Eye injuries can be very graphic and make you cringe when you see them. But eye injuries and proper treatment is not always talked about in class, nor are they always reviewed. In the case of traumatic eye injuries, the treatment done in the field often has a direct effect on outcome. That’s why our lesson is so important – what we do matters, especially for the patient with an eye injury. So, lets get started. . .

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A study done by the American Academy of Ophthalmology and the American Society of Ocular Trauma gave us these statistics. The fact that more men than women suffer eye injuries is no surprise but the relatively high incidence of eye injuries that occur in the home may come as a bit of a surprise. But think about it. . .we do projects, wood working, home repairs, yardwork, cleaning and cooking; all of which can contribute to eye injury. Most of us, especially when we’re at home, don’t think about wearing protective eyewear when we do yard work, clean or cook. About a third of the injuries in the home occurred in the living areas such as the kitchen, bedroom, bathroom, living or family room. But when we think about all the things we do, its surprising that more injury does not occur.

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The injuries we will explore in this session are listed above. These are only a list of more common injuries and some are time sensitive, meaning that the quicker you can get the patient with these injuries to the hospital the better. Other injuries require patching one eye, other require both eyes and some require that the patient be sitting up while others require that the patient be lying flat. Before we get into the specifics of types of injury, lets look at A & P of the eyes. That will help explain why some eye injuries are so serious, why some treatments can make such a difference and why those treatments are so important. The eye and process of seeing is fairly complex, so to simplify the information, we’ll look at three main aspects: First we’ll look at the gross anatomy or structure of the eye, then we’ll look at the process of seeing and finally we’ll examine the protective reflexes of the eye – and you wondered why putting eye drops in was so hard for some people. . .

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The eye is a globe, about 1 inch in diameter. It is surrounded by a relatively tough outer layer known as the sclera or the “white” of the eye. Near the front of the eye, the tissue that forms a clear dome over the iris and pupil, is the cornea. The sclera is covered by a thin mucous membrane called the conjunctiva which runs to the end of the cornea and covers the moist back surface of the eye lids. The iris is the colored part of the eye that changes shape to regulate the size of the pupil and thus the amount of light that strikes the retina. Behind the iris is the lens which divides the eye into two chambers, the anterior and posterior chamber. The anterior chamber is filled with a watery fluid called the aqueous humor. The aqueous humor is produced between the iris and the lens. It slowly flows through the pupil into the front chamber, then drains out of the eyeball through outflow channels located where the iris meets the cornea. If the outflow channels become obstructed, pressure will build in the anterior chamber. The condition of increased in pressure in the anterior chamber is called glaucoma. If unrelieved, increased pressure may blow out the lens into the posterior chamber, causing blindness. The lens is held in place by suspensory ligaments. These ligaments and small muscles (called ciliary muscles) adjust the shape of the lens. By adjusting the shape, the lens focuses light onto the retina. The lens becomes thicker to focus on nearby objects and thinner to focus on distant objects. The posterior chamber is filled with a gel-like fluid called the vitreous humor, about 4 ml in an adult. It is gel-like in consistency due to the collagen and hyaluronic acid that

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it contains. Together the pressure generated by the aqueous fluid and vitreous gel fills out the eyeball and helps maintain its shape. The back wall of the posterior chamber is lined with specialized photo-sensitive tissue called the retina. The most sensitive part of the retina is a small area called the macula, which has millions of tightly packed photoreceptors. The high density of the photoreceptors in the macula makes the visual image detailed. Each photoreceptor is linked to a nerve fiber. The nerve fibers from the photoreceptors are bundled together to form the optic nerve. The optic disk, the first part of the optic nerve, is at the back of the eye. The photoreceptors in the retina convert the image into electrical impulses which are carried to the occipital lobe by the optic nerve.

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The eye sits in a boney chamber called the orbit. Seven bones make up the orbit. The frontal bone forms the top; zygoma on the lateral side; the ethmoid, sphenoid, and palatine forms the back of the orbit while the maxilla forms the floor. The lacrimal bones form the medial side . The bones in the back of the orbit are thin and fragile. The maxillary bone thins as it extends back. This makes the maxilla vulnerable to fracture from blunt trauma. Slightly off center in the back of the eye socket, there is a small hole. The optic nerve passes through this hole to innervate the eye.

