Annals of Emergency Medicine – A Really Bad Poke in the Eye

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Nurses Edition Commentary

Mizuho Spangler, DO, Lisa Chavez, RN, and Kathy Garvin, RN

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Lindsay M. -

A point of concern re: advising routine ED ultrasound of eyes with a suspected IOFB? This was a big topic of discussion at a recent local (Detroit, MI) ocular trauma conference, at which the ophthalmic trauma gurus from all three of our big metropolitan eye institutes categorically forbade it, due to the risk of expelling contents through whatever penetrating wound gave rise to the IOFB in the first place, and/or of worsening an existing hemorrhagic process - traumatic hyphema, vitreous or retinal bleed, etc.

In the context of known IOFB, or highly suspected IOFB in a grossly traumatized eye, we already know this patient is going for emergent surgical management. The U/S likely won't tell the ophthalmologist anything new or useful in the immediate pre-op phase, especially if you can see the IOFB on slit-lamp biomicroscopy and/or you already got a good CT that demonstrates the IOFB, and the procedure carries a fairly high risk of harm in inexperienced hands. (Most ED docs are not scanning dozens of eyes a day even in busy shops, and if you can get away with your shop's slit-lamp being routinely dysfunctional or absent, you're probably not doing enough ophtho business on the whole to make routine ED ocular U/S a good idea.)

If the history is suspicious for IOFB and you can't see it via slit-lamp or on CT, and the ophthalmologist absolutely wants a U/S, then s/he ought to come in and do the study personally. Consider that if there is an IOFB, you'll need the ophthalmologist in-house anyway, and if not, this is still a patient that needs careful management - just as the lack of IOFB on imaging does not rule out IOFB, the lack of an IOFB categorically does not rule out severe intraocular trauma. Indeed, ocular contusions and other closed globe injuries typically have worse visual outcomes than simple penetrating injuries, with or without IOFB.

In any case, the smart play for ED management of IOFB is as stated: shield the eye, start broad-spectrum IV antimicrobial coverage and your pain/nausea combo of choice, keep the HOB elevated, and get the patient to definitive surgical care as quickly as possible. Leave the imaging, be it bedside U/S or otherwise, to the experts.

Anand S., M.D. -

Lindsay - thanks for the great points and thoughts on the topic. Paul and I agree that the focus in these cases should be getting the CT to confirm the presence of the FB and to get your consultant on board expeditiously. In patients with a clear globe laceration, I wouldn't bother with US either. You don't even need the CT - simply call ophtho immediately while you are waiting for the images.
However, some patients aren't as straight forward. Some have relatively minor appearing injuries without an obvious FB. Additionally, many of us work in busy places, okay, I know, we all work in those places. CT prioritization becomes an issue at times. In these circumstances, I think US can be extremely helpful If I see an FB on US, I'll put that person up to the front of the line (maybe not ahead of the dissection or ICH) and call my ophthalmologist immediately.
Bottom line, though, if you aren't skilled with US, defer this test and wait for the CT. Alternatively, take this as a challenge to get good at US . . .

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