Assess Visual Acuity The first step is to assess the visual acuity of both the injured and the unaffected eye The presence of bilaterally poor vision in a patient with unilateral eye trauma suggests that the cause of the poor vision may be unrelated to the trauma Some patients may be unable to perform this task because of eye pain, noncompliance, inability to open swollen lids, or obtundation from accompanying head trauma Even if the eyelids remain closed, the physician should test for light perception By shining a bright light in the direction of the globe through the closed eyelid, the physician can ask the patient whether he or she perceives the additional light on that side A verbal acknowledgment or a reflex contraction of the lids indicates light perception TABLE 114.1 TRAUMA INDICATIONS FOR EMERGENT CONSULTATION WITH AN OPHTHALMOLOGIST Definitive or suspected open-globe injury Inability to open the eyelids to inspect the eye due to severe ocular trauma or periocular injury Visual disturbance related to ocular trauma Hyphema Extraocular movement disturbance Foreign body not able to be removed Absent red reflex Papilledema Retinal hemorrhages If the patient is able to exhibit a greater degree of compliance, the examiner may ask the patient to count fingers that are held at varying distances The maximum distance at which this task is completed should be noted on the chart (e.g., counting fingers at ft) If the patient is able to comply, the examiner should obtain a visual acuity using a distance chart (see Chapter 123 Ophthalmic Emergencies ) If the patient cannot stand but can identify letters or numbers, a commercially available near visual acuity card, a smart-phone eye chart application, or any other reading material may be used to assess near vision This testing has to be done at the appropriate distance from the patient’s eye; all near vision cards will denote the testing distance for the calibrated visual acuity