Open globe injuries: Emergency evaluation and initial management

INTRODUCTION — This topic will discuss the clinical features, evaluation, and management of patients with suspected open globe injuries.

An overview and approach to other eye injuries in the emergency department is provided separately. (See "Overview of eye injuries in the emergency department" and "Approach to diagnosis and initial treatment of eye injuries in the emergency department".)

DEFINITION — Open globe injuries are described by mechanism and then by anatomic site [1,2].

Open globe rupture — Open globe rupture occurs following blunt eye injury, typically at the sites of greatest structural weakness: the limbus and near the equator directly behind the insertion of the rectus muscles (picture 1) [1]. (See 'Pathophysiology' below.)

Open globe laceration — Open globe laceration refers to a penetrating injury to the eye by a sharp object or projectile and is further subclassified as penetrating (entry wound but no exit wound) or perforating (entry and exit wounds) [1]. Intraocular foreign body (IOFB) injuries refer to a foreign body present anywhere inside the globe and are grouped separately because studies have shown that they have a different prognosis (picture 2) [3,4].

Lacerations are also named according to the location of the full thickness break including:

●Corneal laceration – A full thickness injury through the cornea (picture 3)

●Corneal-scleral laceration – A full thickness injury through the cornea also extending laterally through the sclera

●Scleral laceration – A full thickness injury confined to the sclera

Zone of injury — The anatomic region that is lacerated or ruptured provides additional information that is important for injury prognosis (figure 1) [2].

●Zone 1 injury involves the cornea and limbus (junction of the cornea and sclera).

●Zone 2 injury refers to a rupture or laceration located in the anterior 5 mm of the sclera that does not extend into the retina based on operative evaluation.

●Zone 3 injury describes a full-thickness scleral laceration or rupture found more posterior than 5 mm from the limbus.

EPIDEMIOLOGY — The annual incidence of open globe injuries worldwide is estimated at 3.5 eye injuries per 100,000 population, accounting for 203,000 cases annually [5]. Overall, males comprise approximately 80 percent of open globe injuries with an estimated incidence six times higher than females [6-9]. Males age 10 to 30 years are at greatest risk. The chance of blunt globe rupture also increases after ocular surgery such as large incision cataract removal, corneal transplant, glaucoma filtering procedures, or LASIK (laser-assisted in situ keratomileusis) [10-13].

Several observational studies identify the following patterns of globe injury [6-9,14-19]:

●Injuries in young children tend to involve laceration of the eye with sharp objects such as scissors, knives, thorns, or writing instruments [8,14,20].

●Teenage boys often suffer penetrating eye injury from air powered pellet (BB) guns or blunt injury during ball sports, motor vehicle collisions, or fights [7,9].

●Young men frequently sustain penetrating or perforating eye lacerations at work, especially in construction settings that involve hammering on metal or stone [21]. Safety glasses would prevent many of these injuries. Blunt facial trauma during motor vehicle collisions and assaults are also prominent etiologies in this group. Illicit drug use and alcohol consumption commonly contribute to the circumstances of the eye injury [9,22]. Gunshot wounds to the eye and orbit are less common but typically cause severe globe injuries with poor visual outcomes [23].

●Globe rupture is more common than globe laceration in older patients. The usual mechanism involves a fall with subsequent open globe injury at the site of prior eye surgery [6,24].

Intraocular foreign bodies (IOFBs) occur in 18 to 41 percent of open globe injuries [15,16]. The majority of IOFBs are small projectiles resulting from hammering on metal or stone, machine tool use, firing of weapons, explosions, motor vehicle accidents, and lawn mower accidents [8,17,18]. Up to 90 percent of IOFBs are metallic [17,25].

ANATOMY — The eye is composed of three layers (figure 2):

●The external fibrous layer (cornea and sclera)

●The middle vascular layer (chorioid, ciliary body, and iris)

●The internal light-sensing layer (retina)

The junction of the cornea and sclera is known as the limbus.

The lens separates the anterior structures (iris, anterior chamber, and cornea) from the posterior structures (vitreous, retina, choroid, and optic nerve).

