When Sight Is On the Line: Three Steps for EMS Care of Eye Injuries

Introduction

Over two million eye injuries occur annually in the U.S., resulting in approximately 300,000 emergency department visits and costing at least $300 million.^1-3 In fact, ocular trauma ranks second only to cataracts as a cause of visual impairment.⁴ The eye is “extremely intolerant of injury”^5,6 and vision loss is a devastating, often preventable outcome.

Moreover, many eye injuries are extremely time-sensitive. Nonetheless, major EMS/trauma textbooks, EMS model guidelines, and standardized curricula devote little space to the topic.^7,8 Despite limited equipment and capabilities, EMS clinicians can help minimize injury progression and save sight through: proper assessment; immediate, evidence-based care; and triage to an appropriate facility.

This article highlights several common, important mechanisms and introduces a new, three-step algorithm for the EMS approach to eye injuries.

EMS Approach to Eye Injuries

Field Evaluation

While the workplace accounts for almost 50% of documented eye injuries,^1,9 a high index of suspicion should be maintained in many settings and scenarios, such as:

• Industrial, workplace, household, and recreational settings, especially with exposure to cleaning chemicals
• Direct facial & eye trauma
• Traumatic brain injury (TBI)
• Blast injury
• Compressive blunt force trauma (can cause globe rupture)
• Thermal burns, especially to the face
• Metal on metal mechanisms (fragments can penetrate without obvious physical findings)
• Multisystem trauma
• Unconscious patient who cannot report vision disturbance^{(adapted from 2,5,6,10)}

As always, scene and rescuer safety, with appropriate personal protective equipment (PPE), come first, especially when chemical exposure is suspected. Then, the patient’s immediate life threats should be addressed, even if the eye injury is obvious, severe and distracting (Figure 1).

Once immediate life threats have been ruled out or addressed, attention can be directed to eye injuries. Presenting signs and symptoms of eye injuries are described in detail elsewhere.¹² And while the full degree of injury is determined only by a complete ocular examination in the emergency department, EMS clinicians can and should screen for, treat, and triage many of the most urgent and vision-threatening injuries while providing vital adjunct care.

To guide this process, we have developed a three-step EMS screening tool, adapting elements from a similar decision tool for primary care physicians¹³ and from a military medicine “ABC” mnemonic.¹⁴ The unique flowchart in Figure 2 illustrates this stepwise, structured, EMS-focused approach.

Assessing both eyes (to avoid missed injury), the three basic questions – in order of urgency – are:

1. Is a CHEMICAL eye exposure present or suspected?
2. Is an OPEN GLOBE injury present or suspected?
3. Is another, potentially VISION-THREATENING injury, especially ORBITAL COMPARTMENT SYNDROME (OCS), present or suspected?

If the answer is “YES” to any question, the flowchart provides fundamental EMS care and triage guidelines for each major injury category.

Vision-specific clinical assessment includes at least four basic steps, the procedural details of which are reviewed elsewhere:¹⁵

1. Gross Visual Acuity (VA),^2,5,6 preferably with Visual Field testing in all 4 quadrants^2,16
2. Pupils (size, shape, reactivity)^17,18
3. Extra-Ocular Motility (EOM), including patient report of double vision during testing^2,19-22
4. Sensation (bilateral light touch and pinprick over the forehead, cheeks, sides of the nose, and upper teeth)^21,23

The timing and – indeed – the feasibility of each assessment step will vary depending on field conditions and patient stability. The assessments are, however, important, both for patient care and for medical-legal purposes. For example, the initial post-injury VA may be the best predictor of final visual outcome.^5,6,24 Abnormal or asymmetric eye motility, double vision and/or decreased sensation over the ipsilateral cheek/side of the nose/upper teeth may indicate the presence of an orbital floor “blowout” fracture with muscle/nerve entrapment. This is another example of a highly-time sensitive injury which may not be readily obvious on initial exam.^2,25

General and Adjunctive Treatment

In addition to standard, evidence-based trauma care, when an eye injury is known or suspected, it is important to:

• Keep the patient NPO
• Elevate the head 15-30° (except during eye irrigation)
• Treat pain with parenteral analgesics (avoid aspirin or NSAIDs)
• Aggressively treat nausea and prevent vomiting with parenteral antiemetics
• Consider topical ophthalmic anesthetics, if available and if indicated:
  • For chemical exposures, they are recommended to improve patient comfort during irrigation
  • For minor, mechanical eye injuries (such as corneal abrasions) they are not harmful, but there is little direct evidence to support their routine use²⁶ and the decision to use these medications is best reserved for ED professionals after a complete eye examination
  • For a known or suspected open globe injury, they are absolutely contraindicated.

