Textbook of Urgent Care Medicine, Chapter 9, Acute Eye Trauma

Published on October 26, 2026

Original author: Terry Buzzard

Originally published in 2014. Substantially updated and clinically reviewed in 2026 to reflect current evidence, guidelines, and urgent care practice.

Introduction

Eye injuries are common and are responsible for a significant proportion of the visits to an urgent care center. They range from very minor to sight-threatening—or even life-threatening—injuries. It is important to distinguish between those kinds of eye trauma that may be handled safely at the urgent care center and those that require urgent referral or further evaluation. Knowledge of the key features of the medical history and physical exam findings will enable the urgent care provider to expeditiously assess and manage traumatic eye conditions.

Presentation

The patient typically is aware of and reports an injury. This is most commonly the result of a foreign body, sharp or blunt trauma, or chemical exposure. The patient may report various combinations of symptoms that may include pain, foreign-body sensation, bruising, bleeding, redness, tearing, photophobia, decreased vision, and diplopia. The presenting history and symptoms are important clues to the diagnosis.

Triage Pearls

Conduct an emergency evaluation of patients with acute exposure to chemicals in the eye.
Evaluate urgently those with bleeding, trauma-related vision loss, and severe pain.
It is important to remember that although vision loss itself may not be life-threatening, the associated trauma could be, such as in the case of a closed head injury causing eye trauma in addition to an intracerebral hemorrhage.
Begin copious irrigation immediately for an isolated chemical eye exposure. Do not delay irrigation for a detailed history, visual acuity testing, pH testing, imaging, or transfer. Continue until the ocular surface pH is physiologic and stable after a short pause.
Arrange immediate emergency department and ophthalmology evaluation for suspected open globe injury, intraocular foreign body, orbital compartment syndrome, traumatic optic neuropathy, or other vision-threatening injury. Place a rigid eye shield when an open globe is suspected.

History Pearls

How and when did the injury occur? The importance of a detailed account of the timing and mechanism of the injury cannot be underestimated.
Are there associated symptoms? Especially important are vision changes (loss, diplopia, flashes, floaters), pain, bleeding, and loss of consciousness or altered consciousness.
What is the patient’s tetanus status?
What was the patient’s vision status prior to injury?
Has the patient had past ocular disease or surgery, including vision correction surgery?
Is the patient a contact lens user?
Did the patient self-treat for the trauma before presentation? Did the patient irrigate the eye or use eye drops?
Ask specifically about high-velocity metal-on-metal work, power tools, projectiles, broken glass, organic material, and chemical agents. These details can change the threshold for imaging and emergency referral.

Physical Exam Pearls

Develop a systematic and complete approach to examining the eye. It takes only a few minutes, and by doing it consistently, you will be much less likely to miss an abnormal finding. If you do not do any specific part of the eye exam, you should document why it was not done. An exam with a slit lamp is optimal, especially for the cornea and anterior chamber.

External eye (and face): Inspect and palpate bony orbital rims, facial structures, and the scalp, checking symmetry and nerve function. Be sure to examine both eyes.
Visual acuity: Document visual acuity in each eye using the patient’s corrective lenses when available. If the patient has poor vision, report acuity as finger-counting, hand-motion, or light perception. Visual acuity is a vital sign of the eye and should be obtained before treatment when doing so will not delay emergency irrigation or transfer.
Extraocular muscle function and visual fields.
Inspect the conjunctiva (bulbar and tarsal), sclera, cornea, and anterior chamber. Document whether the anterior chamber is normal or abnormal.
Perform a funduscopic examination when the view and clinical situation permit, assessing vitreous clarity, optic disc appearance, and retinal abnormalities.
Use fluorescein when appropriate to detect epithelial defects or an occult Seidel sign. Do not manipulate the eye, perform tonometry, or perform unnecessary fluorescein testing when an open globe is obvious or strongly suspected.
Intraocular pressure (IOP): Measure when clinically indicated only after globe integrity has been reasonably established. Do not palpate, compress, or perform tonometry on an eye with suspected open globe injury.
Afferent pupillary defect: The swinging light test is a quick and useful way to identify asymmetric optic nerve or severe retinal dysfunction.

Diagnosis Pearls

The following traumatic ocular conditions are those seen most frequently in the urgent care setting. History, physical exam, and management pearls are noted for each.

