Advanced Trauma Life Support ATLS Student Course Manual 2018

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APPENDIX A n Ocular Trauma
A
B
n FIGURE A-1 anterior and posterior anatomy
creates another space with limited expansion where
compartment syndrome can also occur.
Assessment
Like all others evaluations, assessment of ocular trauma
includes a focused history and physical examination.
The patient’s pre-injury comorbidities and vision
history may be pertinent. Accurately assessing ocular
trauma can change the patient’s disposition, especially
in a setting in which emergent ophthalmic care is
not available.
History
Obtaining the history necessary to treat ocular trauma is
the same as for any other trauma. It includes a complete
review of systems and the patient’s past medical
history. Make sure to ask the time and mechanism
of injury. Further specific historical information to
obtain is described within the physical exam section
that follows.
Physical Examination
When possible, every eye exam should document
the three “vital signs” of the eye: vision, pupils, and
intraocular pressure. These functions will give the
provider key information about the basic health of the
eye. In addition, physical examination includes the
anterior and posterior segment of the eye.
Vision
A vision exam can be as simple as holding up a
near vision test card or any reading material at the
appropriate distance and recording the vision in each
eye. Always note if the patient normally wears glasses
or contact lenses, and if so, whether for distance or near
(reading) vision. If a refractive error is known, but the
patient does not have glasses, ask the patient to look
through a pinhole, which minimizes the refractive
error, and recheck the vision. To make a pinhole, take
a piece of paper or cardboard and use a ballpoint pen or
paper clip to make a hole of about 0.2 mm in the center
of it. If a professional pinhole occluder is available, use
it to obtain slightly more accurate results.
Pupils
If the patient is wearing contact lenses, they should
be removed. Pupils should be equal, round, reactive
and without an afferent pupillary defect. A sluggish
or poorly reactive pupil indicates a possible brain
abnormality such as stroke or herniation. Be aware
that these findings do not typically indicate ocular
pathology. However, it is important to note that a
pupil can become enlarged due to blunt trauma (e.g.,
pupillary sphincter tear), past surgery, and other ocular
disease processes. When an abnormal pupillary exam
results from an ocular cause alone, the pupil often
retains some reactivity to light, even though it is a
different size. The patient’s medical history should
reflect a positive past ocular history; if it does not,
further investigation and examination is necessary to
evaluate for intracranial pathology.
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