OP10.6 | Ocular Injuries: Classification, Primary Management and Referral — Summary & Reflection

KEY TAKEAWAYS

Ocular Injuries — Key Points:

• Classification: Closed globe (blunt — hyphaema, commotio, blow-out fracture), open globe (penetrating/perforating/IOFB), chemical burns, radiation.
• Chemical burns — alkali is worse than acid: Alkali causes liquefactive necrosis with NO coagulative barrier; penetrates deeply and continues spreading. Acid forms a coagulative protein barrier that limits penetration.
• FIRST ACTION for chemical burns: Immediate copious irrigation with available water/saline — before examination, before calling ophthalmology, before anything else. Irrigate until pH 7.0–7.4.
• Roper-Hall grading: Grade I–II = good prognosis; Grade III–IV = guarded/poor (limbal ischaemia destroys stem cells).
• Open globe do-nots: No pressure pad, no tonometry, no eye drops, do NOT remove impaled objects. Apply Fox shield, give IV antibiotics + tetanus, refer urgently for surgical repair.
• Hyphaema: Blood in AC after blunt trauma; risk of secondary haemorrhage days 2–5; avoid aspirin/NSAIDs.
• IOFB: Never MRI — X-ray/CT only. Siderosis (iron) and chalcosis (copper) are delayed complications.
• Orbital blow-out fracture: CT orbit; limited diplopia on upward gaze + infraorbital anaesthesia.
• Referral: Open globe = emergency; chemical burn with corneal involvement = urgent same day; IOFB = urgent within hours; hyphaema grade ≥II = within 24 hours.

REFLECT

The construction worker in the hook — 15 minutes had already elapsed before he reached the casualty. Had the nurse taken his history for another 10 minutes before starting irrigation, 25 minutes of alkali contact with the cornea and anterior segment would have occurred. The difference between 15 minutes and 25 minutes of lime contact may be the difference between Grade II (good prognosis) and Grade III–IV (high risk of limbal stem cell failure and corneal blindness). In your career, you will encounter chemical burns in a factory, in a household accident (bleach, oven cleaner), or in an assault (acid attack is a medico-legal emergency). The training message is simple: water first, questions later. Knowing this rule — and acting on it instantly — may preserve the sight of a patient who would otherwise lose an eye.