PATHOPHYSIOLOGY

Blunt injury — The orbital bones provide rigid structural support and protection for the eye. High impact blunt trauma can overwhelm bony protection resulting in orbital fractures as well as globe rupture. The site of rupture commonly occurs where the sclera is thinnest and weakest: directly behind the insertion of the rectus muscles (figure 2) [26]. Other potential regions prone to rupture include the limbus, insertion of the optic nerve, and sites of prior eye surgery [10,11].

Penetrating injury — Open globe lacerations involve the cornea in the majority of patients. Scleral or limbal lacerations account for about one-third of cases [17]. Intraocular foreign bodies (IOFBs) are present in many globe lacerations and are most commonly found in the vitreous cavity followed by, in decreasing prevalence, the anterior chamber, retina, lens, or subretinal space (figure 2) [17].

Extrusion of ocular contents — Any increase in intraocular pressure risks further extrusion of ocular contents after an open globe injury. To minimize this risk, there should be no external pressure applied to the injured eye (eg, prompt placement of shield, quiet environment, no manipulation of the eye except by an ophthalmologist) and avoidance of Valsalva which may occur secondary to vomiting or crying (eg, give antiemetic therapy, sedation, and pain control).

Endophthalmitis — Endophthalmitis (internal eye infection) rates have been estimated between 2 to 7 percent for all open globe injures [16,27]. This rate has been reported to be as high as 13 percent in patients with open globe lacerations complicated by IOFBs [28]. However, a standardized management protocol consisting of a dedicated eye trauma service and 48 hours of intravenous antibiotics was associated with a rate of posttraumatic endophthalmitis as low as 0.9 percent [4,29].

Factors associated with infection include open globe laceration, retained IOFB, injury involving organic material (eg, thorn), disruption of the lens, and delay in primary closure beyond 24 hours [16,30-32].

Bacillus species and coagulase-negative Staphylococcus accounts for up to 50 percent of endophthalmitis after open globe injury based on intraoperative cultures [2,30,33,34]. However, Streptococcal species, S. aureus, and gram negative organisms are also common. In addition, up to 12 percent of infections have mixed organisms [2].

CLINICAL FEATURES — The approach to the patient with an open globe injury is summarized in a rapid overview (table 1).

History — A history consistent with injury involving high velocity projectiles, high impact blunt trauma or sharp objects should raise suspicion for an open globe injury. Essential components of the history include exact time and mechanism of the eye injury and composition of any possible intraocular foreign body (IOFB), if known.

History should also include medication allergies, time of last meal, prior ocular surgeries, pre-injury functional status of the eye, and tetanus immunization status.

Physical examination — For patients with a high likelihood of an open globe, the clinician should avoid doing anything that might apply pressure to the eye, such as eyelid retraction or intraocular pressure measurement by tonometry.

In young children, the extent of ocular injury often cannot be assessed due to poor cooperation. In these cases, an examination facilitated by procedural sedation or general anesthesia should be performed by an ophthalmologist whenever the mechanism of injury is highly suggestive of an open globe.

Examination under sedation by the emergency provider after discussion with an ophthalmologist may suffice in situations where the risk of open globe injury is low.

In cases of obvious or likely open globe, the examiner should avoid placing any medication (eg, tetracaine) or diagnostic eye drops (eg, fluorescein) into the eye.

Any protruding foreign bodies should be left in place. Removal should be deferred to the ophthalmologist.

Physical findings of an open globe include:

●Markedly decreased visual acuity

●Relative afferent pupillary defect (figure 3)

●Eccentric or teardrop pupil (picture 4 and picture 5)

●Increased or decreased anterior chamber depth (picture 6)

●Extrusion of vitreous (picture 7)

●External prolapse of the uvea (iris, ciliary body, or choroid) or other internal ocular structures (picture 8 and picture 9 and picture 10)

●Tenting of the cornea or sclera at the site of injury

●Low intraocular pressure (checked by an ophthalmologist only)

●Positive Seidel sign: clearing of fluorescein in a teardrop pattern away from the site of injury (picture 11) (observed at the time of fluorescein installation)

Inspection — Gross deformity of the eye with obvious volume loss is clear evidence of an open globe (picture 5). Obvious corneal lacerations can sometimes be seen with simple penlight illumination (picture 3).

