When a person suffers ophthalmic trauma, they are very vulnerable – both physically and psychologically – and there is a major risk that the injury is worsened by the incautious actions of the patient or well-intentioned bystanders. It is, therefore, extremely important that a clear leadership is established in caring for such patients – this leader not only showing the compassion and care required at such stressful times but also having the quiet wisdom and firm authority needed to assume the leading role in difficult circumstances.

Periocular trauma will occur either as a solely ophthalmic event – in which case the patient might be able to explain the nature of injury and, once calmed somewhat, be able to cooperate with treatments – or as part of a widespread, multiple-system injury. Ophthalmic injuries may be due to mechanical trauma, chemical injuries, thermal damage, electrical injuries or the more insidious effect of radiation injury. Mechanical trauma – by far the commonest type of injury – tends to be due to impact by missiles or fists, falls onto sharp objects or hard surfaces or avulsion of the eyelids or globe. Dog-bite injuries are particularly problematic in the younger patient.

When first assessing the patient with periocular trauma, there are three key questions: First, “Is this solely ocular trauma or are there other injuries that demand urgent intervention?”; secondly, “Is there an open eye injury?”; and thirdly, “Does the patient have any other disease – such as insulin-dependent diabetes or epilepsy – that might suddenly manifest a problem during their acute care?”. A history from the patient or observers will often give a good indication of the likely answers to these three questions, but the physician should continually remain aware of the risk of systemic disease becoming evident during the hours after major injury – either consequent to a premorbid condition (such as hypoglycaemia in an unconscious diabetic) or due to systemic deterioration from occult injuries (such as circulatory collapse due to a ruptured spleen or loss of consciousness due to subacute intracranial haemorrhage).