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Eye movement is controlled by six muscles, in three pairs. Note that there are two muscles, one on the lateral top and the other on the lateral bottom, that are attached at right angles to the globe and are slightly off center. These are the muscles that allow you to look at an angle and “roll” your eyes. Cranial nerves III (Optic), IV (Trochlear) and V (Trigeminal) control the muscles of the eye. Normally the eyes function as a unit, in tandem with each other. That means that the three pairs of muscles work in conjunction with each other. Normally, when one eye looks to the left, the other will also. This is true for any direction the eyes choose to look. There are, however, those people who can voluntarily move their eyes independently of one another. This is an acquired skill. Occasionally the muscles of the eye(s) may become impaired, either by a congenital condition, toxins, medications or fatigue. Impairment may manifest itself by uncoordinated movement (dysconjugate gaze), spasm (nystagmus or strabismus), or weak/absent movement (weak or wandering eye). Note that the muscles are contained within the boney chamber and attach to the sclera. This is why, if you see blood in the white or sclera of the eye, it got there by following the muscle sheath and leaking under the muscle attachment. Note that there is room for the sympathetic nerve plexus and three cranial nerves that control the eye: CN III (Optic), IV (Trochlear), V (Trigeminal). Those nerves and the origin of the muscles all come from the same narrow passageway at the rear of the boney orbit.

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The eye lids cover the portion of the eye exposed to the atmosphere and prevent the eye from drying. The muscle we call the “eye lids” is the orbicularis oculi. It is shaped like a ring and is a type of sphincter muscle which keeps body openings closed when constricted, and open when relaxed. The muscle controls the involuntary closure of the eye (such as blinking), voluntary closure of the lid (such as reactions to wind or bright light), and houses the lacrimal gland which secretes tears. Every time the eye closes, the muscle presses on the lacrimal gland, pushing out tears. As the eye opens again, the orbicularis oculi releases the pressure on the tear gland, which draws moisture back into the sac. More on tears later. The lacrimal glands lie just under the upper lateral portion of the orbit, under the frontal bone. The primary function of the lacrimal gland is to secrete tears. Along with the lacrimal glands, fluid comes from two other places; the glands that are at the edge of the eye lids and the conjunctiva itself. All these fluids have an antiseptic property. Together these fluids provide: a hydrophobic barrier that prevents tears from spilling onto the cheeks; control of infectious agents; osmotic regulation; and protection of the cornea. The eyelids themselves help even the distribution of the tear film. Once produced, the watery fluid drains through the lacrimal duct (tear duct) which is on the inside of the eye, next to the nose. This is why the nose “runs” when the eyes water. This is also why when a person has a nose bleed, if the nostrils are occluded but the bleeding continues, blood may back up through the tear duct causing blood to appear in one or the other eye.

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Speaking of tears, there are three main reasons the eyes water. Basal tears lubricate the eye and help to keep it clear of dust; reflex tears help to wash out irritants that may have come into contact with the eye; and psychic tears or crying/weeping, result in increased lacrimation due to strong emotional response. Cranial nerve V (Trigeminal) is the sensory pathway for tear reflexes and CN VII (Facial) also can stimulate tear production. Cranial nerves, CN V and VII also have an effect on the eyelid muscle function. Crying as an emotional reaction is considered by many to be a uniquely human phenomenon. However, some studies suggest that elephants, gorillas, and camels may cry.

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The ability to see is a remarkable sense. Cranial nerve III is the optic nerve and is responsible for pupillary size as well as the sense of seeing. Nerve signals travel from each eye along the corresponding optic nerve and other nerve fibers (called the visual pathway) to the back of the brain where vision is sensed and interpreted. The two optic nerves meet at the optic chiasm which is an area behind the eyes immediately in front of the pituitary gland and just below the front portion of the brain (cerebrum) There, the optic nerve from each eye divides, and half of the nerve fibers from each side cross to the other side and continue to the back of the brain, ending in the occipital lobe. Thus, the right side of the brain receives the information through both optic nerves for the left field of vision, and the left side of the brain receives information through both optic nerves for the R field of vision. The middle of these fields of vision overlaps. It is seen by both eyes (called binocular vision). An object is seen from slightly different angles by each eye so the information the brain receives from each eye is different, although it overlaps. The occipital lobe of the brain integrates the information to produce a complete picture. Damage to the optic nerve at any point is often reflected in changes in vision. The diagram on the right shows the changes in vision as they site of injury changes.

