Browse categories and answer follow-up questions to refine your symptom profile.
Approach to the Critical Patient
Immediate priorities
Time-critical stabilization
Eye shield rigid
No patching
No pressure on globe
NPO status
Anticipated operative repair
Aspiration risk reduction
Analgesia
Avoid agitation and Valsalva
Hemodynamic stability during pain control
Antiemesis
Vomiting and Valsalva risk
Reduced intraocular content extrusion risk
Head-of-bed elevation
Edema reduction
Comfort
Tetanus prophylaxis
Contaminated wound assumption
Update per immunization status
Immediate ophthalmology consultation
Suspected open globe as surgical emergency
Transfer trigger if no on-call coverage
Broad-spectrum IV antibiotics initiation
Endophthalmitis prophylaxis
Start prior to transfer when indicated
Concomitant trauma evaluation
Head and facial trauma frequency
Cervical spine precautions per mechanism
Red flags and escalation triggers
High-risk presentation
Marked decreased vision
Hand motion or light perception only
Sudden vision loss after penetrating mechanism
Severe ocular pain
Disproportionate pain
Worsening pain with eye movement
Teardrop or peaked pupil
Iris prolapse suspicion
Full-thickness injury suspicion
Shallow anterior chamber
Compared to contralateral eye
Hypotony association
Hyphema
Associated open globe risk
Secondary bleeding risk
360-degree subconjunctival hemorrhage
Occult scleral laceration risk
Posterior rupture concern
Extruded uveal tissue
Brown tissue at wound
Emergent operative repair indication
Relative afferent pupillary defect
Optic nerve or severe retinal injury risk
Poor prognosis marker
High-velocity mechanism
Metal-on-metal
Projectile and explosion
Immediate contraindications
Avoidance list
Tonometry
IOP elevation risk
Wound extension risk
Ocular ultrasound
Probe pressure risk
Defer until globe integrity confirmed
Eye irrigation unless chemical injury
Pressure risk
Exception for ongoing alkali or acid exposure
Foreign body removal outside OR
Expulsion and hemorrhage risk
Operative removal preference
Pressure dressing
Expulsion risk
Avoid even with bleeding
History
Presentation profile
Clinical vignette
Sudden ocular pain and vision loss after trauma
Penetrating injury mechanism
Blunt injury with facial impact
Eye shape change sensation
Soft eye sensation
Fluid leakage sensation
Photophobia and tearing
Anterior segment irritation
Associated corneal injury
Mechanism and timing
Injury context
Time of injury
Time-sensitive repair planning
Infection risk progression
Blunt trauma details
Fist, ball, fall, MVC airbag
Suspected posterior globe rupture
Penetrating trauma details
Knife, glass, metal fragment
Wound contamination likelihood
High-velocity risk
Hammering, grinding, drilling
Intraocular foreign body probability
Chemical exposure
Alkali or acid
Irrigation priority if ongoing exposure
Symptoms and functional impact
Symptom characterization
Visual acuity change
Baseline vision and eyewear
Monocular status
Diplopia
Orbital fracture concern
Extraocular muscle entrapment concern
Flashes or floaters
Retinal tear or detachment risk
Vitreous hemorrhage risk
Nausea and vomiting
Oculocardiac reflex possibility
Valsalva risk
Eye pain severity
Increasing pain trend
Pain with movement
Risk factors and modifiers
Patient factors
Prior ocular surgery
Cataract surgery and wound weakness
LASIK flap considerations
Contact lens use
Infection risk
Corneal findings confounding
Anticoagulants and antiplatelets
Bleeding risk
Hyphema expansion risk
Immunocompromise
Infection risk
Atypical presentations
Tetanus immunization status
Booster need
Immune globulin indications
Physical Exam
General and periocular exam
External survey
Periorbital lacerations
Lid margin involvement
Canalicular injury concern
Periorbital ecchymosis and edema
Orbital fracture association
Baseline exam limitations
Facial step-offs
ZMC fracture concern
Orbital rim instability
Proptosis
Orbital compartment syndrome concern
Retrobulbar hemorrhage concern
Eye exam without pressure
Vision and pupils
Visual acuity best-corrected
Pin-hole if tolerated
Document pre-op baseline
Pupillary size and reactivity
Peaked pupil sign
Anisocoria documentation
Relative afferent pupillary defect
