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Eye trauma and chemical injury in the emergency department
A chemical eye injury requires immediate, copious irrigation before any examination; with a suspected open globe, protect the eye with a rigid shield and do not press on it; and retrobulbar haemorrhage with proptosis and falling vision requires a lateral canthotomy within minutes.
Why it matters in the exam
The classic question describes a patient with a splash of cleaning fluid or lime in the eye. The first step is immediate irrigation with water or saline — at least 1–2 litres or 30 minutes — until the eye pH returns to 7–7.5, even before visual acuity is tested. Alkalis are more dangerous than acids because they penetrate deeply.
Open-globe injury is also tested: a teardrop pupil, fluid leak on the Seidel test, low pressure or prolapsing tissue. Cover with a rigid shield (no pressure patch), give antiemetics and analgesia, IV antibiotics and tetanus, obtain CT for a foreign body, and do not instil drops or measure intraocular pressure. A common distractor is trying to remove an impaled foreign body in the emergency department.
Retrobulbar haemorrhage after trauma (orbital compartment syndrome) shows as proptosis, a hard eye, falling vision and a relative afferent pupillary defect; the treatment is lateral canthotomy within about 90 minutes, before imaging. Other common injuries: corneal abrasion (fluorescein, topical antibiotic, no patch and no anaesthetic drops to take home), orbital floor fracture (diplopia on upward gaze, cheek numbness — no forceful nose blowing), and hyphaema (head up 30 degrees, shield, no NSAIDs).
Key points
- Chemical burn — immediate irrigation to pH 7–7.5; alkalis are more dangerous.
- Open globe — rigid shield, IV antibiotics, CT, no pressure and no drops.
- Retrobulbar haemorrhage — lateral canthotomy within about 90 minutes.
- Corneal abrasion — topical antibiotic, no patch and no anaesthetic drops for home.
- Orbital floor fracture — diplopia on upward gaze and cheek numbness.
Summary table
| Injury | Signs | First action | Forbidden |
|---|---|---|---|
| Chemical burn | Pain, redness, white eye when severe | Immediate irrigation to pH 7–7.5 | Neutralising with acid or alkali |
| Open globe | Teardrop pupil, positive Seidel | Rigid shield, IV antibiotics, CT | Pressure on the eye, drops, removing a foreign body |
| Retrobulbar haemorrhage | Proptosis, hard eye, falling vision | Lateral canthotomy within about 90 minutes | Waiting for imaging |
| Corneal abrasion | Pain, foreign-body sensation, fluorescein uptake | Topical antibiotic; contact lens — Pseudomonas cover | Anaesthetic drops for home, patching |
| Orbital floor fracture | Diplopia on upward gaze, cheek numbness | CT, avoid nose blowing | Routine immediate surgery |
| Hyphaema | Layer of blood behind the cornea | Head up 30 degrees, shield, check intraocular pressure | NSAIDs and antiplatelets |
Free exam questions
בן 23 פונה למלר"ד בשל עייפות, כאב בעכוז, דלקת בלחמית בעין שמאל, דיסוריה, חום, ארתריטיס בברך ימין וקוסטוכונדריטיס. שישה שבועות טרם תלונותיו אלו, מתאר אירוע של מחלה אנטראלית עם שלשול דמי, שחלף ספונטנית לאחר מספר ימים. מה האבחנה? (the question as examined, in Hebrew)
- א. Reactive arthritis
- ב. Psoriatic arthritis
- ג. Toxoplasmosis
- ד. Septic arthritis
מה מהבאים מאפיין Normal tension glaucoma ? (the question as examined, in Hebrew)
- א. המחלה גורמת בדרך כלל לפגם מפושט והיקפי בשדה הראייה
- ב. המחלה נפוצה יותר בנוכחות דום נשימה בשינה apnea Sleep
- ג. חשוב להוריד את הלחץ התוך עיני בלפחות 20%
- ד. המחלה נוטה להתקדם מהר יחסית
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Sources
- American Academy of Ophthalmology, Basic and Clinical Science Course: External Disease and Cornea, 2023–2024 — Chemical injuries; Ocular trauma
- Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9th edition (2020) — Eye emergencies
- Royal College of Ophthalmologists, Ophthalmic Services Guidance: Emergency eye care, 2020 — Chemical injury and open globe
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.