Evaluation of patients with ocular trauma.

When confronted with the ocular trauma patient, the initial evaluation always begins with the assessment of the patient. Once it has been determined that the patient is stable, and other serious nonocular injuries have been addressed, a thorough medical/surgical history is taken followed by a more focused ocular history. Key elements include prior surgery, trauma, and any previously existing eye disease. A full examination is carried out in a methodical and rational fashion, beginning with gross external inspection. Visual acuity is measured in each eye independently. Optic nerve function is assessed by testing for a relative afferent pupillary defect, performing gross confrontational visual field testing, identifying any relative difference in subjective brightness perception, and checking color vision. If appropriate, the IOP is measured and a careful slit lamp examination is performed, combined with dilated indirect ophthalmoscopy. Obvious open globe injury can often be appreciated with a simple penlight examination. Uncooperative patients should be examined under anesthesia in a controlled, monitored setting involving experienced critical care personnel. Additional information may be obtained utilizing ancillary testing (primarily CT and ultrasonography). If the combination of clinical findings and ancillary testing is still not definitive, then formal exploration under anesthesia in the operating room in recommended. Photodocumentation is recommended whenever feasible. Figs. 1-14 provide an overview of many of the points stressed above.