A high suspicion for globe injury should be suspected in any patient reporting any direct eye trauma, continuing eye pain, and vision deficit. The mechanism of the injury should be elicited as well as the time it occurred. It is important also to inquire about any anticoagulant use.

In globe rupture, physical examination findings may reveal decreased vision or frank vision loss, the irregular contour of the globe, teardrop pupil, hyphema, or a shallow anterior chamber on the slit-lamp exam. The Seidel sign is positive in globe rupture, indicating the flow of aqueous humor from the injury site in the fluorescein-stained eye. However, if the globe rupture is obvious, testing for the Seidel sign should be avoided.

The clinical presentation of retrobulbar hematoma is classical with proptosis and severe eye pain. As in globe rupture, vision loss may be reported.

There may be associated periorbital swelling, ecchymosis, or subconjunctival hemorrhage in either of these entities depending on the mechanism of the injury.

Visual acuity should be checked in each of the eyes separately, if possible, taking care not to manipulate any possible intrinsic globe injury.  Pupillary defects should also be noted.

A thorough evaluation of any concomitant intracranial and facial bony injury should be pursued.  A high number of globe ruptures and retrobulbar hematomas are associated with fractures, in particular of the orbital floor.  Extra-ocular motility testing may be decreased in the affected eye because of entrapment, intrinsic globe deformity, or retrobulbar hematoma.

Laboratory evaluation should be pursued as the clinical situation dictates in the setting of trauma or anticoagulant use.   Computed tomography (CT) imaging can rule out any additional maxillofacial injuries while confirming the diagnosis.  In addition to globe deformity and retrobulbar hematoma, CT imaging can evaluate for foreign bodies, scleral disruption, and even vitreous hemorrhage.

For globe rupture, emergency department treatment includes supportive measures to prevent worsening of the injury or extrusion of intraocular contents. Hence, antiemetics should be provided to prevent Valsalva from vomiting, which could lead to increased intraocular pressures and subsequent loss of aqueous fluid. Analgesia should be provided as needed. A rigid eye shield should be placed, and additional manipulation of the eye should be avoided. The patient should be placed in a semi-recumbent position.[8][9][10]

Similarly, in retrobulbar hematoma, analgesia and antiemetic should be provided.  Definitive therapy, however, is immediate decompression with a lateral canthotomy and inferior cantholysis. This can be performed by the emergency medicine provider or the ophthalmologist if there are no delays in the consultant being able to perform this procedure. Vision prognosis is time-sensitive in this setting with poorer outcomes seen in delays of greater than 4 hours from time of symptoms. Prophylactic antibiotics can be used to prevent secondary endophthalmitis.

In the setting of globe injury or retrobulbar hematoma, emergent consultation with Ophthalmology is warranted. Definitive management in these diagnoses is surgical repair by the appropriate ophthalmologic specialist.

The differential diagnosis of blunt trauma to the eye includes globe rupture, retrobulbar hematoma, traumatic glaucoma, hyphema, orbital blowout fracture with entrapment, foreign body, scleral disruption, and vitreous hemorrhage.

In patients receiving prompt treatment and evaluation, outcomes with retrobulbar hematoma and globe rupture can be satisfactory with preservation of vision. However, the extent of the initial injury and mechanism of injury often predicts whether poor outcomes might be expected.

• Avoid any unnecessary manipulation of the globe (including tonometry) to prevent any extrusion of intraocular contents. 
• Obtain appropriate imaging to rule out concomitant bony injury or intracranial trauma.
• Provide analgesia and antiemetics to prevent Valsalva maneuvers that may worsen globe rupture or retrobulbar hematoma.
• A protective rigid eye shield should be utilized to prevent any additional injury; eye patches are contraindicated.
• Provide prophylactic antibiotics to help prevent endophthalmitis.
• Seek emergent Ophthalmology consultation for definitive measures, but do not delay lateral canthotomy for patients with known retrobulbar hematoma.

Eye trauma is very common resulting in loss of vision in many people. Without vision, one becomes handicapped and getting a suitable job is difficult. In many cases, ocular eye injury is preventable and the onus is on all clinicians to educate patients on eye safety. An interprofessional team is probably the best way to educate and monitor patients with eye trauma. Because of a serious shortage of eye surgeons, most patients are followed up by the primary care provider or nurse practitioner as outpatients.

Eye trauma commonly presents to the emergency department. However, in the ED asides from a superficial exam including a visual acuity test, analysis of deeper injury to the eye is not always possible. Hence, healthcare workers including nurse practitioners should always consult with the ophthalmologist on call to assess the eye.

The emergency department physician may treat superficial laceration around the eye but all patients with vision loss should be referred to the ophthalmologist. During follow up the nurse practitioner and primary care provider should communicate with the eye surgeon if there are any vision related problems.

Missing eye injuries can lead to permanent visual loss and may include prolonged litigation.

Finally all clinicians should educate patients on eye safety such as wearing face helmets and safety goggles when working with splashing liquids or flying debris.