Subconjunctival hemorrhage (SCH), particularly 360 degrees of bullous SCH, can mask a scleral laceration and should raise suspicion for a posterior globe rupture (picture 12). In addition, intraocular hemorrhage such as hyphema (blood in the anterior chamber) or vitreous hemorrhage can limit the ability to examine the eye completely (picture 13). (See "Traumatic hyphema: Clinical features and diagnosis".)

In cases of ocular laceration, intraocular contents can plug or tamponade the wound, stopping any external leakage of aqueous (picture 5). The presence of uvea (iris, ciliary body, or choroid) prolapsing into or through the wound is diagnostic of an open globe injury (picture 5). In cases of injury posterior to the limbus, uveal prolapse may appear as a dark black, blue, or brown structure trapped underneath the conjunctiva. This is in contrast to SCH that typically appears bright red. (See 'Anatomy' above.)

The iris should be carefully examined before any mydriatic (dilating) drops are placed into the eye. A noncircular, peaked pupil should raise suspicion (picture 5). Iris tissue prolapsing through a cornea or scleral wound is pathognomonic for an open globe (picture 3). If an open globe is apparent or strongly suspected then the clinician should not place drops in the eye.

In addition to careful inspection for external injuries, visual acuity and evaluation for a relative afferent pupillary defect are the two most important physical examination findings for the clinician to elicit [35].

Visual acuity — Visual acuity should always be checked in each eye separately. Care must be taken to ensure that no pressure is applied to the injured eye while covered during vision testing. A standard Snellen acuity chart can be used at a distance of 20 feet. Alternatively, a near card can be used at the distance indicated on the card. Gross visual field deficits should be assessed by direct confrontation.

If the vision is not adequate to read from an eye chart, the ability to count fingers, detect hand motions, or the presence of light perception versus no light perception should be noted. One should consider that patients over the age of 40 are likely to be presbyopic and may require the use of reading glasses in order to adequately assess their vision with a near card. In children, vision assessment varies by the age and developmental capability of the child. (See "The pediatric physical examination: HEENT", section on 'Vision' and "Vision screening and assessment in infants and children".)

Relative afferent pupillary defect — A relative afferent pupillary defect is assessed using the swinging penlight technique: a bright light source is directed back and forth at each eye. The eye with the afferent defect will paradoxically dilate when exposed to the light after it had previously constricted consensually to the same light applied to the other eye (figure 3).

Other findings — More subtle or partially self-sealing corneal wounds may require special use of fluorescein dye, but this is usually reserved for the consulting ophthalmologist. After topical anesthesia drops are placed, a fluorescein dye strip is moistened and applied to the ocular surface. In cases of full-thickness laceration with aqueous flowing out from the anterior chamber, a clear stream of fluid parting the fluorescein dye (positive Seidel test) is noted by illumination with a Wood's lamp or blue light from a slit lamp or ophthalmoscope.

The ophthalmologist will typically assess color vision using color plates, if available. Alternatively, a red object can be used to test for red desaturation. This finding presents as a graying or washed out perception of red color relative to the normal unaffected eye and indicates optic nerve damage.

A full ophthalmic examination including motility, color vision, IOP, anterior segment, and dilated fundus examination should be performed in the uninvolved eye to provide a basis for comparison, to rule out damage from the event to the "good" eye, and to look for preexisting pathology in the fellow eye that may be pertinent to future vision.

Injury to adjacent structures — Open globe injuries are commonly associated with traumatic hyphema (anterior chamber bleeding) or orbital fractures. (See "Orbital fractures" and "Traumatic hyphema: Clinical features and diagnosis".)

PRIMARY EVALUATION AND MANAGEMENT — The approach to the patient with an open globe injury is summarized in a rapid overview (table 1).

