25: Eye Injuries
Cognitive Objectives
(1 of 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
(2 of 2)
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.
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.
Anatomy of the Eye
Eye Injuries
• Can produce severe
complications
• Examine pupil for shape
and reaction.
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.
• 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.
You are the provider
• 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.
You are the provider continued (1 of
2)
• What precautions would you take on this scene?
• What was the mechanism of injury?
You are the provider
continued (2 of 2)
Scene Size-up
• Observe for hazards.
• Request additional help early.
• 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.
You are the provider continued (1
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?
You are the provider continued
(2 of 2)
Initial Assessment
• Eye injuries can cause permanent disability.
• Can create great anxiety
• Approach patient calmly.
Airway and Breathing
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•
•
•
•
Consider immobilization.
Eye injuries can affect airway.
Check for clear, symmetric breath sounds.
Provide high-flow oxygen.
Palpate chest for DCAP-BTLS.
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
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.
•
•
•
•
•
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.
You are the provider continued (1 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.
You are the provider
continued (2 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?
You are the provider continued (3
of 3)
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.
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.
Baseline Vital Signs/SAMPLE
History
• Baseline vital signs
– Monitor for shock.
• SAMPLE history
– Perform as usual; obtain from responsive patient
or family/bystanders.
Interventions
• Provide complete spinal immobilization.
• Be cautious in bandaging.
• 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.
You are the provider continued
Detailed Physical Exam
• Perform if patient is stable and time allows.
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.
Foreign Objects in the Eye
• For small foreign
objects lying on the
surface of the eye,
irrigate with saline.
• Flush from the nose
outward.
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.
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.
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.
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.
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.
Irrigating the Eye
Thermal Burns
• For thermal burns, cover both eyes with a moist,
sterile dressing.
• Transport patient to a burn center.
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.
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.
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
Hyphema
• Bleeding in the anterior
chamber of the eye
• May seriously impair
vision
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.
Retinal Detachment
• Often seen in sports injuries
• Produces flashing lights, specks, or floaters in field
of vision
• Needs prompt medical attention
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
Pupil Size and Head Injury
• Variation in pupil size
may indicate a head
injury.
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.
Contact Lens Removal (1 of 2)
• If absolutely necessary,
remove a hard contact
lens with a small
suction cup, moistening
the end with saline.
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.
Review
1. The globe of the eye is also called the:
A. lens.
B. orbit.
C. retina.
D. eyeball.
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.
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
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.
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.
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.
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.
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.
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.
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.
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).
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.
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.
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.
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.
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.
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.
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.
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
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).
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.