Online Photo Diagnosis

By William Townsend, OD, FAAO

This injury occurred in the left eye of a 17-year-old male who was playing with his peers and was accidently “poked in the eye” with a toy arrow. He presented with mild pain, foreign body sensation, and uncorrected visual acuities of 20/20 OD and OS. Pupillary reflexes were intact, and no afferent pupil was noted. Extraocular muscle function was unrestricted in all positions of gaze, and intraocular pressures were OD 17mmHg and OS 18mmHg.

Conjunctival lacerations may occur independently or in conjunction with trauma to other ocular or adnexal structures. Accompanying signs typically include edema, hemorrhage, and laceration of the conjunctiva. This condition is usually self-healing without sequele, but it is essential that you thoroughly evaluate the patient to rule out the presence of a foreign body, penetration of the globe, and other conditions that pose a threat to sight. Lacerations associated with an injury that punctures the eyelids carry an increased risk for penetration of the globe. The wound should be carefully evaluated for Seidel's sign to rule out loss of intraocular fluids. In the case of suspected penetrating injury, avoid applying significant pressure to the eye to prevent possible prolapse of the orbital contents. Tonometry is valuable in determining whether the affected eye is hypotensive compared to the fellow eye. A significant difference in tonometric findings, especially if the affected eye is hypotensive, is suggestive of globe penetration.

The wound should be carefully examined for the presence of a foreign body; if one is present, irrigate the area so that blood does not obscure good visibility of the wound. If a foreign body is present it may be “plugging” the entry wound. Once the examiner determines that no Seidel sign is present, the foreign body is carefully removed and cultured for bacterial and fungal contamination using appropriate media. A history of conjunctival laceration associated with a high-speed object may be associated with an intraocular foreign body. CT scan, MRI, or ultrasonography may be used to rule out an intraocular object. Suspected metal foreign bodies are a contraindication to MRI of the globes.

The management of conjunctival lacerations varies depending on the size of the lesion. Most lacerations, even up to 20mm, eventually close over time. In the absence of frank infection, it is advisable to prescribe a topical broad-spectrum antibiotic until the lesion heals. Chronic edema and inflammation following a conjunctival laceration may be caused by a low-grade infection or an entrapped foreign body and should be evaluated and treated appropriately.

Patients who have conjunctival laceration should be questioned regarding their last tetanus immunization; if it is not current, refer the patient for a tetanus booster.