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You are born with your eyes fully formed, fully developed and at the same size they will be your entire life. The eye itself has the greatest concentration of capillary beds than any other tissue in the body. However, the cornea is the only living tissue with no blood supply. The cornea is the most sensitive body part, with the ability to detect two objects only 1/1,000 of a millimeter apart. Your eyes are the only part of the human body that can function at 100% ability at any moment, day or night, without rest. However, your eyelids and the external muscles of your eyes need rest, the lubrication of your eyes requires replenishment, but your eyes themselves never need rest. No one knows why, but your eyes have a dependent and symbiotic relationship to one another. The important part of this relationship is the care that must be taken to absolutely avoid further injury. When one eye is adversely affected, the tendency is for the other eye to acquire the same problem. This is not true for problems such as uncomplicated foreign body irritation. However, if the inflammation continues beyond the normal time frame for healing (24-48 hrs), there is a high risk that the unaffected eye will manifest signs of inflammation as well. This property can result in major treats to vision if the eyes are neglected or mistreated. Your eyelashes, important for keeping dust and airborne particles out of your eyes, are replaced about every 5 months. It is impossible to keep your eyes open when you sneeze – probably to prevent extrusion of the globe during the sneeze.

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The condition of anisocoria has traditionally been used to describe the congenital condition of unequal pupils. When a congenital condition occurs, the pupils may still react but are still unequal. However, acquired unequal pupils may also be referred to as anisocoria. In this case, an injury or surgery on the eye is the usual cause of the unequal pupil. In these cases of acquired anisocoria, usually the pupil is not reactive. The patient may or may not be able to see out of the effected eye depending on the cause. Unequal pupils may be temporary, for instance when albuterol/atrovent is nebulized by mask and the fit around the nose leaks on one side. The eye on that side will be temporarily effected by the atrovent. The rule of thumb is, if a patient is talking and making sense in the presence of unequal pupils, the problem is with the eye itself, not with the brain or pressure on the optic nerve.

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The first condition we’ll talk about is a flash burn. Flash burns are due to intense light, usually the ultraviolet part of the light without appropriate protection. One common natural cause is reflected light, reflected off water or snow. Occupational causes include welder’s arc, photographer’s flood lamps, light of copy machines, and halogen desk lamps. Depending on the source, both eyes are usually effected but sometimes one eye is more effected than the other.

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By the time someone realizes that a problem exists, its too late – the onset of pain is gradual but steady and can be intense. The reaction of the patient is to keep their eyes closed. If forced to open eyes, photophobia is present and headache is a common result. Excessive tearing with c/o blurred vision are also typical. Because the cornea has suffered its own version of “sun burn”, the sensation of the eye blinking is highly irritating to the point where the patient thinks a foreign body is present.

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Tetracaine is very helpful for pain management. Ensure that no contraindication to tetracaine exists (an open injury to the eye). Tetracaine will only manage pain from the eyes, so assessing for other c/o pain is appropriate, especially if the patient was engaging in an outdoor sport. Because the patient will have bilateral eye patching, they will essentially be blind so make sure you orient them to what is going on and give them something to hold on to (like the arm rests), particularly prior to moving the stretcher. You will run into common home remedies and some are very helpful. One is a grated raw potato in cheese cloth or muslin, put over the eyes. The starch in the potato is very soothing to the eye and helps with healing. Regardless of the home remedy used, remove the treatment, gently irrigate the eye(s) if necessary, apply 1-2 gtts tetracaine, patch bilaterally, and transport.

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One of the most common injuries to the eye is a corneal abrasion. Corneal abrasions can be caused by drying of the cornea or foreign bodies. If a patient does not completely close an eyelid for longer than several minutes, the area of the cornea exposed will dry out, destroying the outer layer of the cornea which causes an “abrasion”. A more common cause is an eyelash. Any foreign body, when scraped across the cornea or conjunctiva by the eyelid, has the tendency to create an abrasion. An abrasion is highly irritating, causes extreme tearing and is extremely painful until it heals. The extreme tearing is the body’s method of flushing out the irritant. Most abrasions will heal on their own if the area is small enough, is kept covered by the eyelid for 12- 24 hours and it doesn’t get infected. Abrasions cannot be seen by the naked eye unless they are very large. Most are identified in the Emergency Department by a dye called floresceine which stains the abrasion. Picture A and B are examples of corneal abrasions stained by floresceine. Sometimes the foreign body gets “stuck” or fixed to the cornea or conjunctiva. Foreign bodies of wood or metal commonly get stuck. Metal foreign bodies will often leave a rust ring which may also serves as an irritant. No matter what the foreign body, the eye will react almost instantly with the sensation of pain. Pain is caused by the eyelid blinking which scrapes across the abrasion or the foreign body if its still present. The eye will tear, blood vessels become prominent and the conjunctiva appears “blood-shot” or very red. Vision often is blurred due to the copious tears. C – This is a view of a metal foreign body on the edge of the cornea on the iris.

