Eye Injury Field Treatment: Foreign Body, Chemical, and Blunt Trauma

Chemical Eye Burns

Immediate Response (First 30 Seconds)

This is the most time-sensitive eye emergency. Chemical burns — particularly alkali burns from lime, cement, oven cleaner, and drain cleaners — continue damaging ocular tissue as long as the chemical remains. Every second without irrigation is additional permanent damage.

Irrigate immediately:

1. Do not stop to assess the extent of injury first
2. Hold the eye open — instinct is to close it; the eyelids must be held open
3. Pour clean water continuously over the eye
4. Tilt head so water flows across the eye and away from the other eye
5. Continue for minimum 20-30 minutes
6. After 30 minutes, if significant pain persists, continue irrigating for another 30 minutes

Water source priority: Any clean water immediately available. Sterile saline is ideal but not worth a 60-second delay to find. Garden hose, river water, canteen water — anything immediately available is better than any brief delay for better water.

Technique for holding eye open: Place two fingers at the eyelid margins (top and bottom eyelid) and gently but firmly hold them open against the patient's squeezing reflex. An assistant holding the eyelids open is invaluable.

After irrigation: Gently evert the lower eyelid (pull down the lower lid while the patient looks up) to expose the lower cul-de-sac and irrigate there specifically — chemical agents pool in this fold and are difficult to wash out without deliberate effort.

Acid vs. Alkali

Acids (battery acid, some industrial cleaners): Cause protein coagulation at the surface, which paradoxically limits penetration. Bad but usually less deep than alkali.

Alkalis (lime, ammonia, lye, oven/drain cleaners): Cause saponification — dissolve cell membranes and penetrate deeply and rapidly. Extremely destructive. A few minutes of alkali contact can cause permanent injury; 30+ minutes can cause near-total loss of vision.

After Irrigation: Assessment

After thorough irrigation, assess:

• Can the patient open their eyes?
• Is vision intact?
• Is the cornea (normally transparent) cloudy or white? (Indicates significant chemical burn)
• Is the conjunctiva (white of the eye) blanched white rather than pink/red? (Paradoxically, a white, bloodless conjunctiva after alkali burn indicates severe ischemic injury)

Mild burn: Eye is red, painful, but vision clear and cornea transparent. Treat with antibiotic ointment to prevent secondary infection, patch for comfort if needed, re-irrigate with sterile saline 3-4 times daily.

Moderate to severe burn: Any vision reduction, cloudy cornea, or white ischemic conjunctiva. Cover the eye with a clean, moist dressing. Evacuate urgently — corneal transplant may be required.

Foreign Body

Surface Foreign Body (Conjunctival)

A particle sitting on the surface of the conjunctiva (inner eyelid surface or white of the eye) without penetrating the cornea.

Signs: Gritty, scratchy feeling that intensifies with blinking. Often the sensation is in the upper lid (but the particle may be under the lid). Photophobia (light sensitivity) if it has scratched the cornea.

Removal:

1. Irrigation first — many superficial foreign bodies wash out with 30-60 seconds of gentle saline or clean water irrigation
2. Evert the upper eyelid to examine for foreign body: have the patient look down, grasp the upper lid lashes and fold the lid upward over a cotton swab placed horizontally at the lid margin — this everts the lid revealing its inner surface
3. A foreign body visible on the conjunctival surface can be gently swept away with a moist cotton swab
4. Do not rub the eye after removal (risk of corneal abrasion from embedded particle)

Corneal Foreign Body

Metal fragments, wood splinters, or other materials embedded in the corneal surface.

Signs: Intense pain, photophobia, tearing, visible embedded particle on the cornea (appears as a brown/rust spot on the clear cornea for metallic particles). A "rust ring" — orange-brown discoloration around a metal particle — develops within 24-48 hours.

Field management:

• Do NOT attempt to remove with a pin, needle, or firm instrument
• Irrigate gently — loosely attached particles may wash out
• If particle does not wash out: antibiotic ointment, eye patch for comfort, evacuate for slit-lamp removal
• Rust rings must be removed by trained provider — delay increases the difficulty of removal

Penetrating Foreign Body

Any object that has penetrated the eye globe is a true emergency.

