You are called to a 28 year old male who has been shot in the eye with a paintball gun. On your arrival you find the staff at the paintball arena have rinsed the eye for approximately one minute, as per the manufacturer’s instructions. The patient is alert, oriented, responds appropriately to your questions, and self ambulated towards you when informed of your arrival.
On examination, you see a swollen orbital region with significant swelling to the eye lid. The whole structure appears intact, including the pupil and iris. The eye as a whole structure appears very swollen. The patient states they have lost vision from this eye, and can see normally from the uninjured eye.
Although this patient presents without any changes to the shape of the pupil, a high index of suspicion should be held for alterations in the structures of the eye. The risk of chemical burns have been mitigated by the rinse provided on scene.
The swelling of the eyeball in the presence of blunt force eye trauma should consider the risk of raised intra-occular pressure, which is often associated with the risk of lens dislocation, retinal haemorrhage, corneal abrasions, and retrobulbar haematoma. All of these require prompt (sub 6 hour) examination or risk loss of sight, or side effects increasing intra-occular pressure such as nerve and vascular damage, headache, nausea, and photophobia.
The examination should include:
- the orbital cavity (eye socket) for bruising, swelling, lacerations and tenderness.
- the eyelids for bruising, swelling, and tenderness.
- the conjunctivitis for redness, pus, blood, and foreign bodies.
- the globe (eyeball) for redness, colouring, laceration, swelling, and structural integrity.
- the pupils for size, shape, equality and reactivity to the light.
The eyes are linked by the optic nerve which feeds both eyes simultaneously. Accordingly the optic muscles work in tandem in everyday use, so moving the uninjured eye will cause movement and aggravation of the injured area. In order to minimise movement of the injured eye, a blindfold would be used to cover both eyes. In this context, communication with the patient is very important to support them in feeling safe.
Research suggests that the highest risk factor for eye injuries is a balance between the speed and mass of the foreign body. A paintball has a very high risk factors, as do BB’s and mechanical equipment where foreign bodies are thrown into the eye.
If you read one, make it this: a discussion on terminology for eye injuries
Kuhn, F., Morris, R., Mester, V., Witherspoon, C. D. (2008) Terminology of Mechanical Injuries: the Birmingham Eye Trauma
Terminology (BETT) Occular Traumatology
Alphonse, V., Kemper, A., (2013) Literature Review of Eye Injuries and Eye Injury Risk from Blunt Objects. Virginia Tech-Wake Forest Centre for Injury Biomechanics. Retrieved from https://vtechworks.lib.vt.edu/handle/10919/23812
Mistovich, J., and Karren, K. (2010) Chapter 33: Eye, Face, and Neck Trauma. Prehospital Emergency Care. Pearson: New Jersey
Wyatt, J., Illingworth, R., Graham, C., Hogg, K (2012) Chapter 11: Opthamology. Oxford Handbook of Emergency Medicine. Oxford University Press: New York, USA.