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Metal is easier to see with the naked eye than wood, dust or plastic. Occasionally the foreign body has enough substance or force to penetrate one or both chambers. Whenever a the iris is misshapen and trauma is involved, suspect the possibility of a corresponding ruptured globe. More on ruptured globes later.

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Treatment of foreign bodies in the eye differ according to whether penetration of the chamber(s) is likely. If the foreign body is small and no chamber penetration is likely, tetracaine is indicated to reduce the pain. However, when the pain is gone, the patient still has an urge to rub their eye. This will increase the potential for or worsen an abrasion to the cornea. So application of tetracaine should be followed by patching the effected eye. This can be done by taking a 4x4, folding it in half and taping it across the effected eye. A little pressure from the 4x4 will help keep the eyelid closed. Tell the patient NOT to rub or touch the effected eye. If, however, chamber penetration is likely (identified by visualizing the object, presence of a cloudy substance across the iris, or a misshapen pupil), tetracaine is NOT indicated. More on this later.

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Another common injury to the eye occurs when blunt trauma is the cause. Blunt trauma often results in bruising to the effected eye. Sometimes the bruising is due to an associated nasal bone fracture where blood drains into the eyelid of one or both eyes. Whether or not the nasal bone is broken, ruptured capillary beds cause blood to accumulate in the eyelid. As a result, the eyelid becomes swollen and discolored. Sometimes the swelling extends to the tear duct, preventing normal fluid drainage causing the eye to tear. Sometimes the blunt force is sufficient enough to cause blood to collect under the conjunctiva. Treatment of a “black eye” is a cold compress to manage pain and swelling. However, it is not uncommon for blunt trauma to the eye to have an associated fracture to the orbit of the eye or have enough trauma that there is blood in the anterior chamber. Blood in the anterior chamber is called a “hyphema”. More on that coming.

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Blood collecting under the conjunctiva is termed subconjunctival hemorrhage. The prefix, “sub” refers to under and “conjunctival” refers to the conjunctiva. This can occur from blood leaking down under the tissues that create the conjunctiva. It may take as long as 48 hours for subconjunctival hemorrhage to occur. Usually the appearance of a subconjunctival hemorrhage is not serious, just unsightly. It may take 6-8 weeks for subconjunctival blood to resolve.

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A fracture to the orbit of the eye may be felt if the boney rim of the eye is palpated. This may or may not be done in the field. Sometimes the fracture is in the bones at the back of the orbit. In that case, it cannot be palpated. If the fracture extends into the orbit, one of the muscles of the eye may get caught in the fracture site resulting in a fixed gaze in one position.

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A – In this picture the patient was asked to look at the examiner. Aside from the obvious soft tissue bruising, you will also note the presence of subconjunctival hemorrhage in the injured eye, lateral to the iris of the right eye. B – In this picture the patient was asked to look up. As you can see, the right eye is unable to move up because the muscle is caught in the fracture site. Assessing normal eye movement is a simple technique that will quickly identify presence of an orbital fracture. Not all fractures however, will trap a muscle.

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For any bruising, cold packs will help to control bleeding/swelling. Avoid putting the cold pack on bare skin, use a washcloth or 4x4 to protect the skin. In many patients, dysconjugate gaze and the resulting diplopia (double vision versus blurred vision) often result in nausea. Therefore, avoid rapid movement of the eyes or cover the effected eye to control nausea. Because the origin of the nausea is due to a dysfunction of gaze, neither Zofran or Phenergan are very effective. If nausea is present, avoid Phenergan. Phenergan is a sedative and may confuse assessment of mental status. In those cases where nausea is due to another cause, Zofran may be effective and is the drug of choice.

