PRN Education · The Curbside · Ophthalmology

Vision Before Imaging.

The eye exam in three passes: function, front, and back. In trauma, clear the globe before pressing on it.

CORE PEARL

Visual acuity is the vital sign. Localize before imaging. Acuity measures lost function. An RAPD points toward asymmetric retinal or optic-nerve dysfunction.

The Three-Pass Exam

Before drops. Before the scan.

Function

Is vision threatened?

Acuity, each eye separately
Pupils and RAPD
Confrontation fields
EOMs and diplopia
Red desaturation if nerve injury fits

Pinholes improve refractive blur. They do not rescue retinal or optic-nerve loss.

Front

Surface or anterior chamber?

Lids, lashes, conjunctiva
Evert the upper lid when safe
Cornea in white light
Fluorescein and Seidel
Chamber depth, cell, flare, blood

Measure IOP only after open globe is excluded.

Back

Retina, vitreous, or nerve?

Flashes, floaters, curtain
Fundus when visible
Ocular POCUS when safe
Explain any RAPD or field cut
Ask: monocular or binocular?

A quiet front does not clear the back.

Trauma: Clear the Globe

The safety branch

Open globe possible? Stop pressing.

High-velocity metal, glass, projectile, penetrating mechanism, markedly reduced acuity, irregular or peaked pupil, distorted chamber, prolapsed tissue, dense 360° subconjunctival hemorrhage, or positive Seidel should stop the routine exam.

No tonometry
No ocular ultrasound
No forced lid opening
No pressure patch

Rigid shield. Analgesia. Antiemetic. NPO. CT orbits for contour and foreign body. Immediate ophthalmology. Tetanus and systemic antibiotics per local open-globe protocol.

PITFALL

Negative Seidel ≠ closed globe

A wound can self-seal. Posterior rupture may never leak where you can see it.

PITFALL

Normal CT ≠ cleared globe

CT supports the diagnosis and finds foreign bodies. It does not replace the examination or ophthalmology assessment.

Pattern → Location

Name the layer first

Finding	Think first	Move
Focal uptake	Corneal abrasion	Evert the lid. Exclude infiltrate and penetration.
Vertical linear defects	Upper-lid foreign body	Evert and sweep when globe is closed.
Dendrite or geographic ulcer	Herpetic keratitis	No topical steroid. Urgent ophthalmology plan.
Opacity or infiltrate	Infectious keratitis	Contact lens use raises the stakes. Urgent ophthalmology.
Cell and flare	Uveitis / traumatic iritis	Look for consensual photophobia. Coordinate treatment.
Cloudy cornea + fixed mid-dilated pupil	Acute angle closure	Check IOP if globe is closed. Treat and call now.
Blood in chamber	Hyphema	Shield, head elevation, avoid NSAIDs, urgent follow-up or admission by risk.
Flashes, floaters, curtain	Retinal tear / detachment	Dilated exam. POCUS may support, but does not rule out a tear.

Four Complaint Lanes

Same exam. Different branch.

TRAUMA

Open or closed?

Then: anterior, posterior, or orbital injury? Check entrapment, hyphema, lens, retina, and nerve.

PAINFUL RED EYE

Surface or deeper?

Worry: decreased acuity, corneal defect or infiltrate, consensual photophobia, chamber reaction, or high IOP.

PAINLESS VISION CHANGE

Retina, vessel, nerve, or brain?

First split: monocular or binocular. Persistent or transient. RAPD and fields localize before CT.

FOREIGN-BODY FEELING

Does the exam explain the pain?

Find: abrasion, retained foreign body, keratitis, dry eye, or occult penetration. Evert the lid.

Before You Call

Give ophthalmology a localization

HAVE READY

Function + mechanism

Timing. Contact lens use. Prior surgery. Anticoagulants. Acuity each eye. Pupils and RAPD. Fields. EOMs and diplopia.

HAVE READY

Front + back

Fluorescein and Seidel. Chamber findings. IOP only if safe. Fundus or POCUS findings. CT results when the mechanism warrants it.

Epic Note Block

“Vision intact” is not an exam

.EYEEXAM

Visual acuity: OD [ ], OS [ ], OU [ ], corrected [Y/N].
Pupils [ ]; RAPD [present/absent]. Fields [ ]. EOMs [ ]; diplopia [ ].
External/lids [ ]. Conjunctiva/sclera [ ]. Cornea [ ].
Fluorescein [ ]. Seidel [ ]. Anterior chamber [ ].
IOP: OD [ ], OS [ ] [or deferred due to concern for open globe].
Fundus/ocular POCUS [ ]. Ophthalmology [consulted / follow-up arranged].

Selected Sources

Reviewed July 25, 2026

AAO EyeNet: Open Globe Injury ACEP Sonoguide: Ocular Emergencies AAO EyeWiki: Acute Ocular Trauma Evaluation AAO EyeWiki: Anterior Segment Trauma