Injury to the eye
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7430.36 (Published 01 January 2004) Cite this as: BMJ 2004;328:36
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We enjoyed reading this excellent article on injury to the eye (1)
but would like to comment on the authors’ observations regarding the
management hard tissue injuries of the orbit that commonly accompany
trauma to the eye.
Although an isolated orbital fracture can occur, it is more commonly
found as part of a fracture of the zygomatic complex or midface (2).
In our experience, a patient presenting with a subconjunctival
haemorrhage, swollen eyelid, loss of cheek sensation with ipsilateral
nosebleed is more likely to have a fracture of the zygomatic complex with
inevitable orbital involvement. An isolated orbital blowout fracture is
more likely to present with restricted vertical eye movement as the main
clinical feature. The other signs and symptoms may not be present and are
often absent in a pure isolated blowout fracture of the orbit.
Considering this, the diagram entitled “Signs of a left orbital
blowout fracture (patient looking upwards)”, should be considered as
representative of the features of a fracture of the zygomatic complex,
rather than of an isolated orbital blowout fracture.
Although plain radiographs are helpful in the initial assessment of
orbital and zygomatic complex fractures, CT (computerized tomography) or
MR (magnetic resonance) imaging should be used to assess orbital injuries
prior to definitive treatment (3). The classic radiological hanging drop
sign, for example, may actually represent a haematoma contained within the
antral periosteum. Fluid in the maxillary sinus following facial trauma is
likely to be blood arising from a fracture of the antral wall. This can be
any part of the antral wall and does not in itself indicate an orbital
blowout fracture or fracture of the orbital floor.
The statement that the fracture may need repair should be qualified
by limiting surgery to those cases where there has been trapping of the
orbital contents by the fracture, alteration in the position of the globe
or changes in orbital volume (4).
As practitioners who regularly assess and treat orbital fractures we
must disagree with the statement that patients with orbital blowout
fractures “should be referred to an ophthalmic department”. We believe
that the most appropriate path of referral is initially to a Maxillofacial
Surgery Department. Most Oral and Maxillofacial surgeons treat
orbitozygomatic injuries as part of their surgical scope (5). We do
however work closely with our ophthalmic colleagues and would request a
full Ophthalmic and Orthoptic assessment prior to planned surgical
exploration of the orbit.
1. Khaw PT, Shah P, Elkington AR. Clinical Review, ABC of Eyes,
Injury to the eye. BMJ. 2004;328:36-38.
2. al Qurainey IA, Stassen LF, Dutton GN, Moos KF, el Attar A. The
characteristsics of midfacial fractures and the association with ocular
injury: a prospective evaluation. British Journal of Oral and
Maxillofacial Surgery. 1991;29(5):291-301.
3. Ilankovan V, Hadley D, Moos K, el-Attar A. A comparison of imaging
techniques with surgical experience in orbital injuries. Journal of
Craniomaxillofacial Surgery. 1991;19(8):348-352.
4. Shumruck KA, Campbell AC. Management of the orbital rim and floor
in zygoma and Midface fractures; criteria for selective exploration.
Facial Plastic Surgery. 1998;14(1):77-81.
5. Lynham AJ, Monsour FN, Chapman P. Management of orbitozygomatic
fractures. Australia and New Zealand Journal of Surgery. 2002;72(5):364-366.
Competing interests:
None declared
Competing interests: No competing interests
I was interested to read in Clinical Review of the recommendation on
patching corneal abrasions. In the course of carrying out an audit on
corneal abrasions as an Accident and Emergency SHO, I researched the
evidence base for the recommendations of my own department which included
patching. Among other studies, a single-blinded randomised controlled
trial (1) showed that in 163 corneal abrasions patching the eye was of no
benefit in speeding healing and decreasing discomfort. Indeed this study
cited others that pointed to additional adverse consquences including a
risk of anaerobic bacterial infection in contact lens wearers,
monocularity and decreased visual field (impairing driving ability and
early return to work) and increased discomfort leading to premature patch
removal. The authors recommend more effort be put into reducing pain which
remains high in the 24 hours post injury.
1. Le Sage N, Verrault R, Rochette L. Efficacy of eye patching for
traumatic corneal abrasions: a controlled clinical trial. Ann Emerg Med
August 2001;28:129-134.
Competing interests:
None declared
Competing interests: No competing interests
In the recent article ‘ABC of eyes Injury to the eye’ BMJ 328 3
January 2004 the author states that the one of the main aims of the
treatment of corneal abrasions is to speed healing and protect the eye by
the use of an eye pad.
Several studies looking at the use of eye patches have shown no
difference in healing rates with some showing faster healing rates in
those patients treated without eye patches.(1-8) Patches may reduce
oxygenation of the cornea, prevent repeat dosing of topical medication and
involve a loss of binocular vision, reducing the visual field and depth
perception thus interfering with everyday activities. I would suggest that
patches should no longer be routinely used in treating corneal abrasion.
The author also suggests using oral analgesia for this painful
condition. Topical non steroidal anti inflammatory agents are a useful
adjunct to oral analgesia showing reduced pain scores with no effect on
healing rates. (9-13)
1.Kirkpatrick J: No eye pad for corneal abrasion. Eye 1993 468-71
2.Kaiser P: Comparison of pressure patching versus no patching for
corneal abrasions due to trauma or FB removal .Ophthalmology 102(12) 1995
1936-42
3.Campanille T: Evaluation of eye patching in the treatment of
traumatic corneal epithelial defects. Journal of emergency medicine 15(6)
1997 769-74
4.Jackson H: Effect of eye pad on healing of simple corneal
abrasions. BMJ 1960 Sept 3,713
5.Hulbert M: Efficacy of eyepad in corneal healing after corneal
foreign body removal. Lancet 337,March 16 1991,643
6.Rao G: Letter to the editor. Eye 1994 8 371-2
7.Patterson J: Eye patch treatment for the pain of corneal abrasion.