The Three Steps For EMS Care Of Eye Injuries

Step 1: Is There A Chemical Exposure? “Immediately Irrigate and Expedite”

Chemical exposures are the #1 TIME-SENSITIVE OCULAR INJURY,^2,5,6 a very real vision threat, and the number one priority in the emergency assessment and treatment of eye injuries. Details for all possible caustic chemical exposures are beyond the scope of this article, but comprehensive, web-based resources are available for real-time consultation.²⁷ Acids and (especially) alkalis deserve emphasis because of their widespread use and the rapid, severe damage they can cause.^28,29 Common examples of acids, alkalis, their pH and common sources are listed in Figures 3 and 4.

Alkali injury tends to be more severe because it causes rapid, deep, liquefactive necrosis, versus the more superficial coagulative necrosis associated with acid exposure. Hydrofluoric acid (HF) (found in heavy duty household, porcelain, automotive and masonry cleaners; and in glass etching products), however, is unique because it behaves more like an alkali (causing rapid, deep necrosis). HF can also cause systemic toxicity (such as hypocalcemia, seizures, and cardiac dysrhythmias) with significant dermal or respiratory exposure.^2,31

After respiratory involvement has been addressed, emergency management of eye exposures to acids, alkalis, crowd-control agents and other caustic chemicals entails “IMMEDIATE IRRIGATION & EXPEDITED TRANSPORT.” This is crucial as the eventual visual prognosis depends most on the time interval to initial irrigation:²⁸

• Remove patient from the source:
  • Consider need for dermal decontamination
• Defer detailed VA, pupillary, motility and sensation examination
• Position the patient supine and irrigate BOTH eyes continuously with AT LEAST 2 liters of fluid (“any non-toxic liquid”, either isotonic crystalloid, sterile water or cool tap water) (5,6, 28):
  • MUST begin IMMEDIATELY, on-scene, and continue en route:
    • Minimum 2-3 hours of continuous irrigation for alkali burns
  • If pH paper is available, check ocular pH both before and after irrigation, but do NOT delay irrigation:
    • Target pH: 7.0 – 7.5
    • Improvisation: cut off all but the bottom (pH) indicator of a urine dipstick²
  • Do NOT use acidic or alkaline fluid to attempt to “neutralize” pH²⁸
  • Remove contact lenses, if possible (irrigation may facilitate this)
  • Up to 20 liters may be needed^2,5,6,28
  • If a Morgan Lens® (scleral lens)³² is available, a topical ophthalmic anesthetic (such as proparacaine or tetracaine) is recommended to improve patient comfort, but should NOT delay irrigation:^5,6,7,28,33
    • If ophthalmic anesthetic is unavailable, consider adding 100 mg (10 mL) of preservative-free, 2% “cardiac” lidocaine to each liter, but do NOT delay irrigation³⁴
  • If a Morgan lens® is unavailable, nasal cannula oxygen tubing can be connected to standard IV tubing using an adapter or a 3-way stopcock^5-7,35,36
  • Physical restraint or procedural sedation may be needed for patients who cannot cooperate, such as young children²⁹
  • EXCEPTIONS to IMMEDIATE WATER IRRIGATION:²⁹
    • Dry lime (“quicklime”, calcium oxide) – brush off dry particles BEFORE irrigating:
      • Calcium oxide reacts with water to form an extremely strong alkali
    • Wet plaster/cement – swab eyes to remove visible material, if possible, BEFORE direct, manual irrigation:
      • These materials are likely to leave retained material
    • Phenol – gently wipe away gross material with very wet, water-soaked gauze:
      • Complete removal requires a solvent unavailable to EMS
  • NEVER use water to irrigate for elemental metals, e.g., sodium, potassium or magnesium:²⁹
    • These combust or produce toxic by-products when exposed to water
• Obtain event history, especially chemical type, SDS (Safety Data Sheet), injury timing, use of eye protection, and first aid administered, especially if/when irrigation was started
• Keep NPO and parenterally treat pain and nausea/vomiting:
  • High-dose ketamine (2-5 mg/kg) is controversial due to possible risk of elevating intraocular pressure and causing nystagmus,³⁷ but lower, analgesic doses (0.1-0.4 mg/kg) are considered safe
• Expedite transport to an appropriate ED, with the chemical container/packaging/SDS or other available documentation:
  • Crowd control agents are typically fast onset-fast resolution, especially with prompt irrigation. Persistent signs and symptoms 30 minutes or more after exposure warrant EMS transport to an appropriate ED to exclude injury.

