Eye injuries
Acuity, evert the upper lid, fluorescein, and think penetrating injury after hammering metal. Never send home with anaesthetic drops.
A 30-year-old welder has two painful, watery, gritty eyes that started 8 hours after welding without a mask. He can't open them in the light.
A 26-year-old woman had lime (chuna) splashed into her right eye 10 minutes ago while whitewashing a wall.
A 35-year-old man was hammering a metal chisel when something hit his left eye. Vision is blurred and the pupil looks slightly irregular.
Which one do you treat before taking a history, and which needs the eye team now?
- Chemical injuryIrrigate immediately with saline or clean water for at least 30 minutes. Check pH. Before anything else.
- Penetrating injuryDon't press on the eye. Rigid shield, antiemetic, nil by mouth, analgesia, imaging, eye team now.
- Visual acuity in every eye injuryFirst, except for chemical irrigation.
- FluoresceinAbrasion, foreign body, Seidel test for a leak.
- Evert the upper lidSubtarsal foreign body.
- Arc eyeAnalgesia, lubricant, cycloplegic if needed. Heals in 24–48 hours.
- Blunt injuryHyphaema, blow-out fracture, retinal injury.
- No rubbing, no contact lensesUntil healed. Don't give anaesthetic drops to take home.
- Chemical injury
- Suspected penetrating injury or intraocular foreign body
- Reduced vision
- Hyphaema
- Blow-out fracture with restricted eye movement
- Rust ring or embedded foreign body
- Retrobulbar haemorrhage (tense, proptosed eye, falling vision)
- Penetrating injury (high-velocity metal from hammering or grinding)
- Intraocular foreign body
- Alkali burn
- Retrobulbar haemorrhage
- Retinal detachment after blunt injury
- Orbital fracture with trapped muscle
| Chemical irrigation | At least 30 minutes (or 1–2 litres), until pH 7–7.5, recheck pH after 20 minutes |
| Alkali (lime, cement, ammonia) | Worse than acid: penetrates deeper |
| Seidel test | Fluorescein streaming from a wound: perforation |
| Hyphaema | Blood in the anterior chamber: eye team, head up, check pressure |
| Blow-out fracture | Double vision on looking up, numb cheek, sunken eye: CT, maxillofacial and eye |
| Chloramphenicol ointment | 3–4 times daily for 3–5 days after abrasion or foreign body removal |
| Topical anaesthetic | For examination only, never to take home |
Check every dose against a current drug reference and your hospital protocol.
On this page
By type of injury
- Irrigate now
- check pH
- eye team
- Penetrating injury or intraocular foreign body
- shield
- X-ray or CT orbit
- eye team
- Hyphaema, blow-out fracture, retinal injury
- acuity and eye movements
- Abrasion, foreign body or arc eye
- fluorescein, remove, lubricant
Chemical injury
- Start nowSaline, Ringer's lactate or clean tap water. Don't wait for pH paper.
- Anaesthetic dropsTo allow the eye to open; lid speculum or retractor if needed.
- IrrigateAt least 30 minutes or 1–2 litres; evert the lids and sweep the fornices for particles (lime).
- Check pHAim for 7–7.5; recheck 20 minutes after stopping, irrigate more if it rises.
- Eye teamAll significant chemical injuries, especially alkali.
Lime (chuna), cement and ammonia are alkalis and cause deeper, more damaging burns than acids. Remove solid particles from under the lids.
Corneal abrasion and foreign body
- Pain, watering, grittiness, light sensitivity after a scratch or grit.
- Anaesthetic drops, then fluorescein: abrasions glow green under blue light.
- Evert the upper lid to find subtarsal foreign bodies (vertical linear abrasions are a clue).
- Superficial foreign bodies: remove with a moist cotton bud or the edge of a fine needle under magnification.
- Rust rings, embedded or central foreign bodies: eye team.
- Treatment: chloramphenicol ointment for 3–5 days, analgesia, no contact lenses until healed. Review if not better in 48 hours.
Arc eye (welder's flash)
- Ultraviolet keratitis, 6–12 hours after unprotected welding (or sun on snow).
- Both eyes painful, watery, gritty, light sensitivity; fluorescein shows punctate staining.
- Oral analgesia, lubricant drops or ointment, cycloplegic drops if very painful, cool compresses. Heals in 24–48 hours.
