Open Globe Injury

A full thickness wound of the cornea, sclera or both. It is an ophthalmic surgical emergency, with a risk of endophthalmitis (1 to 8 percent, higher with delay or foreign body), proliferative vitreoretinopathy, retinal detachment, and sympathetic ophthalmia.

• Terminology:
  • Rupture: full thickness wound caused by blunt force (inside out mechanism).
  • Laceration: full thickness wound from a sharp object (outside in): penetrating (entrance only), intraocular foreign body (retained object), perforating (entrance and exit wounds).
• Location: zone 1 (cornea and limbus), zone 2 (sclera up to 5 mm behind the limbus), zone 3 (sclera more than 5 mm posterior to the limbus); worse prognosis with posterior wounds.
• Poor prognostic factors: initial vision of light perception or worse, relative afferent pupillary defect, zone 3 wound, wound length above 10 mm, vitreous haemorrhage, retinal detachment, lens damage, uveal prolapse, and delayed repair.

• Pain, reduced vision, history of sharp or high velocity injury or severe blunt trauma.
• Corneal or scleral wound, positive Seidel test (aqueous leaking, stream of clear fluid washing away fluorescein), flat or deep anterior chamber (deep chamber with scleral rupture behind), peaked or teardrop pupil pointing to the wound, uveal tissue or vitreous prolapse, hyphaema, 360 degree subconjunctival haemorrhage (occult scleral rupture), soft eye, lens subluxation or cataract, vitreous haemorrhage, and enophthalmos.
• Signs that suggest occult rupture: bullous subconjunctival haemorrhage with chemosis, dark uvea under conjunctiva, low pressure, and limited motility.

• Clinical diagnosis. Avoid any pressure on the globe, intraocular pressure measurement, forced lid opening, drops, ointment, or removal of protruding tissue or foreign objects.
• Gentle examination with a penlight and slit lamp; visual acuity, pupil and relative afferent pupillary defect; document the wound and mark time.
• CT orbits with thin slices (1 mm) with coronal reconstruction: scleral discontinuity, flat globe or "flat tyre" sign, intraocular air, loss of volume, lens displacement, intraocular foreign body; B-scan ultrasound only by experienced examiners without pressure when diagnosis is uncertain; avoid MRI until metal is excluded.
• Dilated fundus examination at surgery when media is clear.
• Blood tests for surgery, tetanus status, anaesthetic assessment, and time since last meal.

• Pre-hospital and emergency: rigid shield over the orbital rim (no patch, no pressure), supine at 30 degrees, nil by mouth, analgesia (paracetamol 1 g IV, morphine 2 to 5 mg IV), antiemetic (ondansetron 4 mg IV), and tetanus prophylaxis (toxoid 0.5 mL IM, tetanus immunoglobulin 250 IU IM for dirty wounds).
• Systemic antibiotics (start immediately, continue 5 to 7 days): moxifloxacin 400 mg orally or IV daily, or levofloxacin 750 mg daily; alternatively vancomycin 1 g IV every 12 hours with ceftazidime 1 g IV every 8 hours; for children, weight based dosing (cefazolin 25 to 50 mg/kg/day divided or ceftriaxone 50 mg/kg daily).
• Surgical repair under general anaesthesia within 24 hours (ideally within 12 hours) while avoiding drugs and manoeuvres that raise intraocular pressure (use a rapid sequence induction with rocuronium if a full stomach; avoid coughing, straining, and succinylcholine where alternatives exist):
  • Primary closure of cornea with interrupted 10-0 nylon sutures, limbus and sclera with 8-0 or 9-0 nylon (scleral exploration under conjunctival peritomy with 360 degrees inspection when occult rupture is suspected, including beneath rectus muscles).
  • Reposition viable uveal tissue (excise only necrotic tissue), remove prolapsed vitreous with a vitrector or sponge and scissors, and reform the anterior chamber with viscoelastic or balanced salt solution.
  • Avoid primary lens removal unless the capsule is disrupted and the lens swollen.
  • Intracameral cefuroxime 1 mg or moxifloxacin 0.5 mg, or intravitreal vancomycin 1 mg with ceftazidime 2.25 mg for contaminated wounds or retained foreign body.
  • Subconjunctival antibiotics at the end of the case (cefuroxime 125 mg or gentamicin 20 mg with steroid).
• Postoperative: topical moxifloxacin 0.5 percent four times daily, prednisolone acetate 1 percent four to eight times daily, atropine 1 percent twice daily; shield at night; follow for endophthalmitis (increasing pain, hypopyon).
• Secondary surgery (7 to 14 days): pars plana vitrectomy for vitreous haemorrhage, retinal detachment, or proliferative vitreoretinopathy with silicone oil tamponade as necessary.
• Eyes without light perception and unsalvageable (extensive disorganisation): primary or secondary enucleation or evisceration within 10 to 14 days to reduce the risk of sympathetic ophthalmia, after discussion of consent and prosthesis.
• Sympathetic ophthalmia (granulomatous panuveitis in the fellow eye, typically 2 weeks to 3 months after injury): oral prednisolone 1 to 1.5 mg/kg daily with steroid sparing agents (azathioprine, mycophenolate, ciclosporin).
• Counselling about visual prognosis, monocular precautions, and eyewear.