Table 1. Summary of Management of Acute Eye Trauma

Situation	2026 urgent care approach
Every eye injury	Check and document visual acuity in both eyes when this does not delay immediate irrigation or transfer. Examine both eyes, pupils, extraocular movements, anterior segment, and visual fields as appropriate. Use illumination and magnification. Document what could not be examined and why.
Chemical exposure	Start copious irrigation immediately with water or available irrigating solution. Remove contact lenses and retained particulate material when this can be done safely. Continue until pH is approximately 7.0–7.2 and remains stable after a pause; then complete the examination and obtain urgent ophthalmology guidance for significant injury.
Suspected open globe / penetrating injury	Do not apply pressure, patch, perform tonometry, or remove protruding objects. Avoid ocular ultrasound. Place a rigid shield, keep the patient NPO, provide analgesia/antiemetic as needed, obtain urgent CT orbits when it will not delay care, and transfer emergently for ophthalmologic management.
High-velocity projectile / possible IOFB	Maintain a low threshold for thin-cut CT of the orbits. MRI is contraindicated when a metallic foreign body is possible. Treat a suspected penetrating injury as an open globe until proven otherwise.
Hyphema	Shield the eye, elevate the head, restrict activity, avoid aspirin and NSAIDs, and arrange prompt ophthalmology follow-up. Measure IOP only if an open globe has been excluded. Sickle cell disease or trait increases risk from elevated IOP and warrants particular urgency.
Corneal abrasion	Exclude penetrating injury and retained foreign body. Treat pain; consider topical antibiotic prophylaxis, especially for contact lens-related or contaminated injuries. Do not patch uncomplicated abrasions. Short-term outpatient topical anesthetic use remains controversial and should be limited to carefully selected simple abrasions under a defined protocol.

Corneal Abrasion (Corneal Epithelial Defect)

Corneal abrasion is a very common injury presenting to urgent care centers.
Presentation and medical history: Acutely painful red eye, foreign-body sensation, tearing, photophobia, typically with known trauma.
Etiology: Abrasion is frequently due to a foreign body hitting the eye or getting stuck under the lid. Other common causes include tree branch injuries, paper cuts, and fingernail injuries.
Ask about prior injuries and abrasions. If the abrasion and symptoms occur on awakening, consider recurrent corneal erosion.
Physical exam: Use topical anesthetic in the clinic when needed to facilitate examination. Fluorescein under cobalt blue light identifies epithelial defects. Multiple linear abrasions should prompt lid eversion and a search for a subtarsal foreign body.
Before calling an injury a simple abrasion, exclude an open globe, corneal ulcer or infectious keratitis, retained foreign body, and a high-velocity mechanism suggesting an intraocular foreign body.
Treatment: Oral analgesics and/or topical ophthalmic NSAIDs may be used for pain. Topical antibiotics are commonly prescribed; contact lens-related abrasions should receive antipseudomonal coverage and close follow-up.
Patching is not recommended for uncomplicated corneal abrasions because it does not improve healing or pain and may delay recovery.
Outpatient topical anesthetic use is an area of continuing debate. ACEP guidance permits a tightly limited 24-hour supply for carefully selected simple corneal abrasions under a defined protocol, but it should not be used when infection, contact-lens-related keratitis, penetrating injury, large/complicated abrasion, unreliable follow-up, or other high-risk features are present.
Disposition: Most uncomplicated abrasions heal within 24 to 72 hours. Arrange ophthalmology follow-up for large, central, recurrent, contact lens-related, nonhealing, or worsening injuries, or for any decrease in vision.

Foreign Bodies

Corneal Foreign Bodies

Corneal foreign bodies are common causes of eye injuries. They may be made of any material, including metal, plastic, plant, or glass. Because of the risk of penetrating intraocular injury, it is important to ask if the injury involved a high-velocity projectile.
Conduct a complete exam. Evaluate both eyes, evert the lids, and look for subtarsal foreign bodies. A small entry wound after high-velocity impact may be the only external clue to deeper injury.
Superficial foreign bodies may be removed by irrigation, a moistened swab, spud, needle, or ophthalmic burr by a clinician trained in the technique. Stop if the object is deep, central, difficult to remove, or if perforation is possible.
A rust ring may remain after removal of an iron-containing foreign body. Remove as much as can be done safely; a deep or central rust ring should prompt ophthalmology referral rather than aggressive debridement.
After removal, recheck the cornea, assess the residual epithelial defect, and perform a Seidel test when a deep defect raises concern for perforation. Broad-spectrum topical antibiotic prophylaxis is commonly used until re-epithelialization.