- Don't give anaesthetic drops to take home (they delay healing and hide damage).
Penetrating injury
- High-velocity metal from hammering, chiselling, grinding; sharp objects; glass.
- Reduced vision, irregular or peaked pupil, shallow anterior chamber, prolapsed dark tissue, positive Seidel test.
- Don't press on the eye, don't remove protruding objects, no drops or ointment.
- Rigid shield (not a pad), antiemetic (vomiting raises eye pressure), analgesia, nil by mouth, tetanus, IV antibiotics per eye team, X-ray or CT orbit (not MRI if metal suspected), eye team now.
Blunt injury
| Injury | Clues | Action |
|---|---|---|
| Hyphaema | Blood level in the anterior chamber | Eye team, head up, avoid NSAIDs, check pressure |
| Blow-out (orbital floor) fracture | Double vision on looking up, restricted upgaze, numb cheek and upper lip, sunken eye | CT, maxillofacial and eye; no nose blowing |
| Retinal detachment | Flashes, floaters, curtain | Same-day eye review |
| Retrobulbar haemorrhage | Tense proptosed eye, falling vision, high pressure | Emergency: lateral canthotomy by trained clinician, eye team |
| Lid laceration | Through the lid margin or near the tear duct | Eye or plastic surgery repair |
Treatment
Common mistakes
- Taking a history or checking acuity before irrigating a chemical injury.
- Irrigating for 2 minutes instead of 30.
- Missing a penetrating injury in someone who was hammering metal.
- Padding or pressing on a possibly perforated eye.
- Giving anaesthetic drops to take home.
- Not everting the upper lid.
Frequently asked questions
What is the first aid for a chemical in the eye?
Irrigate immediately with lots of clean water or saline for at least 30 minutes, until the pH is normal, then see the eye team.
What is arc eye?
A corneal burn from ultraviolet light (welding without protection), causing painful, gritty eyes 6–12 hours later. It heals in 1–2 days with lubricants and pain relief.
How is a corneal abrasion treated?
Antibiotic ointment (chloramphenicol) for 3–5 days, pain relief and no contact lenses until healed. Review if not better in 48 hours.
What are the signs of a penetrating eye injury?
Reduced vision, an irregular or peaked pupil, a shallow anterior chamber, visible tissue at a wound, and fluorescein streaming from the wound (positive Seidel test).
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. Lime splashed into a woman's eye 10 minutes ago. What is the first action?
Answer: Irrigate for 30 minutes. Alkali burns penetrate deeply; immediate prolonged irrigation saves the eye.
- Refer to clinic next day: Emergency.
- Check visual acuity first: Irrigation comes before everything.
- Apply chloramphenicol: Not first.
- Pad the eye: No.
2. A man hammering metal felt something hit his eye. Vision is reduced and fluorescein streams from a corneal wound. What does this show?
Answer: Penetrating eye injury. Positive Seidel test: shield the eye, no pressure, imaging and eye team.
- Arc eye: No.
- Conjunctivitis: No.
- Subconjunctival haemorrhage: No.
- Corneal abrasion: No leak.
3. A welder has painful gritty eyes 8 hours after welding without protection. What is the diagnosis?
Answer: Arc eye. Ultraviolet keratitis heals in 1–2 days with lubricants and analgesia.
- Chemical injury: No.
- Uveitis: No.
- Acute glaucoma: No.
- Retinal burn: Usually not.
4. A mother was scratched in the eye by her baby’s fingernail. The eye is painful and watering; fluorescein under cobalt blue light shows a green-staining epithelial defect; vision is normal. Which management is correct?
Answer: Antibiotic ointment; no patch. Corneal abrasion: epithelial loss from fingernails, paper, branches, contact lenses; pain, photophobia, tearing, foreign-body sensation. Fluorescein stains exposed basement membrane green under cobalt-blue light (it also shows dendrites, punctate keratitis, and Seidel leaks). Evert the upper lid to look for a subtarsal foreign body (multiple vertical linear abrasions). Treatment: antibiotic ointment/drops to prevent infection (contact lens wearers — anti-pseudomonal fluoroquinolone and no lens wear), oral analgesia, cycloplegic for comfort; patching doesn’t speed healing; no take-home anaesthetic; heals in 24–72 h. Fingernail and vegetative injuries may cause recurrent corneal erosion syndrome (pain on waking) — lubricant ointment at night.
