pupillary constriction to bright light C. Both eyes moving in opposite directions D. Inability to look upward when instructed to

66. Review Answer: B Rationale: The pupils normally constrict in bright light and dilate in dim light. Suspect a head injury if the pupils do not react appropriately, are asymmetrical (unequal), do not move together (dysconjugate gaze), or if the patient is unable to look upward (paralysis of upward gaze).

67. Review 7. Which of the following signs is LEAST indicative of a head injury? A.Asymmetrical pupils Rationale: This may be an indication of a head injury. B. Pupillary constriction to bright light Rationale: Correct answer C. Both eyes moving in opposite directions Rationale: This may be an indication of a head injury. D. Inability to look upward when instructed to Rationale: This may be an indication of a head injury.

68. Review 8. A 32-year-old man was assaulted and has a heavily bleeding laceration to his right eyelid. You should: A. flush the eye with sterile saline or water. B. apply a pressure dressing to the entire eye. C. apply gentle, manual pressure to the injury. D. apply heat to the injury to decrease bleeding.

69. Review Answer: C Rationale: Bleeding from a lacerated eyelid may be heavy, but can usually be controlled by gentle, manual pressure. Never apply excessive pressure (ie, pressure bandage) to any eye injury; this may cause further injury. It is not necessary to flush a lacerated eyelid unless an associated chemical burn injury is present.

70. Review 8. A 32-year-old man was assaulted and has a heavily bleeding laceration to his right eyelid. You should: A.flush the eye with sterile saline or water. Rationale: It is not necessary to flush an injury to the eyelid unless it is associated with a chemical burn. B. apply a pressure dressing to the entire eye. Rationale: Never apply excessive pressure to the eye. C. apply gentle, manual pressure to the injury. Rationale: Correct answer D. apply heat to the injury to decrease bleeding. Rationale: Heat will cause vasodilation and increase the bleeding. Cold application will help slow the bleeding.

71. Review 9. An eyeball that is protruding from the eye socket should be treated by: A. stabilizing the eye with a dry, sterile dressing. B. stabilizing the eye with a moist, sterile dressing. C. carefully replacing the eye back into the socket. D. placing the patient in the prone position during transport.

72. Review Answer: B Rationale: The eyeball may be displaced from its socket (avulsed) following a serious eye injury. Do not attempt to reposition the eye or replace it back into the eye socket. Simply cover the eye, and stabilize it with a moist, sterile dressing. Place the patient supine during transport.

73. Review 9. An eyeball that is protruding from the eye socket should be treated by: A.stabilizing the eye with a dry, sterile dressing. Rationale: You must use a moist, sterile dressing. B. stabilizing the eye with a moist, sterile dressing. Rationale: Correct answer C. carefully replacing the eye back into the socket. Rationale: Do not attempt to reposition the eye or replace it back into the socket. D. placing the patient in the prone position during transport. Rationale: Cover both eyes and place the patient in the supine position.

74. Review 10. To remove hard contact lenses from a patient's eyes, you should: A. use a suction cup moistened with sterile saline solution. B. pinch the lenses off with your thumb and index finger. C. carefully flush the lenses out with copious amounts of water. D. remove the lenses with a pair of tweezers or similar instrument.

75. Review Answer: A Rationale: To remove hard contact lenses from a patient's eyes, you should use a specialized suction cup moistened with sterile saline solution. The only time that contact lenses should be removed immediately in the field is when there is a chemical burn to the eye. If the contact lens is left in place, it can trap the chemical, making irrigation difficult.

76. Review 10. To remove hard contact lenses from a patient's eyes, you should: A.use a suction cup moistened with sterile saline solution. Rationale: Correct answer B. pinch the lenses off with your thumb and index finger. Rationale: You must use a suction cup. C. carefully flush the lenses out with copious amounts of water. Rationale: You must use a suction cup for removal. Only remove the lenses when there is a chemical burn to the eye. D. remove the lenses with a pair of tweezers or similar instrument. Rationale: Never use a sharp object to remove contact lenses. Always use a suction cup.