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Hyphema is the term used when blood is present in the anterior chamber. Blood in the anterior chamber is due to blunt trauma either to the head generally or the eye directly. In any case, an associated head injury is likely. A – shows an example of how blood can collect in the anterior chamber. Blood, being liquid, will find a fluid level due to gravity. If the blood does not cover the pupil, the patient may not know they have it. If the fluid does cover the pupil, the patient may c/o “seeing through a brown bottle” or “seeing through a muddy lake”. For the care provider, if the iris of the eyes are blue, the fluid level looks brown and is easy to see. If the iris is brown, however, the fluid level is not so easy to see and the provider must actively look for it. It is important to note the presence of the hyphema because as it collects, it exerts pressure in the chamber. The only structure that has any “give” in the anterior chamber is the lens. If the pressure from the blood reaches a critical level, the pressure can “blow out” the lens into the posterior chamber. That is a very serious condition that can result in loss of sight in that eye. B is an example of minor hyphema in a blue-eyed person. C is an example of major hyphema in a brown-eyed person

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Treatment for hyphema is geared toward reducing pressure in the anterior chamber. This is best done by inhibiting bleeding into the chamber by elevating the head and shoulders (sitting up is the best position) and promoting a calm atmosphere to avoid raising systolic pressure. Do NOT apply an eye patch or an ice pack because any additional pressure to the effected eye may contribute to rupture of the lens. If the patient is on a back board and shock is not an issue, raise the head of the board. It is also very important to prevent any valsalva movement such as vomiting because this increases pressure in the eye. To prevent any nausea or vomiting, administer Zofran is prophylactically.

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Next to chemical burns to the eye, a torn retina, or retinal detachment, is one of the most time critical eye emergencies encountered. There are many causes of a torn retina, and trauma is one of them, especially blunt trauma to the eye from paintball injuries. Both blunt trauma to the eye or to the back of the head, and penetrating trauma can result in retinal detachment. This terms refers to separation of the inner layers of the retina from the retinal epithelium embedded in the choroid. A torn retina cannot be seen by observation of the eye. It is seen by use of an opthalmascope as shown in the picture on the bottom left and what is seen through the microscope that the opthamologist uses in surgery on the bottom right. In the field a torn retina is suspected by the patient’s complaints. The patient may complain of the sensation of flashing lights and a shower of floaters, wavy distortion of objects, and a “curtain” falling across their vision. “Floaters” are from blood escaping from torn retinal blood vessels. Generally, the new onset of floaters associated with flashing lights indicates a retinal tear until proven otherwise.

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Because the mechanism for a torn retina is usually direct trauma to the eye, treatment is confined to the immediate mechanism and any associated injuries. Many times the actual trauma occurred hours before the defect in vision is noted. In those cases, treatment is up to the medic depending upon any other associated signs or symptoms that may be present.

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A ruptured globe is an opthalmologic emergency. If damage extends to the posterior segment of the eye, there is a high frequency of permanent visual loss. A ruptured globe may be caused by direct blunt trauma to the eye or by a severe laceration completely through the sclera or conjunctiva. A penetrating wound may or may not have the foreign body present. The sclera tends to be self-sealing, so observation of a penetrating wound (from flying metal, glass, etc.) may not be readily apparent. However, a laceration of the globe that extends through the sclera or conjunctiva/cornea into the chambers of the eye are at risk for leaking aqueous fluid and/or vitreous gel. Preventing or minimizing loss of these fluids is critical to preserving the ability to see. Therefore, it is very important to recognize when a penetrating wound is likely. When looking at the eye, if the portion of the eyelid directly over the eye is lacerated or tissue is exposed at the lacrimal duct, there is a high suspicion that the globe is also lacerated. If this is the case, and the patient keeps the eyelid closed, it is NOT necessary to open the eyelid to examine the eye itself. Keeping the eyelid closed will help keep the chamber fluids or humors (aqueous and/or vitreous) where they belong. On the other hand, if the patient can open the eyelid, suspect a rupture if the eye itself is misshapen with tissue prolapsing out of an anterior scleral or corneal wound.

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Foreign bodies that actually penetrate the eye, are more serious and can result in several different presentations depending on the mechanism. Any penetrating object into the eye is considered a mechanism for a ruptured globe. A – in this case a small metal wire was being cut and the free end flew into the patient’s eye. You can see the object, which has penetrated one or both chambers, and a cloudy fluid. The cloudy fluid is from the chamber penetrated. You will also note the deformity of the iris itself. This suggests that the lens has been ruptured. B and C – are examples of small penetrating objects that penetrated at the point of the iris joining the conjunctiva. B was a small plastic bead, C was a larger metal object. You’ll note the attachment for the iris has been disrupted, which is very noticeable. This deformity is usually permanent. D – shows evidence of puncture through the conjunctiva and the sclera The more important implication for all these examples is that a foreign body is either in the posterior chamber or has penetrated into the brain. Assessing mental status is important.