- Topical steroid drops: Steroids delay epithelial healing.
- Take-home anaesthetic drops: Topical anaesthetics are toxic to the cornea with repeated use.
- Pressure patch for a week: Pressure patching does not speed healing and is not needed.
5. A man was hammering metal on metal when something hit his eye. He has a small self-sealing corneal laceration, a peaked pupil and a positive Seidel test. What is the correct immediate management?
Answer: Shield, CT orbits, surgery. Hammering metal on metal (chisel, hammer) projects high-velocity fragments that can penetrate the globe with minimal pain; always suspect an intraocular foreign body (IOFB). Signs of penetration: wound, peaked/irregular pupil (iris plugging the wound), shallow anterior chamber, positive Seidel test (fluorescein dilution by leaking aqueous), hyphaema, low IOP, lens damage, vitreous haemorrhage. Management: don’t press on the eye (no pressure patch, no IOP measurement), rigid shield, analgesia and antiemetics (prevent Valsalva), nil by mouth, CT (MRI contraindicated for metallic FB), systemic antibiotics (endophthalmitis prophylaxis — e.g. fluoroquinolone), tetanus prophylaxis, urgent primary repair and FB removal. Retained iron → siderosis bulbi; copper → chalcosis. Sympathetic ophthalmia is a rare risk to the fellow eye. Prevention: eye protection.
- MRI orbits, then surgery: MRI can move a metal fragment and is dangerous.
- Pressure patch, review: A pressure patch can extrude eye contents.
- Irrigate and discharge: Irrigation and discharge miss a penetrating injury.
6. A man punched in the eye has numbness of the cheek and upper lip and double vision on looking up. The eye looks sunken. What is the most likely injury?
Answer: Blowout fracture of the orbital floor. A blow to the globe raises orbital pressure and breaks the thin floor (the maxillary bone over the maxillary sinus). Orbital fat and the inferior rectus herniate into the sinus. Trapping of inferior rectus restricts upward gaze and causes diplopia. Injury to the infraorbital nerve in its groove causes numbness of the cheek, side of the nose and upper lip. Enophthalmos follows as the orbit enlarges. A medial wall (ethmoid) fracture can let air into the orbit on nose blowing.
- Fracture of the orbital roof: A roof fracture involves the anterior cranial fossa, not the infraorbital nerve.
- Fracture of the lateral orbital wall: The lateral wall is thick and rarely blows out.
- Le Fort III fracture: Le Fort III separates the whole face from the skull.
- Fracture of the zygomatic arch alone: An isolated arch fracture causes trismus, not diplopia.
7. Touching the right cornea causes neither eye to blink. Touching the left cornea makes both eyes blink. Which nerve is damaged?
Answer: Right trigeminal (V1). The afferent limb of the corneal reflex is the ophthalmic division of the trigeminal nerve (via the nasociliary nerve), and the efferent limb is the facial nerve to orbicularis oculi on both sides. Touching the right cornea produces no blink on either side, so the right afferent (V1) is lost. Touching the left cornea produces blinking on both sides, so both facial nerves work. A facial nerve lesion would abolish blinking only on that side, whichever eye is touched.
- Right facial nerve: A right VII lesion would leave the left eye blinking when the right is touched.
- Left facial nerve: A left VII lesion would stop left blinking from either side.
- Right oculomotor nerve: III does not take part in the corneal reflex.
- Left trigeminal (V1): Touching the left cornea gave a normal reflex.
References and dose sources
- NICE CKS — Corneal superficial injury
- RCOphth — Eye injury guidance
- Chloramphenicol eye drops and ointment dosing: Drugs.com: Chloramphenicol ophthalmic (see also our chloramphenicol eye drops and ointment dose page)
- Paracetamol dosing: Drugs.com: Acetaminophen (paracetamol) dosage (see also our paracetamol dose page)
- Ondansetron dosing: Drugs.com: Ondansetron dosage (see also our ondansetron dose page)
- Tetanus toxoid and immunoglobulin dosing: Drugs.com: Tetanus toxoid dosage (see also our tetanus toxoid and immunoglobulin dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.