Southern medical journal 1996 Vol. 89(2) 227-9
8.Arbour J: Should we patch corneal abrasions?. Archives of
ophthalmology 115 1997 313-317
9.Brahama A: Topical analgesia for superficial corneal injuries.
Journal of Accident & Emergency Medicine.1996 .186-188
10.Haynes RJ. Topical diclofenac relieves pain from corneal rust
ring. Eye 1996 10,443-446
11.Jayamanne D: Effectiveness of topical diclofenac in relieving
discomfort following traumatic corneal abrasions. Eye 1997(11) 79-83
12.Kaiser P: Study of topical NSAIDs and no pressure patching in the
treatment of corneal abrasions. Ophthalmology 104 1997 1353-1359
13.Szucs P: Safety and efficacy of diclofenac ophthalmic solution in
the treatment of corneal abrasions. Annals of emergency medicine. Feb 2000
131-136
Competing interests:
None declared
Competing interests: No competing interests
The evidence based literature does not concur with the recommendation
that cornal abrasions be padded [1,2,3]. In fact the topical use of NSAIDs
has been preferred [4].
Arc eye is incredibly painful and the pain often
recurs at night after the patient has left your surgery. Is there evidence
that the use of two x 0,5ml vials of local anaesthetic eye drops self-
administered at home, if necessary, is toxic to the cornea.
Finally there
is little evidence recommending routine use of topical antibiotics for
corneal abrasions, especially after removal of foreign body. Would it not
be better if we prescribed hydoxypropyl methylcellulose/dexran-70 solution
and/or topical NSAIDs, and used the topical antibiotics only as needed,
until the necessary trials answering this very common problem are done?
1). Flynn CA et al. Should we patch corneal abrasions: a meta-
anaylsis. J Family Prac 1998 47(4). 264-270
2). JG Michael et al. Management of corneal abrasion in children: a
randomised controlled trial. Annals of Emergency Medicine. Jul 2002
3). JD Arbour et al. Commment: Should we patch corneal erosions? Archives
of Opthalmology 1997 115(3).
4). Solomon A. et al. Comparison of topical indomethacin and eye patching
for minor corneal trauma. Annals of Opthalmology 2000 Vol 32(4).
Competing interests:
None declared
Competing interests: No competing interests
The article recommends three treatments for corneal abrasion, none of
which appear to be supported by the literature.
A meta-analysis of studies of eye patching for corneal abrasion found
that it did not improve healing rate or reduce pain. The authors
recommended against patching because of loss of binocular vision and
possible increase in pain.(1)
A meta-analysis of studies examining cycloplegics for corneal
abrasion found only one study that met their criteria. While this study
was not blinded and had other flaws, it did not show any benefit to
cycloplegics. The authors concluded that "Cycloplegics cannot be
recommended for use in patients with corneal abrasion."(2)
There is a similar paucity of evidence regarding the use of topical
antibiotics.
While these three treament modalities are classically taught, the
article (and the upcoming book it is adapted from) should indicate the
lack of supporting evidence for them.
References
1. Flynn CA, D'Amico F, Smith G. Should we patch corneal abrasions: a
meta-analysis. Journal of Family Practice 1998; 47(4):264-270.
2. Carley F, Carley S. Mydriatics in corneal abrasion. Emerg Med J
2001; 18:273.
Competing interests:
None declared
Competing interests: No competing interests
Posterior segment trauma
Editor,
We read with interest the Clinical review of Khaw et Al “injury to the
eye”.
However , there are some points that we believe need clarification
concerning the management of posterior segment trauma.
Firstly, a lot of times intraocular foreign bodies(IOFB) are not visible
with fundoscopy either due to their location or to concurrent vitreous
hemorrhage; In such cases radiographic tests to detect IOFB should be
performed, however it should be emphasized that MRI should not be
performed if the presence of a metallic IOFB is suspected.
Secondly, in penetrating traumas with IOFBs it is very important to
perform as soon as possible the primary repair[1]; Timing of vitreoretinal
surgery for IOFB removal is controversial in the literature[2-5] Some
authors prefer the early vitrectomy to eliminate the risk of
endophthalmitis, when others suggest that vitreoretinal surgery should be
performed later (within 10 to 15 days from the injury) as spontaneous
vitreous detachment will have occur and facilitate vitrectomy.
Competing interests: None declared
1. Aylward GW: Vitreous management in penetrating trauma: primary
repair and secondary intervention. Eye 2008, 22(10):1366-1369.
2. Cupples HP, Whitmore PV, Wertz FD, 3rd, Mazur DO: Ocular trauma treated
by vitreous surgery. Retina 1983, 3(2):103-107.
3. Ryan SJ, Allen AW: Pars plana vitrectomy in ocular trauma. Am J
Ophthalmol 1979, 88(3 Pt 1):483-491.
4. Jonas JB, Knorr HL, Budde WM: Prognostic factors in ocular injuries
caused by intraocular or retrobulbar foreign bodies. Ophthalmology 2000,
107(5):823-828.
5. May DR, Kuhn FP, Morris RE, Witherspoon CD, Danis RP, Matthews GP, Mann
L: The epidemiology of serious eye injuries from the United States Eye
Injury Registry. Graefes Arch Clin Exp Ophthalmol 2000, 238(2):153-157.
Competing interests:
None declared
Competing interests: No competing interests