Subtarsal Foreign Body

Presentation: Acute onset of pain and foreign-body sensation, worse with blinking; redness and tearing may be present.
Physical exam: The external examination may be otherwise normal. Fluorescein may show multiple linear corneal abrasions. Evert the eyelid and inspect the fornices.
Treatment: Remove the foreign body with irrigation or a moistened cotton-tipped applicator when appropriate. Treat any associated abrasion as described above.

Intraocular Foreign Body

Suspect an intraocular foreign body after high-velocity debris, metal-on-metal work, power tools, explosions, projectiles, or a small laceration with unexpectedly little external injury.
Do not rely on a benign external appearance or normal visual acuity. Entry wounds can be very small and may be hidden by subconjunctival hemorrhage.
Thin-cut CT of the orbits is the preferred initial imaging study for most suspected metallic or radiopaque intraocular foreign bodies. Plain radiographs have a limited role. MRI is contraindicated when a metallic foreign body is possible.
If penetration or open globe is suspected, do not manipulate the eye, perform tonometry, remove a protruding object, or perform ocular ultrasound. Place a rigid shield, keep the patient NPO, and arrange immediate ED/ophthalmology transfer. Systemic broad-spectrum antibiotics are generally initiated in the hospital because of the risk of endophthalmitis.

Table 2. Summary of Management of Suspected Intraocular Foreign Body

Element	Management
History / mechanism	High-velocity projectile, metal-on-metal activity, power tools, explosions, sharp laceration, or uncertain penetrating mechanism.
Exam	Check visual acuity without pressure, pupils/RAPD, external eye, slit lamp when safe, and fundus when visible. Avoid forceful examination if an open globe is suspected.
Imaging	Thin-cut CT orbits is preferred. Do not use MRI if metallic IOFB is possible. A negative CT does not completely exclude an open globe when clinical suspicion remains high.
Immediate action	Rigid eye shield, no pressure or tonometry, NPO, analgesia/antiemetic as needed, emergency transfer for ophthalmology; hospital-based systemic antibiotics are commonly used for penetrating injuries.

Hyphema

Traumatic hyphema most often follows blunt trauma and may present with eye pain, photophobia, nausea, vomiting, and impaired vision.
The most obvious finding is blood in the anterior chamber. Estimate the amount of hyphema and look for associated injuries. Measure IOP only after open globe injury has been excluded.
Shield the eye, limit activity, and elevate the head approximately 30° to 45°. Avoid aspirin and NSAIDs because of rebleeding risk.
Arrange ophthalmology evaluation and close follow-up during the first several days, when rebleeding risk is greatest. Patients with sickle cell disease or trait, elevated IOP, a large hyphema, bleeding diathesis, inability to comply with follow-up, or other serious ocular injury require greater urgency and may need hospitalization.

Chemical Exposure to the Eye

The patient classically presents with acute onset of eye pain and redness after chemical exposure. Immediate irrigation is the first treatment and should begin before a full history or examination.
If the first contact is by telephone, instruct the patient to begin irrigating immediately with clean running water and to continue while emergency care is arranged. Do not delay for a preferred solution.
If pH paper is immediately available, check both eyes without delaying irrigation. Continue irrigation until the ocular surface pH is approximately 7.0–7.2, then pause for at least 5 minutes and recheck. Resume irrigation if the pH remains abnormal or rebounds.
Remove contact lenses when readily possible without interrupting irrigation. Once an open globe has been excluded, evert the lids and remove retained particulate matter from the fornices. Retained lime, cement, or other particles can continue to cause injury after irrigation.
After decontamination, document visual acuity, corneal and conjunctival injury, limbal ischemia, and fluorescein uptake. Measure IOP only when globe integrity permits. Strong alkali, hydrofluoric acid, limbal ischemia, corneal opacity, significant epithelial loss, persistent abnormal pH, or any decrease in vision warrants urgent ophthalmology evaluation.

Eyelid Lacerations

Get the specifics of how and when the injury occurred. Check visual acuity and carefully assess the globe for associated injury before repairing the lid.
Simple superficial lacerations away from the lid margin may be repaired in urgent care by clinicians experienced with eyelid anatomy.
Refer large or full-thickness lacerations, wounds involving the lid margin, medial canthus or canaliculus, levator injury with ptosis, visible orbital fat, tissue loss, bite wounds, or any laceration associated with suspected globe injury or retained foreign body.