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Rupture also occurs when a blunt object impacts the orbit, compressing the globe along the anterior-posterior axis causing an elevation in intraocular pressure to a point that the sclera tears. Ruptures are most common at the sites where the sclera is the thinnest. These areas are behind the boney rim of the orbit and may not be readily apparent. Absence of complaint of pain is not reliable. There aren’t many pain receptors in the back of the eye. There may also be pain from other injuries. Because blunt trauma is involved, a blowout fracture is common so evaluating extraoccular movement for a trapped muscle is appropriate. Other signs/symptoms of a ruptured globe from blunt trauma includes c/o of severely impaired vision (inability to see details, limited sight to light/dark and movement, etc.), observation of a misshapen eye, presence of global subconjunctival hemorrhage with blurred iris, or presence of a tear-drop shaped pupil. A - The tear-drop appearance is noted in the picture above. B - Also note the slight deformity of the iris above the tear-drop pupil.

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In either case, cover both eyes without exerting pressure on the effected eye. Keep the patient still, consider immobilizing the head, elevate the head of the bed or head of the BB and transport. Keeping the head immobilized will help minimize or prevent further leaking of chamber fluids. It is very important to prevent vomiting. Use Zofran prophylactically.

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Severe blunt trauma, usually (but not always) to the back of the head, may result in enucleation (avulsion) of one or both eyes. A & B show the eye eviscerated but the optic nerve is still attached, very stretched, but intact. These are usually dramatic injuries so attention to airway, breathing and circulation, particularly uncontrolled bleeding, are the priority. C shows the rare occasion where the eye has literally been knocked out. As with any other tissue, it must be found and taken with the patient to the hospital. It’s not that the eye will be re-implanted, but rather, the avulsed eye is helpful for the surgeon to determine probable condition of the socket.

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Even though the optic nerve may have been irreparably stretched, an attempt to replace the eye in the socket is done surgically. Every attempt is made to aid in reattachment of the muscles of the socket to the eye so normal eye movement is possible, even if normal vision is not. Because the eye is not protected by the eyelid, it is vulnerable to drying. So, to help the success of reattachment, the eye must be kept moist (dried tissue will cause tissue death and/or infection); any pressure on the effected eye must be avoided (this contributes to ischemia of the ocular tissue); and eye movement prevented. So, use a moist (NOT dripping wet) 4x4 over the enucleated eye, cover the effected eye with a cone to prevent pressure and bandage both eyes. Keep the patient still with the patient’s head immobilized. Because a corresponding head injury is usually present, the patient will be on a backboard. Keep the patient still and the atmosphere quiet. Avoid vomiting and use Zofran.

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Specific assessment for the eye includes visualizing for normal appearance, presence of a FB, any deformity of the globe itself and pupil size, appearance and reaction. Assessing for gross eye movement includes having the patient look up, down, to either side and toward the center (nose). You are looking for symmetry in motion. What one eye does the other should do also. Assessing for normal sight may be as easy as asking the patient if they can see normally and if not, what’s different. Sometimes all you can do is assess for number of fingers they see. Be sure to document the number of fingers and how far away from their face your fingers were.

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Specific assessment of the eye comes ONLY when the initial or primary assessment has been completed. Once that’s done, then the specific assessment of the eye can be completed. Pain control is limited to use of tetracaine (used only in cases of non-penetrating injury such as dust, specks of metal, etc.) or Fentanyl in cases of penetrating trauma, ruptured globe or avulsed eye. In most cases, patching is important. In simple corneal abrasions and non-penetrating FB, patching the effected eye with the eyelid closed, using a 4x4 is helpful. Position of comfort is normal. In cases of a bruise to the eye or blood in the sclera, no specific treatment is necessary other than an icepack for bruising of the soft tissue may help modify the amount of bruising. In cases of hyphema, patching is avoided to prevent pressure on the eye itself. Keeping the patient upright will help minimize further bleeding into the chamber. In cases of penetrating injury, ruptured globe or avulsion, patching both eyes is necessary. The most important principle is to avoid any pressure on the effected eye. Using a cone created from a cup or a modified 4x4 is more appropriate. Using moist dressings for an avulsed eye prevents the globe from drying. Positioning is important for hyphema, ruptured globe, and avulsion. Keeping the patient still, head immobilized and elevating the head of the bed or backboard will prevent or inhibit pressure. If shock is present, keep the patient supine.

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