Initial emergency assessment and treatment — The standard trauma evaluation should be followed to evaluate for life-threatening injuries in multi-trauma patients before attention is focused on the eye.

In patients requiring intubation, an open globe is a relative contraindication for the use of "high" dose ketamine (6 mg/kg intravenous [IV]) or succinylcholine due to the potential for developing increased intraocular pressure with risk of extrusion of ocular contents [36-38]. Low doses of ketamine (<3 mg/kg) do not appear to increase intraocular pressure [37], but emesis is a common adverse reaction, thus making other sedatives (eg, midazolam, propofol, dexmedetomidine) better choices.

Safe use of succinylcholine in 73 patients undergoing open eye surgery has been described in one case series [39]. In addition, premedication with dexmedetomidine can mitigate increased intraocular pressure if rapid sequence induction is absolutely necessary [40]. However, the administration of other paralytic agents (eg, rocuronium) avoids the risk of intraocular hypertension entirely when emergent endotracheal intubation is necessary. (See "Classification of trauma in children" and "Severe traumatic brain injury (TBI) in children: Initial evaluation and management" and "Evaluation and acute management of cervical spine injuries in children and adolescents" and "Rapid sequence intubation (RSI) in children for emergency medicine: Medications for sedation and paralysis", section on 'Succinylcholine'.)

If an open globe is strongly suggested by history or gross inspection of the eye, the clinician should make every attempt to avoid sudden intraocular hypertension which could cause extrusion of ocular contents and further wound contamination. (See 'Extrusion of ocular contents' above.)

Additional steps to take:

●Avoidance of any eye manipulation

●If an open globe is present on gross eye inspection, avoidance of any eye solutions (eg, fluorescein, tetracaine, cycloplegics)

●Eye shield placement over the affected eye

●Bed rest

●No oral intake

●IV antiemetic therapy (eg, in adults, ondansetron 4 to 8 mg; in children, 0.15 mg/kg, up to 8 mg per dose)

●Pain medication (eg, IV morphine or IV fentanyl). Nonsteroidal antiinflammatory drugs (NSAIDs) are discouraged because of their platelet inhibiting properties.

●Sedation, as needed (eg, lorazepam 0.05 mg/kg, maximum dose: 2 mg)

Blunt force with an object larger than the orbital rim is often associated with orbital bony injury in addition to an open globe, including:

●Blowout fracture with ocular muscle entrapment (see "Orbital fractures", section on 'Orbital floor fracture')

●Orbital hemorrhage with proptosis

●Orbital compartment syndrome: a rapid expansion of a retro-ocular hematoma in the rigid compartment of the bony orbit, leading to elevated orbital pressure with possible optic nerve or central retinal artery ischemia and permanent vision loss within a very short time period. (See "Overview of eye injuries in the emergency department", section on 'Orbital compartment syndrome'.)

Ophthalmology consultation — Patients with an open globe require emergent evaluation by an ophthalmologist.

Imaging — Axial and coronal computed tomography (CT) of the eye without contrast, utilizing 1 to 2 mm cuts through the orbits, is the preferred modality for further assessment of suspected open globe injuries [35]. CT is superior to ultrasound in assessing the location and size of intraocular foreign bodies (IOFBs) and requires no direct contact with the eyelids or globe. CT is faster than magnetic resonance imaging (MRI), has less motion artifact, and will not cause movement of metallic foreign bodies.

CT findings suggestive of open globe injury include IOFB, intraocular air, eye wall or globe deformity, vitreous hemorrhage, volume loss of the eye, decreased anterior chamber depth, and irregular scleral contour (picture 1) [41-43].

However, observational studies indicate that the sensitivity and specificity of ocular CT in detecting open-globe injuries varies from 56 to 77 percent and 79 to 100 percent [41,42,44,45].

Thus, ocular CT has limited ability to demonstrate an occult open globe injury and should not be used as the sole determining factor for decisions regarding surgical exploration.

Additional emergency treatment — Once an open globe is diagnosed, treatment begins with providing antibiotic and tetanus prophylaxis, and then preparing the patient for definitive surgical management. (See 'Definitive management' below.)