Optic nerve injury clue
Severe retinal injury clue
Ocular alignment and motility
Extraocular movements gentle
Entrapment concern with pain
Avoid forceful testing
Diplopia pattern
Orbital fracture clue
Cranial nerve injury clue
Slit lamp and anterior segment
Surface and chamber findings
Corneal laceration
Seidel test only if minimal manipulation and ophthalmology guidance
Avoid if obvious open globe
Shallow anterior chamber
Asymmetry compared to other eye
Hypotony association
Hyphema
Microhyphema
Layered hyphema
Uveal tissue prolapse
Iris prolapse
Ciliary body prolapse
Lens injury
Traumatic cataract
Lens dislocation signs
Posterior segment limited assessment
Fundus limitations
Gross view only if safe
Avoid pressure
Avoid prolonged exam
Vitreous hemorrhage suspicion
Poor red reflex
Sudden vision loss
PITFALLS
Common errors
Mislabeling as simple corneal abrasion
Persistent pain with decreased vision
High-risk mechanism
Tonometry performed before excluding open globe
Vision-threatening complication risk
Documentation and safety issue
Eye patching
Increased pressure risk
Expulsion risk
Differential Diagnosis
Vision-threatening differentials
Open globe spectrum
Rupture of globe (ICD-10 S05.3)
Blunt mechanism typical
Scleral laceration posterior risk
Penetrating injury with full-thickness laceration (ICD-10 S05.6)
Sharp object mechanism
Seidel positive possibility
Intraocular foreign body (ICD-10 S05.5)
High-velocity mechanism
Metallic fragment risk
Closed globe but urgent
Orbital compartment syndrome
Proptosis with tight orbit
Vision loss and RAPD
Retrobulbar hematoma
Increasing pain and proptosis
Decreased vision progression
Retinal detachment
Flashes and floaters
Curtain-like vision loss
Traumatic hyphema without rupture
Microhyphema
Elevated IOP risk if closed globe
Lens dislocation
Iridodonesis
Monocular diplopia
Orbital blowout fracture
Restricted upgaze
Infraorbital numbness
Mimics and confounders
Surface injury mimics
Corneal abrasion
Pain with preserved vision
Fluorescein uptake superficial
Conjunctival laceration
Localized subconjunctival hemorrhage
No chamber shallowing
Traumatic iritis
Photophobia with ciliary flush
Cells and flare without full-thickness wound
Laboratory Tests
Baseline and pre-op testing
Preoperative readiness
Complete blood count
Bleeding concern
Baseline anemia assessment
Electrolytes and renal function
Contrast planning for CT if needed
Medication dosing support
Coagulation profile
Warfarin or liver disease concern
Surgical planning support
Type and screen
Operative planning
Significant hemorrhage risk scenarios
Infection and contamination considerations
Infection risk modifiers
Blood glucose
Diabetes screening support
Infection risk correlation
Wound contamination documentation
Soil exposure
Farm injury exposure
Point-of-care adjuncts
Bedside support
Pregnancy test when applicable
Imaging planning
Medication safety planning
Ethanol level when relevant
Sedation planning
Trauma mechanism clarification
Diagnostic Tests
Scoring Systems
Prognosis and classification tools
Birmingham Eye Trauma Terminology System (BETTS)
Open globe injury definition
Full-thickness wound of cornea or sclera
Laceration vs rupture
Rupture
Blunt trauma mechanism
Inside-out failure at weakest point
Laceration
Outside-in full-thickness wound
Penetrating vs perforating
Intraocular foreign body category
Open globe with retained IOFB
Metallic vs organic risk differences
Ocular Trauma Score (OTS)
Baseline visual acuity category
No light perception
Light perception or hand motion
Counting fingers to 20/200
20/200 to 20/50
20/40 or better
Adverse prognostic factors
Globe rupture
Endophthalmitis
Perforating injury
Retinal detachment
Relative afferent pupillary defect
Clinical use
Counseling and documentation
Not a delay-to-repair tool
MRI
MRI considerations
Avoidance with suspected metallic IOFB
Migration risk
Tissue injury risk
Limited acute role
CT preferred in acute trauma
Logistics and time delay
Selective later use
Nonmetallic IOFB characterization
Complex posterior segment evaluation when stable
CT
CT orbit and head
Non-contrast CT orbits
Thin slices 1 mm to 2 mm
Bone and soft tissue windows
Key CT findings
Globe contour abnormality