Blunt-Force Trauma to the Eye

Blunt-force trauma is typically related to sports, fights, and falls. Ascertain the nature and time of injury. Ask about loss of consciousness and any vision changes. Evaluate the patient as potentially having a closed head injury.
Document visual acuity, pupils and RAPD, extraocular movements, anterior chamber, fluorescein findings when safe, and the fundus when visible. Evaluate for corneal abrasion, hyphema, lens injury, retinal injury, orbital fracture, open globe, and traumatic optic neuropathy.
Be alert for orbital compartment syndrome: rapidly decreasing vision, proptosis, a tense orbit or tight eyelids, RAPD, restricted extraocular movement, severe orbital pain, and elevated IOP when it can be measured safely. This is a vision-threatening emergency. Do not delay definitive decompression for imaging when the diagnosis is clinically clear; activate EMS/ED/ophthalmology immediately and perform lateral canthotomy/cantholysis only if trained, equipped, and within local scope.

Suspected Globe Rupture / Open Globe

Suspect an open globe after penetrating trauma or substantial blunt trauma when there is marked vision loss, irregular or peaked pupil, extrusion of ocular contents, abnormal anterior chamber depth, 360° subconjunctival hemorrhage, vitreous hemorrhage, or a positive Seidel sign in an otherwise occult wound.
Do not force the eyelids open, apply pressure, palpate the globe, perform tonometry, or perform ocular ultrasound. Avoid unnecessary drops or manipulation when the diagnosis is obvious.
Place a rigid noncontact eye shield. Do not patch. Keep the patient NPO, control pain and vomiting, and arrange immediate emergency department/ophthalmology transfer. CT of the orbits is useful for associated fractures and foreign bodies but does not completely exclude an open globe.

Suspected Orbital Blowout Fracture

Patients may present with orbital trauma, diplopia, pain with eye movement, infraorbital numbness, enophthalmos, or restricted extraocular movement.
CT of the orbits is the preferred imaging study; plain facial radiographs are not adequate when clinically important orbital fracture or entrapment is suspected.
In children and young adults, a relatively normal-looking eye can still have a trapdoor fracture with muscle entrapment. Nausea, vomiting, bradycardia, syncope, or marked pain with attempted eye movement can reflect the oculocardiac reflex and requires urgent specialist assessment.
Advise the patient not to blow the nose. Routine systemic antibiotics are not required solely for every uncomplicated closed orbital floor fracture; use antibiotics when there is an open/contaminated injury, infection, or another specific indication, and follow local specialist guidance.

Flash Burn to the Eye or Ultraviolet Keratitis

Flash burn to the eye, or ultraviolet keratitis, classically follows exposure to a welding arc, tanning device, or other intense ultraviolet source. Patients often present several hours later with bilateral pain, tearing, photophobia, and foreign-body sensation.
Fluorescein typically shows diffuse punctate epithelial uptake. Look for a retained foreign body or focal abrasion when the history suggests it.
Treatment is supportive with oral analgesics, lubricating drops or ointment, and avoidance of further ultraviolet exposure. Most cases improve within 24 to 72 hours. Persistent pain, reduced vision, unilateral findings, or an atypical course warrants ophthalmology evaluation.

Traumatic Optic Neuropathy

Traumatic optic neuropathy should be suspected after head or orbital trauma when visual acuity or color perception is reduced and an RAPD is present despite a relatively normal-appearing globe and optic disc.
Obtain CT imaging of the orbits and head when indicated to evaluate associated fractures, hemorrhage, or compressive lesions, and arrange urgent ophthalmology or neuro-ophthalmology evaluation.
High-dose corticosteroids and optic canal decompression have not shown uniform benefit over observation for indirect traumatic optic neuropathy. Treatment should be specialist-directed rather than initiated routinely in urgent care.

Medicolegal Pearls

Keep a high index of suspicion for penetrating globe injuries even when the patient reports wearing protective eyewear.
Always check and document visual acuity, or document why it could not safely be obtained before transfer or irrigation.
Document the mechanism of injury, contact lens use, tetanus status when relevant, and the examination of the fellow eye.
Evaluate chemical exposure injuries immediately. Copiously irrigate all chemical eye exposures and document serial pH checks when performed.
Do not document a reassuring IOP or negative CT as proof that an open globe has been excluded when clinical suspicion remains high.
Hyphemas require close ophthalmology follow-up because of the risk of rebleeding and pressure-related complications.

References

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