👁️ Eye Injury & Ocular Emergencies
What to irrigate, what never to touch, and the one red eye that is an emergency.
🚨 Sort it first — what cannot wait
Eye complaints look alike and are not alike. Four go straight to the front of the queue because sight is lost in hours.
| Emergency | How it presents | First action |
|---|---|---|
| Chemical burn | Pain, tearing after a splash. Alkali is worse than acid — it keeps burning inward. | Irrigate immediately — before assessment, before history, before anything. |
| Penetrating / globe rupture | Visible object, irregular pupil, fluid leaking, sudden vision loss | Rigid shield over the eye. Do not touch. Nothing by mouth; surgery. |
| Acute angle-closure glaucoma | Sudden severe eye pain, halos around lights, vomiting, fixed mid-dilated pupil, hazy cornea | Immediate pressure-lowering treatment. Sight is lost within hours. |
| Retinal detachment | Floaters, flashes, a curtain coming across the vision. Painless. | Urgent referral, keep the head still, position as directed. |
Painless curtain = detachment. Painful eye with halos and vomiting = angle-closure. Vomiting with an eye complaint is a classic misdirection — the stem hopes you will chase the stomach.
💧 Chemical burn — irrigate first
Nothing comes before irrigation. Not the visual acuity, not the history, not waiting for the provider. Every second of contact is more tissue destroyed.
- Remove contact lenses if present — they trap the chemical against the cornea.
- Hold the lids open; the reflex is to squeeze shut.
- Never neutralize an acid with an alkali or the reverse — the reaction generates heat and a second burn.
- Bring the container or name of the chemical if anyone can.
Why alkali is the feared one. Acid coagulates protein and forms a barrier that partly limits its own depth. Alkali dissolves through tissue and keeps traveling into the eye, so damage continues long after the splash. Drain cleaner and lye are worse than battery acid.
🧭 Foreign bodies & blunt trauma
The rule that decides most questions. Never remove a penetrating or embedded object. It may be the only thing plugging the wound; pulling it can empty the eye.
Penetrating — object still in
- Stabilize it where it is; cover with a rigid shield, never a pressure patch
- Cover both eyes if directed — the eyes move together, so the uninjured one drags the injured one
- Nothing by mouth — surgery is likely
- Elevate the head about
30°; keep the patient calm and still - Do not let the patient bend, strain, cough or vomit — give an antiemetic if needed
Surface foreign body — loose, not embedded
- Try irrigation first
- No rubbing — it drags the particle across the cornea
- Persisting foreign-body sensation after irrigation needs examination for a corneal abrasion
🧿 Blunt trauma
- Ice, no pressure, for the first 24 hours; elevate the head.
- Hyphema — blood pooling in the front chamber, visible as a level line. Rest with head elevated; watch for a pressure rise.
- Orbital blowout fracture — double vision, an eye that will not look up, numbness of the cheek. Tell the patient not to blow their nose — it forces air into the orbit.
Always document visual acuity. Each eye separately, with their glasses on, as early as it is safe to do so — except in a chemical burn, where irrigation comes first. It is the baseline every later assessment is measured against, and it has medico-legal weight.