Assessment of the eyes and visual pathways in the multiply injured patient with co-existing craniofacial injuries can be very difficult. Although ocular injury is common in facial trauma, vision-threatening injuries and severe visual impairment are less frequently seen and may be associated with specific injury patterns. Some vision-threatening injuries require early diagnosis and treatment if useful sight is to be preserved, but at the same time this must not interfere with any ongoing investigations and resuscitation. Progressive swelling, blood loss and some therapeutic interventions may all potentially contribute to loss of vision later on, highlighting the need for repeated assessment. In many cases initial assessment is limited, especially in the confused, agitated or unresponsive patient, but early recognition of significant ocular injuries is important for a number of reasons. Arguably, initial assessment should be to confidently exclude a sight-threatening injury, requiring emergent or urgent intervention. More detailed ophthalmic examination can be performed later, when the patient is in a better condition. The management of the severely proptosed eye in the multiply injured unconscious patient is also a very difficult area, particularly if the precise cause is unknown. A number of causes exist and these may require different therapeutic strategies, which are discussed.