Critical rule: Do not remove the object. Do not irrigate. Do not apply pressure.

Signs: Visible object in the eye, history of high-velocity fragment impact (grinding, hammering, explosion), irregular pupil, collapsed anterior chamber, soft eyeball on gentle touch.

Field management:

1. Keep the patient calm and still — eye movement can worsen injury
2. Cover both eyes — covering only the injured eye causes the covered eye to move in response to the uncovered eye's movement (conjugate gaze), which causes the injured eye to move
3. Use a protective shield over the injured eye (paper cup, rigid shield) — tape it in place without any pressure on the eye itself
4. Do not rub or press on the eye
5. Keep the patient face-up, as still as possible
6. Evacuate urgently to ophthalmology

Blunt Trauma

Initial Assessment

After any significant blunt trauma to the eye:

1. Test visual acuity in each eye separately — cover one, then the other
2. Examine pupil shape and reactivity — pupils should be round and equal, contracting symmetrically to light
3. Look for blood in the anterior chamber (hyphema) — visible as a red layer in the bottom of the iris
4. Gently palpate the globe (with closed eyelid, no direct pressure): normal firmness vs. soft (suggests rupture) or very hard (suggests increased intraocular pressure)
5. Ask about floaters or flashes of light (retinal detachment)

Subconjunctival Hemorrhage

Red blood visible on the white of the eye without other findings. Blood between the conjunctiva and sclera. Alarming appearance; almost always benign. Resolves in 1-2 weeks without treatment. No intervention required unless there is associated injury.

Hyphema (Blood in Anterior Chamber)

Blood visible pooling in the lower anterior chamber of the eye — behind the cornea, in front of the iris.

Risk: Rebleeding (worse than initial bleed), increased intraocular pressure, corneal blood staining.

Management:

• Keep head elevated 30-45 degrees
• Eye shield over the eye (not pressure)
• Avoid NSAIDs (antiplatelet effect increases rebleed risk) — use acetaminophen for pain
• Avoid any activity that increases intraocular pressure (Valsalva, bending over, heavy lifting)
• Evacuate — hyphema requires ophthalmological monitoring

Orbital Blowout Fracture

A high-velocity impact can fracture the orbital floor, causing the eye to sink into the socket and trapping extraocular muscles.

Signs: Restricted upward gaze (patient cannot look up), double vision in certain gaze directions, sunken appearance of the eye (enophthalmos), numbness of the cheek or upper lip on the same side (inferior orbital nerve).

Field management: Analgesics, ice pack over the orbit (not direct on eye), do not blow the nose (air can enter the orbit from the sinus and worsen the injury), evacuate for surgical evaluation.

Eye Patches and Dressings

Pressure patching: Was historically used for corneal abrasions. Current evidence does not support it for improving healing — many ophthalmologists no longer use pressure patching for simple abrasions. Use for comfort only if the patient finds it helpful.

Protective shield (no pressure): Appropriate for any globe injury, hyphema, or post-operative eye. Creates protection without any pressure on the eye.

Moist dressing for chemical burns: After initial irrigation, a moist (not soaked) sterile dressing over the closed eye provides comfort and prevents drying of the conjunctival surface during evacuation.

Antibiotics for Eye Injuries

Corneal abrasion: Antibiotic ointment (erythromycin or polymyxin/trimethoprim eye drops) prevents secondary bacterial infection. Apply 3-4 times daily until healed.

Chemical burns: Antibiotic ointment after irrigation, as above.

After foreign body removal: Antibiotic ointment.

Not indicated: Subconjunctival hemorrhage alone, blunt trauma without open wound or abrasion.

Never Do

• Never apply pressure to a suspected ruptured globe
• Never attempt to remove an embedded foreign body
• Never use raw cotton wool directly in the eye (fibers are difficult to remove and cause additional irritation)
• Never use full-strength corticosteroid drops unless prescribed (masks infection, causes corneal perforation in certain infections)