Deformity or flattening
Posterior scleral discontinuity suggestion
Intraocular air
Pneumoglobus
Open globe association
IOFB identification
Metallic density
Glass fragments visibility
Vitreous hemorrhage density
Hyperdense vitreous
Layering or clot
Orbital fractures
Blowout fracture
ZMC fracture
CT limitations
Normal CT does not exclude open globe
Small lacerations missed
Clinical suspicion predominance
Sensitivity variability
Operator and protocol dependence
Posterior rupture detection limits
Guideline framing
High clinical suspicion warrants ophthalmology involvement regardless of imaging (ACEP Level C consensus-style)
Ultrasound
Ultrasound role
Avoidance in suspected open globe
Probe pressure risk
Expulsion risk
Conditional use after globe integrity confirmed
Retinal detachment evaluation
Vitreous hemorrhage evaluation
POCUS pearls when allowed
Minimal pressure technique
Copious gel mound
Hand braced on bony orbit
Signs
Retinal detachment membrane
Vitreous debris
Disposition
Level of care and transfer
Disposition pathways
Emergent ophthalmology surgical management
Operative repair planning
Endophthalmitis prevention priority
Admission criteria
All suspected or confirmed open globe
Need for IV antibiotics or operative repair
Transfer criteria
No ophthalmology coverage
No operative capability
Transport precautions
Eye shield maintained
Avoid lying flat when possible
Timing considerations
Repair generally within 24 hours when feasible
Earlier repair when contaminated wound or tissue prolapse
Monitoring and perioperative planning
In-hospital management needs
Pain and nausea control
Prevent Valsalva
Prevent agitation
Antibiotic continuation
IV regimen completion per ophthalmology
Transition to oral when appropriate
NPO maintenance
OR scheduling variability
Aspiration risk reduction
Treatment
Eye protection and supportive care
Protection and physiology
Rigid eye shield
Continuous use
Removal only by ophthalmology
Activity restrictions
Bedrest or limited ambulation
Avoid bending and straining
Antiemesis strategy
Ondansetron IV 4 mg
Repeat 4 mg every 6 hours as needed
Max daily dose per local policy
Metoclopramide IV 10 mg
Alternative agent
Avoid in significant QT prolongation risk
Analgesia strategy
Fentanyl IV 25 mcg to 50 mcg
Titration 25 mcg every 5 minutes to comfort
Respiratory monitoring
Hydromorphone IV 0.2 mg to 0.5 mg
Titration 0.2 mg every 10 minutes
Geriatric dose reduction consideration
Antibiotics for endophthalmitis prophylaxis
Systemic prophylaxis
Preferred IV regimen for high-risk open globe
Vancomycin IV 15 mg/kg
Max single dose 2 g
Infusion time at least 60 minutes
Ceftazidime IV 2 g
Frequency every 8 hours
Renal adjustment as needed
Coverage intent
Gram-positive including staphylococci
Gram-negative including Pseudomonas
Alternative IV regimen when ceftazidime contraindicated
Vancomycin IV 15 mg/kg
Same dosing principles
Monitor infusion reaction
Ceftriaxone IV 2 g
Frequency every 24 hours
Limited Pseudomonas coverage
Oral option in selected lower-risk cases per ophthalmology
Levofloxacin PO 750 mg
Frequency daily
Tendinopathy risk counseling
Moxifloxacin PO 400 mg
Frequency daily
QT risk consideration
Timing principle
Initiate as early as feasible when open globe suspected
Do not delay for imaging when clinical signs strong (Class I style consensus)
Tetanus prophylaxis
Immunization management
Tdap or Td booster
Indicated if last dose more than 5 years for dirty wound
Indicated if unknown or incomplete series
Tetanus immune globulin
Indicated for unknown or incomplete immunization with contaminated wound
Separate injection site from vaccine
Operative and ophthalmology-directed therapies
Specialist-led components
Primary globe repair
Corneal or scleral closure
Uveal tissue repositioning decisions
Intravitreal antibiotics when indicated
High contamination risk
Suspected endophthalmitis
Corticosteroids selective use
Inflammation control
Infection exclusion priority
Cycloplegia and topical therapies
Iritis control when appropriate
Avoid topical pressure increasing maneuvers
What to avoid
Harm reduction
Topical drops requiring pressure
Avoid forced eyelid opening
Avoid manipulation until protected
