A 26-year-old, previously healthy man comes to the emergency department due to an eye injury. The patient was hiking earlier today when the person in front of him pushed and let go of a small tree branch, which snapped back and hit him on the face. He had sudden pain in the right eye followed by a persistent foreign-body sensation and increased tearing. On physical examination, the patient appears in moderate distress. Right eye examination reveals no foreign bodies, but there is mild conjunctival erythema, especially around the limbus. The cornea is clear with no blood in the anterior chamber. The pupil is small, round, and reactive to light. Visual acuity is normal. Left eye examination reveals no abnormalities. Which of the following is the best next step in management of this patient?

Question

A 26-year-old, previously healthy man comes to the emergency department due to an eye injury.  The patient was hiking earlier today when the person in front of him pushed and let go of a small tree branch, which snapped back and hit him on the face.  He had sudden pain in the right eye followed by a persistent foreign-body sensation and increased tearing.  On physical examination, the patient appears in moderate distress.  Right eye examination reveals no foreign bodies, but there is mild conjunctival erythema, especially around the limbus.  The cornea is clear with no blood in the anterior chamber.  The pupil is small, round, and reactive to light.  Visual acuity is normal.  Left eye examination reveals no abnormalities.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient sustained a high-velocity eye injury with persistent pain, tearing, and foreign body sensation. High-velocity injury to the globe carries a significant risk of corneal abrasion and open globe laceration (OGL). A large OGL may present with globe deformity, extrusion of vitreous or iris, or visible entry wound. However, smaller lacerations and abrasions may not be visible on routine inspection. Depending on the mechanism of injury, small particulate matter (eg, metal shards, glass fragments) can occasionally penetrate the globe, leading to a retained foreign body. Further assessment of ocular injury can be obtained with fluorescein drops; as aqueous humor drains through an OGL site, fluorescein may be seen streaming away from the site or clear fluid may be seen flowing through the fluorescein. In the case of corneal abrasion, fluorescein instillation in the eye preferentially stains the corneal defect and appears yellow (an ophthalmoscope with a cobalt blue filter can facilitate visualization if needed). (Choice A) Saline irrigation can be used to clear a superficial foreign body but should not be performed unless OGL has been ruled out and a foreign body identified. (Choice B) CT scan is used to diagnose orbital fractures, which commonly cause diplopia, pain on lateral gaze, ecchymosis, stepoff, or crepitus, none of which are seen in this patient. CT scan is unlikely to identify a corneal abrasion, and fluorescein staining should be performed first. (Choice D) Ocular tonometry is used primarily to identify elevated intraocular pressure associated with glaucoma. If there is concern for OGL, tonometry is typically avoided as it can cause further extrusion of aqueous and vitreous humor. (Choice E) Ocular glucocorticoids are used for certain inflammatory conditions (eg, uveitis) but would likely slow healing in a patient with a high-velocity injury and may predispose to infection or corneal perforation. Educational objective: High-velocity injury to the globe can lead to corneal abrasion or open globe laceration (OGL). Small injuries may not be visible on routine inspection, but further assessment can be obtained with fluorescein instillation. In OGL, fluorescein may reveal extrusion of fluid through the laceration; in corneal abrasion, fluorescein stains the corneal defect and appears yellow.

A 26-Year-Old, Previously Healthy Man Comes to the Emergency Department