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measures. Normal near vision usually indicates that the patient has not sustained a
significant ocular injury.
If a patient demonstrates poor acuity in the traumatized eye, the clinician
should suspect that the deficit is injury-related. However, one can readily
establish whether this deficit is related to the trauma or uncorrected refractive
error using the pinhole test. When a person looks through a pinhole and
experiences improvement in performance on visual acuity testing, he or she may
have uncorrected refractive error as the cause of the initially tested poor vision. If
the visual deficit does not improve through a pinhole and therefore is likely
related to the trauma, an ophthalmologist should be consulted. The urgency of
evaluation will depend on the mechanism of injury and other physical
examination findings.

Inspect the Periorbital Tissues and Eyelids Thoroughly
The periorbital tissues and eyelids should be carefully examined for ecchymosis,
laceration, deformity, swelling, tenderness, and ptosis. Palpation of the orbital
bones should be performed to assess for tenderness, deformity, or step-off that
may suggest orbital fracture. If crepitus is present, it may be indicative of a
fracture communicating with a sinus. Laceration in the periorbital tissue should
be assessed for fat prolapse, which suggests communication with the orbital
compartment and need for ophthalmology consultation. It should also be assessed
for occult foreign bodies that may embed innocuously into the orbital
compartment. Examine sensation to evaluate for infraorbital or supraorbital nerve
injury secondary to laceration, blunt trauma, or orbital fracture. For eyelid
lacerations, careful attention should be paid to the location of the laceration and
the depth of the wound. The eyelid should be everted to evaluate for
subconjunctival and globe involvement, indicating that the laceration may be a
full-thickness, complete perforation. Lacerations in close proximity to the medial
canthus should prompt ophthalmology consultation for evaluation of the integrity
of the lacrimal duct system.

Open the Eyelids
If the patient is unable to open the eyelids voluntarily, the examiner should assist
the patient. A warm compress may be applied gently to the eyelashes to loosen
any crust, blood, or discharge that may be holding the eyelashes together. When
opening the eyelids, avoid pressure on the globe, which might lead to extrusion of
intraocular contents via an underlying open-globe injury. The examiner’s thumbs
can be placed on the supraorbital and infraorbital ridges while exerting pressure
against the underlying bone, and then pulled away from each other such that the