Special consideration: For hydrofluoric acid (HF) exposure with associated dermal or respiratory exposure, cardiac dysrhythmias are common. In addition to eye irrigation, continuous ECG monitoring and treatment of the “double danger” of dysrhythmias will be needed.³⁸

Other unique features of HF exposure include:

• Delayed symptom onset, even as tissue damage progresses rapidly
• Severe, “out of proportion” pain, requiring parenteral treatment
• First aid treatment with topical calcium gluconate gel and calcium gluconate eye wash solution necessitates immediate EMS transport.

Step 2: Is There An Open Globe? “Shield and Ship”

While many blunt, penetrating and blast eye injuries will be obvious on routine physical examination, this is not always the case. The number two priority of EMS assessment, therefore, is to consider the possibility of an open globe injury. This may be caused by penetrating injury, blunt trauma (even a minor blow or fall), or blast injury (primary blast injury or fragmentation).

Detailed EMS management of a known or suspected open globe entails a “SHIELD & SHIP” approach adopted from military medicine.^{2,5,6,14,39-41} Key concepts include:

• Do not manipulate the eye or surrounding structures
• Restrict ambulation and movement
• Assess & document bilateral gross Visual Acuity (VA), if possible
• Elevate the patient’s head 15-30°
• Do NOT attempt to remove objects impaled or embedded in the injured eye
• Do NOT put anything into the injured eye, including topical ophthalmic anesthetics
• SHIELD (NOT “patch”) the injured eye(s) and avoid any pressure on the eye:
  • Nothing should touch the injured eye
  • Nothing should be placed under the shield
  • Tape should be applied only to the cheek and forehead, NOT to the orbit or eye
  • If a Fox eye shield or other commercial device is unavailable, a disposable drinking cup, eyeglasses, or protective eyewear  can be used^2,5,6
• Consider shielding or patching the uninjured eye, to reduce eye movements
• Keep NPO and parenterally treat pain and nausea/vomiting:
  • Retching, vomiting, coughing, straining or any Valsalva maneuver can increase intraocular pressure, leading to extrusion of ocular contents and worsening injury^2,5,6,39,41
  • Ketamine guidance follows that described above under “Chemical Injuries”
• Expedite transport to an appropriate ED.

Step 3: Is There Another Potentially Vision-Threatening Injury? “Shield and Ship”

If neither chemical injury nor open globe injury is suspected, the more detailed, four-step field evaluation described above can be performed, in order to screen for other potentially vision-threatening and/or time-sensitive injuries. Orbital Compartment Syndrome (OCS), like chemical eye injury, is another extremely time-sensitive eye injury. OCS is characterized by a rapid increase in intraorbital pressure and may occur in both trauma and non-trauma settings. Findings may include: proptosis (“bulging” eye), pain, “rock hard” eyelids, decreased vision, decreased EOM motility, and an abnormal pupillary exam.⁴² OCS is a true ocular emergency – permanent vision loss is likely if treatment to relieve the increased intraorbital pressure is delayed past 90-120 minutes.^15,43,44

Finally, field evaluation may suggest the possibility of less immediately time-sensitive, vision-threatening injuries, such as hyphema (blood in the anterior chamber,)⁴⁵ corneal foreign body,^5,6,46,47 corneal bee sting,^48-50 eyelid laceration,^5,6 or other diagnosis. In this case, the patient should be managed according to “shield and ship” guidelines, with immediate EMS transport for a full ED ocular evaluation, care and follow-up.