Nasal positive pressure devices when facial fractures suspected
Orbital emphysema risk
Worsening orbital pressure risk
Succinylcholine during induction when alternatives available
IOP rise concern
Anesthesia team decision-making
Special Populations
Pregnancy
Pregnancy considerations
Imaging safety
CT orbit radiation localization
Shielding and dose minimization
Medication selection
Ondansetron risk-benefit discussion
Avoid tetracyclines and aminoglycosides when alternatives exist
Antibiotic choices
Cephalosporins generally compatible
Fluoroquinolones risk-benefit individualized
Obstetric coordination
Viability and fetal monitoring when trauma significant
Rh status considerations when abdominal trauma present
Geriatric
Older adult considerations
Anticoagulation and antiplatelet use
Coagulopathy reversal planning with trauma team
Increased hemorrhage risk
Medication sensitivity
Opioid dose reduction
Delirium risk with sedatives
Prior ocular surgery
Pseudophakia vulnerability
Occult rupture with mild external signs
Pediatrics
Pediatric considerations
Examination limitations
Anxiety and cooperation barriers
Early procedural sedation coordination
Weight-based dosing
Vancomycin IV 15 mg/kg
Dosing interval per age and renal function
Infusion reaction monitoring
Ceftazidime IV 50 mg/kg
Max single dose 2 g
Frequency every 8 hours typical
Non-accidental trauma consideration
Inconsistent history
Additional injury screening
Background
Epidemiology
Population patterns
Ocular trauma burden
Common cause of monocular vision loss
Male predominance in many cohorts
Mechanism distribution
Blunt trauma in sports and falls
Penetrating trauma in work-related metal-on-metal
High-risk contexts
No eye protection in grinding or hammering
Assault-related facial trauma
Pathophysiology
Injury mechanics
Rupture mechanism
Sudden IOP spike after blunt impact
Failure at weakest scleral point
Laceration mechanism
Sharp object full-thickness cut
Direct uveal exposure risk
Complication pathways
Endophthalmitis
Microbial inoculation at time of injury
Delayed presentation risk
Retinal detachment
Vitreoretinal traction after trauma
Progressive vision loss risk
Sympathetic ophthalmia
Autoimmune bilateral uveitis risk
Rare but vision-threatening
Therapeutic Considerations
Why key treatments matter
Shielding
Prevents inadvertent pressure
Reduces further extrusion risk
Antiemesis and analgesia
Reduces Valsalva and squeezing
Reduces secondary expulsion risk
Early antibiotics
Endophthalmitis prevention goal
Broader coverage for contaminated wounds
Timely surgical closure
Restores globe integrity
Reduces infection and tissue prolapse risk
Evidence framing
Antibiotic prophylaxis and early repair supported by expert consensus and observational data (ACEP Level C style, Class I style consensus)
Patient Discharge Instructions
copy discharge instructions
Transfer and post-repair instructions
Eye shield at all times
No rubbing or pressure
No patching under shield
NPO until cleared
Pending surgery or transfer
Aspiration risk reduction
Activity restrictions
No heavy lifting
No bending or straining
Medication adherence when prescribed
Antibiotics exactly as directed
Antiemetics for nausea prevention
Return to ED immediately for
Worsening vision
Increasing eye pain
New nausea or vomiting
Bleeding from eye
Fever or systemic illness symptoms
Follow-up and timing
Ophthalmology follow-up as scheduled
Same-day evaluation if any red flags
References
Clinical guidelines and core sources
Core guidance
American Academy of Ophthalmology guidance on open globe injury evaluation and management
Eye shield and avoidance of tonometry
Urgent ophthalmology consultation and repair
Birmingham Eye Trauma Terminology System (BETTS)
Standard terminology for rupture and laceration
Communication and documentation standardization
Ocular Trauma Score (OTS)
Prognostication framework
Counseling support
Evidence-based reviews
Reviews on systemic antibiotic prophylaxis for open globe injuries and endophthalmitis prevention
Broad-spectrum coverage rationale
Timing and contamination risk factors
Imaging reviews for ocular trauma
CT orbit protocols
IOFB detection considerations
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.