anesthetic When strips are used, they must be wet with either saline or topical anesthetic before instillation Otherwise, the strip itself may cause a corneal abrasion Examiners should be careful to instill just a touch of this dye to avoid false positive readings Fluorescein, which is orange, fluoresces yellow-green when exposed to blue light The examiner can view this fluorescence using the blue filter on the direct ophthalmoscope or using a Wood or Burton lamp If the staining pattern reveals one or more vertical linear abrasions, the examiner should suspect the presence of a retained foreign body under the upper eyelid This foreign body may be viewed and removed by upper eyelid eversion ( Fig 114.2 ) Perform Direct Ophthalmoscopy to Evaluate for Papilledema or Retinal Hemorrhages If either is noted, emergency consultation with ophthalmology is required Pharmacologic dilation of the pupil may be used to assist in evaluating the posterior portion of the eye ( Table 114.2 ) Even so, this is a difficult procedure to perform for most providers especially in children with eye injuries If this cannot be completed successfully, ensure that an attempt has been made to obtain a red reflex (see “Check the Red Reflex” above) Consider Bedside Ultrasound Emerging evidence suggests that bedside ocular ultrasound can identify serious injuries to the globe, particularly in patients who are unable to open the affected eye Papilledema, retinal detachment, vitreous hemorrhage, and lens dislocation have been identified successfully Of the applications, retinal detachment is the best-established, with high sensitivity and specificity for identification However, bedside ultrasound is highly user-dependent, and experience affects performance of the modality Therefore, proper training and credentialing are necessary before using bedside ultrasound clinically in the evaluation of ocular trauma TABLE 114.2 Emergency Department Ocular Dilating Regimen a Phenylephrine 2.5% Tropicamide 1% For brown irides replace tropicamide with cyclopentolate 1% a May repeat regimen in 30 minutes if needed Instilling proparacaine or tetracaine prior to these dilating drops will enhance the dilation effect OPEN-GLOBE INJURY