American Society of Ophthalmic Trauma Back to home

Ophthalmic Symptom & Triage Support · Sample pathway

The polytrauma patient

Injury to two or more organ systems with at least one life-threatening. Ocular and orbital injury affects roughly 1 in 13 polytrauma patients and is frequently overlooked. Work through the exclusions in order; each answer takes about ten seconds at the bedside.

Life before sight. Complete the ATLS primary survey and resuscitation first. Then remember that two clocks run at once: orbital compartment syndrome and open globe will not wait for the tertiary survey.

The full pathway at a glance

  1. ATLS primary survey and resuscitation. Life before sight.
  2. Chemical exposure: irrigate copiously now, before any further examination.
  3. Orbital compartment syndrome (proptosis, tense lids, raised pressure, afferent pupillary defect): lateral canthotomy and inferior cantholysis at the bedside, without waiting for imaging.
  4. Open globe (peaked pupil, uveal prolapse, hypotony, positive Seidel): rigid shield, no pressure on the globe, nothing by mouth, tetanus prophylaxis, systemic antibiotics. Do not check intraocular pressure. Closure within 24 hours lowers endophthalmitis risk.
  5. Intraocular foreign body: thin-cut noncontrast CT of the orbits. Wood is radiolucent and mimics air; MRI only once a metallic foreign body is excluded.
  6. Visual vital signs before sedation closes the window: acuity in each eye, pupils including a swinging-light test, and pressure once open globe is excluded. Presenting vision is the strongest predictor of final outcome.
  7. Orbital fracture with entrapment: release now if there is an oculocardiac reflex, otherwise within 24 to 48 hours. Stage other fracture repair.
  8. Hand off: report the visual vital signs to the trauma team, re-examine at the tertiary survey, and stage definitive reconstruction by damage control principles.

Damage control ophthalmology

Do now, during resuscitation

  • Lateral canthotomy with inferior cantholysis for orbital compartment syndrome
  • Copious irrigation of chemical injury
  • Rigid shield, nothing by mouth, tetanus prophylaxis, systemic antibiotics
  • Watertight primary closure of an open globe
  • Removal of organic or toxic foreign body, or with suspected endophthalmitis
  • Release of entrapment with oculocardiac reflex

Stage, once physiologically stable

  • Definitive orbital fracture repair
  • Removal of an inert, well-tolerated intraocular foreign body
  • Secondary reconstruction of the globe and adnexa
  • Cataract, corneal, and eyelid reconstruction
  • Cosmetic repair

Definitive reconstruction is staged until hypothermia, acidosis, and coagulopathy resolve. Restore function first; cosmesis waits for a stable patient.

References
  1. Kuhn F, Maisiak R, Mann L, Mester V, Morris R, Witherspoon CD. The Ocular Trauma Score (OTS). Ophthalmol Clin North Am. 2002;15(2):163-165.
  2. Zhou Y, DiSclafani M, Jeang L, Shah AA. Open globe injuries: review of evaluation, management, and surgical pearls. Clin Ophthalmol. 2022;16:2545-2559.
  3. Li J, Zhou LP, Jin J, Yuan HF. Clinical diagnosis and treatment of intraorbital wooden foreign bodies. Chin J Traumatol. 2016;19(6):322-325.
  4. McMaster D, Bapty J, Bush L, et al. Early versus delayed timing of primary repair after open-globe injury. Ophthalmology. 2025;132(4):431-441.
  5. Ohlhausen M, Menke BA, Begley J, et al. Advances in the management of intraocular foreign bodies. Front Ophthalmol (Lausanne). 2024;4:1422466.
  6. Rowh AD, Ufberg JW, Chan TC, Vilke GM, Harrigan RA. Lateral canthotomy and cantholysis: emergency management of orbital compartment syndrome. J Emerg Med. 2015;48(3):325-330.
  7. Wei LA, Durairaj VD. Pediatric orbital floor fractures. J AAPOS. 2011;15(2):173-180.
  8. Kuhn F, Slezak Z. Damage control surgery in ocular traumatology. Injury. 2004;35(7):690-696.

Adapted from the authors' chapter, Management of the Polytrauma Patient (Varghese D, Hawthorne K), written for the Manual of Ophthalmic Emergencies and Trauma, a joint project of the American Society of Ophthalmic Trauma and APEC. The full chapter carries the complete reference list, the Ocular Trauma Score, and the trauma-scoring tables.