NPO (nil per os) status — The patient should receive nothing by mouth.

Empiric antibiotic therapy — Although no trials have evaluated the benefit of prophylactic antibiotics in patients with open globe injury, endophthalmitis is clearly associated with poor outcomes [4]. Thus, we suggest that patients with open globe lacerations receive prophylactic antibiotic treatment with Vancomycin (15 mg/kg, maximum dose: 1.5 g) and ceftazidime (50 mg/kg: maximum dose 2 g) to cover organisms commonly associated with posttraumatic endophthalmitis (Bacillus species, coagulase-negative Staphylococcus, Streptococcal species, S. aureus, and gram negative organisms). Patients allergic to penicillin can receive a fluoroquinolone in place of ceftazidime. This initial prophylaxis is typically augmented by topical antibiotics postoperatively [2,30,33,34]. (See 'Endophthalmitis' above.)

Tetanus prophylaxis — Tetanus status should be determined in patients with open globe injuries and tetanus prophylaxis should be administered based on the nature of the wound and the time since last immunization (table 2) [27]. An open globe rupture is typically considered a clean wound. Ocular lacerations, especially those occurring in rural settings or associated with IOFBs, are considered tetanus prone.

DEFINITIVE MANAGEMENT — Any significant ocular injury resulting in altered vision should prompt urgent ophthalmologic evaluation. When there is suspicion or definite evidence of globe rupture or laceration, immediate ophthalmic consultation is indicated, with prompt transfer to another hospital if ophthalmology consultation is not readily available.

Many community based ophthalmologists may prefer transfer of open globe patients to a tertiary trauma center if they are not experienced with surgical globe repair. Transfer should not delay the institution of antibiotics.

Rapid primary closure of an open globe injury by an ophthalmologist promotes the best visual outcome for the patient. Many factors determine optimal timing for surgical repair [12]. In general, closure within 24 hours of injury is ideal.

OUTCOMES — Preservation of useful vision has been described in up to 75 percent of patients with open globe injury [46]. The extent of initial injury, mechanism of injury, and initial eye findings at presentation are important predictors of final outcome. Rapid primary closure (ideally within 24 hours of injury) and antibiotic treatment to prevent endophthalmitis are the core of ophthalmologic intervention.

Factors associated with poor visual outcome, defined in different studies as visual acuity of 20/200 (6/60), no light perception (unable to see the brightest possible light), or enucleation following open globe injury, include [2,16,41,44,47-50]:

●Open globe rupture from a blunt mechanism [46]

●Initial visual acuity of hand movements or worse (eg, no light perception or gross evisceration) [47-49]

●Relative afferent pupillary defect on initial examination [46-49] (see 'Physical examination' above)

●Posterior wound location (Zone 3) [47-49]

●Metallic intraocular foreign bodies (IOFBs) caused by BB or pellet injury [51]

●Associated injuries, especially lid laceration, orbital fracture, hyphema, lens damage, vitreous hemorrhage, or retinal detachment [46,48,49]

●The degree of injury present on CT, especially moderate to severe scleral deformity [41,44]

●Elapsed time between injury and primary closure [48]

●Development of endophthalmitis [2,16]

Two scoring systems have been developed to provide prognostic guidance to ophthalmologists and their patients:

●The Ocular Trauma Score, derived from analysis of 2500 eye injuries, is a point system based on initial visual acuity, the presence of globe rupture, endophthalmitis, perforating injury, retinal detachment, and/or relative afferent pupillary defect. This system has not been prospectively validated [5,52,53].

●A separate model, developed from analysis of 214 patients with open globe injuries, found that variables most predictive of outcome were initial visual acuity, relative afferent pupillary defect, posterior wound location, and associated lid laceration. During prospective validation, the model predicted blindness with a sensitivity of 86 percent and identified patients with vision survival with a specificity of 92 percent [5].

