Ocular injuries: documentation that holds up

Visual acuity is the vital sign of the eye, and a handful of injuries blind within hours. The defensible chart records acuity in both eyes, the mechanism, and that the sight-threatening diagnoses — open globe, retrobulbar hemorrhage, chemical burn — were found or excluded.

01What's at stake

Two emergencies are measured in minutes: a chemical burn (irrigate before anything else) and orbital compartment syndrome from a retrobulbar hemorrhage (optic-nerve ischemia causes permanent loss within 60–120 minutes; decompress within ~2 hours). Open globe can self-seal and look unremarkable. The medicolegal exposure is highest in work-related injuries — and a documented visual acuity is the central record.

02Sight-threatening can't-miss

• Open globe / rupture — blunt or penetrating; irregular/teardrop pupil, positive (or sealed-off, falsely negative) Seidel, low IOP.
• Retrobulbar hemorrhage / orbital compartment — proptosis, ↓acuity, afferent pupillary defect, pain, IOP >40; the one proptosis that needs lateral canthotomy.
• Chemical burn — alkali worse than acid (hydrofluoric acts like alkali); irrigate first.
• Intraocular foreign body — metal-on-metal/hammering history.
• Traumatic hyphema, retinal detachment, lens dislocation — observe open-globe precautions when relevant.

03Exam — acuity first, then a sequence

• Visual acuity on every patient, both eyes, with correction or pinhole; if formal testing isn't feasible, record count-fingers / hand-motion / light perception. Normal acuity does not exclude serious injury. → the eye's vital sign
• Chemical burn is the exception — irrigate before history/exam.
• Sequence: observation → acuity → pupil (shape, red reflex, APD) → EOM → anterior chamber → fluorescein/Seidel → fundus → IOP last.
• Suspected open globe → stop, shield, and do NOT check IOP (no pressure on the globe); a negative Seidel doesn't exclude a sealed rupture — go by mechanism.
• Re-examine and re-document after any symptom change or procedure (e.g., FB removal).

04Imaging & management

• CT orbit (thin cuts) is the modality of choice for foreign body/fracture; exclude a metallic IOFB before any MRI; bedside ultrasound is sensitive but use caution with suspected rupture (no pressure).
• Chemical burn: copious irrigation (≥2 L), recheck pH 5–10 min after stopping, target neutral; never neutralize the agent; document solution, duration, and pH values/times.
• Open globe: rigid shield, head up, analgesia + antiemetics to avoid Valsalva, tetanus, IV antibiotics (e.g., ceftazidime + vancomycin), urgent ophthalmology.
• Orbital compartment syndrome: immediate lateral canthotomy with inferior cantholysis — don't wait for imaging; medical measures (mannitol, acetazolamide, timolol) are adjuncts only.

05What to document

06Where charts fail

• No documented visual acuity (the eye's vital sign, and key in workers' comp).
• Examining before irrigating a chemical burn.
• Ruling out open globe on a negative Seidel, or checking IOP on a suspected rupture.
• Not asking about eye protection / metal-on-metal mechanism.
• Arranging routine follow-up when the injury needs ophthalmology within 24 hours.

07Sources

• Messman AM. Ocular injuries: new strategies in emergency department management. Emergency Medicine Practice (EB Medicine). 2015;17(11).
• Logothetis HD, Leikin SM, Patrianakos T. Management of anterior segment trauma. Dis Mon. 2014;60(6):247-253.
• Vassallo S, Hartstein M, Howard D, et al. Traumatic retrobulbar hemorrhage: emergent decompression by lateral canthotomy and cantholysis. J Emerg Med. 2002;22(3):251-256.
• Brandt MT, Haug RH. Traumatic hyphema: a comprehensive review. J Oral Maxillofac Surg. 2001;59(12):1462-1470.

© 2026 Kim Trinh, MD. All rights reserved. Educational only — synthesized from EB Medicine and primary literature. Synthetic examples. Not medical advice — apply local protocol and judgment.