Thermal, Laser & Radiation

Thermal: Respiratory involvement & other trauma (especially life threats) must be considered. Patients should be treated according to standard burn protocols/guidelines. Excessive fluid resuscitation can contribute to OCS.

Laser: Blinking usually prevents or decrease serious eye injury, but other health effects are possible.

Radiation: Ultraviolet (UV) radiation eye injury (e.g., through welding, sun lamps, and tanning beds) is not rare. UV injuries spiked during the COVID-19 pandemic and remain a vision threat, due to the use of UV wands and other “sterilizing” devices.⁵¹

Special Considerations

Complex & Combined Mechanisms

Some eye injuries involve combined chemical, blunt, penetrating and/or thermal mechanisms. Notable examples include injuries from fireworks^52,53 and airbags (especially when the airbag ruptures).⁵⁴ The decision to “irrigate and expedite” or to “shield and ship” must be taken on a case-by-case basis, perhaps in consultation with online medical control.

Pediatric & Geriatric

Many excellent reviews provide detailed information about pediatric eye injuries.⁵⁵ Notably, non-accidental trauma must be considered in this age group, especially if the history does not align with the physical exam. Periorbital ecchymosis (“raccoon eyes”) and/or lid edema, subconjunctival hemorrhage, and orbital fractures may be present in abusive head trauma (AHT), although the absence of external eye findings does not exclude this diagnosis.^56-59

“Red eye” (or “pink eye”) is a descriptive term, not a diagnosis. In addition to infectious and inflammatory conditions, foreign bodies, trauma and chemical injury must also be considered in the red eye differential diagnosis.⁶⁰ And, in preschoolers/toddlers, laundry detergent pods are a very common cause of chemical eye injury requiring irrigation.⁶¹

For geriatric patients, ground level falls are the number one cause of open globe injury,³⁹ especially in patients with prior eye surgery. It is therefore imperative to examine elderly fall patients to exclude this time-sensitive, vision-threatening injury. Non-accidental trauma must also be considered in this age group, especially in the context of suspicious injury patterns.^{62, 63}

Documentation

Key elements of history documentation include: general history, ocular history (if possible), mechanism of injury, TIMING of injury, use of eye protection, witnessed vs. unwitnessed, First Aid prior to EMS arrival; and tetanus history.

Key elements of EMS care documentation include:

• Chemical:  chemical type; timing & volume of irrigation; pH before and after irrigation (if available); treatment for pain and nausea/vomiting
• Blunt, penetrating & blast: gross VA (if feasible); shielding (not “patching”) of injured eyes(s); treatment of pain and N/V; consideration of possible open globe, Orbital Compartment Syndrome (OCS), orbital blowout fracture, hyphema and other vision-threatening injuries.

If any elements of the four-step field evaluation (bilateral VA, pupils, EOM and cheek/forehead sensation) are omitted, the rationale for this omission should be documented. With chemical eye injuries, for example, it would be appropriate to document deferral of VA, pupillary exam, EOM testing and facial sensation in order to begin immediate irrigation.

Triage Considerations & the Continuum of Care

Time is of the essence, especially for chemical exposures, OCS and possible open globe injuries. Destination decision-making, as always, will depend on EMS agency clinical care guidelines, local hospital capabilities and other case-specific factors.

Because of the eyes’ intolerance to injury, the devastating implications of possible vision loss, and the limitations of EMS eye injury assessment and treatment, all patients with even seemingly minor-appearing eye injuries should be strongly encouraged to accept EMS transport for full ED evaluation, definitive care and specialist referral. Refusal to accept EMS transport should be meticulously documented according to local guidelines and protocols.

Conclusion

The EMS approach to assessment, care and triage of eye injuries entails three steps. After addressing immediate life threats, Step 1 is to evaluate for chemical exposure and, if present or suspected, immediately “irrigate and expedite” EMS transport. Step 2 is to assess for a possible open globe and, if present or suspected, use a “shield and ship” approach. Step 3 uses a more detailed evaluation to detect orbital compartment syndrome or other time-sensitive, vision-threatening injury. When present or suspected, a similar “shield and ship” approach should be used. These three steps will help EMS clinicians prevent injury progression and subsequent vision loss.

The authors gratefully acknowledge Vijay Khetpal, MD, for expert manuscript review.

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