Traumatic cataract is the most common complication that limits vision and can occur at any time from one day to years after an injury. In addition, Zone 1 injuries may lead to corneal scarring (typically weeks to months after injury), and Zone 2 or 3 injuries may develop retinal detachment (immediately or weeks to months later due to retinal scar formation) [54]. (See "Cataract in children" and 'Zone of injury' above.)

SUMMARY AND RECOMMENDATIONS — The approach to the patient with an open globe injury is summarized in a rapid overview (table 1).

●Open globe rupture occurs following blunt eye injury at the site of greatest structural weakness [1]. (See 'Definition' above and 'Pathophysiology' above.)

●Open globe laceration refers to a penetrating injury to the eye by a sharp object or projectile and is further subclassified as penetrating (entry wound but no exit wound) or perforating (entry and exit wounds) [1]. Open globe laceration may also be complicated by an intraocular foreign body (IOFB) (picture 2). (See 'Definition' above.)

●A history consistent with high risk eye trauma such as a high velocity projectile, high impact blunt trauma, or injury from a sharp object should raise suspicion for open globe injury. (See 'History' above.)

●In patients with a high likelihood of an open globe, the clinician should avoid any examination procedure that might apply pressure to the eyeball, such as eyelid retraction or intraocular pressure measurement by tonometry. (See 'Physical examination' above.)

●In cases of obvious or very likely open globe (picture 4 and picture 5 and picture 8 and picture 9 and picture 10), the examiner should avoid placing any medication (eg, tetracaine) or diagnostic eye drops (eg, fluorescein) into the eye. (See 'Physical examination' above.)

●Gross deformity of the eye with obvious volume loss is clear evidence of an open globe (picture 6). (See 'Inspection' above.)

●In addition to careful inspection for obvious injuries, visual acuity and evaluation for a relative afferent pupillary defect are the two most important components of the physical examination (table 1). (See 'Visual acuity' above and 'Relative afferent pupillary defect' above.)

●The standard trauma evaluation should be followed to evaluate for life-threatening injuries in multiple trauma patients BEFORE attention is focused on the eye. (See "Trauma management: Approach to the unstable child", section on 'Initial approach' and "Trauma management: Approach to the unstable child", section on 'Primary survey'.)

●If an open globe is strongly suggested by history or gross inspection of the eye, the clinician should make every attempt to avoid sudden intraocular hypertension with resulting extrusion of ocular contents caused by Valsalva (vomiting or crying) and external eye compression (see 'Initial emergency assessment and treatment' above). Specific measures include:

•Avoidance of any eye manipulation

•If an open globe is present on gross inspection of the eye, avoidance of any topical eye solutions (eg, fluorescein, tetracaine, cycloplegics)

•Eye shield placement over the affected eye

•Bed rest

•Antiemetic therapy (eg, ondansetron, intravenously)

•Sedation and analgesia (eg, morphine or fentanyl, intravenously)

●Patients with a known or highly suspected open globe require emergent evaluation by an ophthalmologist. (See 'Ophthalmology consultation' above.)

●Axial and coronal computed tomography [CT] of the eye without contrast, utilizing 1 to 2 mm cuts through the orbits, is the preferred modality for further assessment of suspected open globe injuries. (See 'Imaging' above.)

●We suggest that patients with open globe lacerations receive prophylactic antibiotic treatment (Grade 2C). Vancomycin (15 mg/kg, maximum dose: 1.5 g) and ceftazidime (50 mg/kg: maximum dose 2 g) provide empirical coverage for the most common organisms. Penicillin-allergic patients may receive a fluoroquinolone in place of ceftazidime. (See 'Empiric antibiotic therapy' above and 'Endophthalmitis' above.)

●Tetanus prophylaxis should be administered based on the nature of the wound and the time since last immunization (table 2). An open globe rupture is typically considered a clean wound. Ocular lacerations, especially those occurring in rural settings or associated with IOFB, are considered tetanus prone. (See 'Tetanus prophylaxis' above.)

●Rapid primary closure of an open globe injury by an ophthalmologist promotes the best visual outcome for the patient. Many factors determine optimal timing for surgical repair. In general, closure within 24 hours of injury is ideal. (See 'Definitive management' above.)