The Mighty Paper Clip

You’re working in the ED on a busy Halloween evening. So far you have seen patient’s in all manner of costumes.. 2 Donald Trumps, 1 Santa Claus, a father-daughter pairing of Beast and Belle. Your next patient is dressed as Kylo Ren. He is a 16 yo M who was out trick or treating with some friends when they started to play fight with their lightsabers.  He was attempting to block a strike when his friends lightsaber bounced off his and hit him in the right eye.  He immediately had severe pain in the eye and face and noticed some loss of vision.  He went home and showed his parents who brought him to see you in the ED.

On exam you note that he has significant periorbital edema surrounding the right eye. You are concerned about a globe rupture or orbital fracture with entrapment and want to fully examine the eye for signs of abnormal extraocular movements, pupil asymmetry, obvious rupture of intraocular contents, and hyphema but the patient is unable to open his eye spontaneously secondary to pain. You gently attempt to open the patient’s eyelids but are met with significant discomfort and resistance on the part of the patient and a creeping fear in your stomach that you may be putting too much pressure on the globe as you attempt to open his eye.

So what to do? If you work in an academic center with ophthalmology on call, you could phone a friend. But, really you should get a full exam before calling your consultant. And, if you do not have ophthalmology on call (as would be the case in most ED’s), you’ll need to get a good look at the patients globe to figure out if there is significant pathology needing immediate transfer to a facility with ophthalmology on call. Enter the lowly paper clip…

As seen in the photos below, you can create makeshift eyelid retractors with a couple of paper clips.

  1. Unbend them and re-bend them to the shape shown in Image 1.

  2. Clean them with an alcohol wipe.

  3. Open the patient’s eyelids as shown in Image 2. It can be helpful to have an assistant hold the paperclips at this point, allowing you to fully examine the patient’s eye.

  Image 1  - Correct form of the paperclip eyelid retractors.  Photo courtesy of Michael Spigner, MD, PGY-3 University of Cincinnati Department of Emergency Medicine

Image 1 - Correct form of the paperclip eyelid retractors.

Photo courtesy of Michael Spigner, MD, PGY-3 University of Cincinnati Department of Emergency Medicine

  Image 2  - Paperclip Eyelid Retractors in Action  Photo courtesy of Michael Spigner, MD, PGY-3 University of Cincinnati Department of Emergency Medicine

Image 2 - Paperclip Eyelid Retractors in Action

Photo courtesy of Michael Spigner, MD, PGY-3 University of Cincinnati Department of Emergency Medicine