Penetrating Eye Injury

A full thickness laceration of the cornea or sclera by a sharp object with a single entrance wound and no exit wound. When the object passes through and exits (such as high velocity missiles), the term perforating injury applies, and a retained object is an intraocular foreign body.

• Causes: knives, scissors, needles, pencils, wire, glass, wood splinters, fish hooks, thorns, darts, fireworks, and gunshot or pellet injuries.
• The wound classification by zone (zone 1 corneal and limbal; zone 2 anterior sclera to 5 mm from the limbus; zone 3 posterior to 5 mm) predicts the risk of retinal injury and visual outcome.
• Organic and soil contamination (vegetable matter, thorn injuries) carry a high risk of bacterial and fungal endophthalmitis.
• Self-sealing small corneal wounds can be missed and later cause endophthalmitis.

• Sudden pain and loss of vision after an injury with a sharp object; some are painless with minimal symptoms.
• Visible full thickness wound, positive Seidel test, shallow anterior chamber, peaked pupil, iris prolapse or plugging the wound, lens opacity or capsule rupture (traumatic cataract), vitreous prolapse, hyphaema, vitreous haemorrhage, and low pressure.
• Retinal tear or detachment, endophthalmitis (increasing pain, hypopyon, loss of vision within days) and intraocular foreign body signs if the object is retained.
• Children: small injuries with few symptoms; consider amblyopia risk.

• Careful history of the object and force; examination with minimal manipulation; slit lamp and Seidel test when the wound is small and the globe is not obviously open.
• CT orbits with thin slices to detect retained foreign body and assess posterior extension; B-scan only by experienced operators.
• Document visual acuity, pupils, wound location and size, lens status and posterior segment findings.
• Culture of wound or intraocular fluid when infection is suspected.

• Shield, nil by mouth, tetanus prophylaxis, and systemic antibiotics (moxifloxacin 400 mg daily for 5 to 7 days, or vancomycin 1 g every 12 hours with ceftazidime 1 g every 8 hours for contaminated wounds).
• Surgery within 24 hours:
  • Small clean self-sealed corneal wounds (under 2 to 3 mm with formed chamber and negative Seidel test) can be managed with a bandage contact lens, aqueous suppressant (timolol 0.5 percent twice daily), topical antibiotic four times daily and close monitoring.
  • Larger corneal and corneoscleral wounds: suturing with 10-0 nylon, reposition or excision of prolapsed iris, formation of the anterior chamber, and repair of lens or capsule injury with lensectomy and anterior vitrectomy when required.
  • Scleral wounds: peritomy, wound closure with 8-0 or 9-0 nylon, avoiding incarcerated vitreous (cut with vitrector or sponge and scissors), cryopexy or laser around anterior retinal breaks.
  • Primary or delayed pars plana vitrectomy (7 to 14 days) for retinal detachment, vitreous haemorrhage, and posterior wounds.
  • Traumatic cataract: remove at primary repair if disrupted, otherwise delayed lens extraction with intraocular lens implantation.
• Intracameral cefuroxime 1 mg in 0.1 mL (or moxifloxacin 0.5 mg) and intravitreal vancomycin 1 mg with ceftazidime 2.25 mg for organic matter contamination or established endophthalmitis.
• Postoperative therapy: topical antibiotic, prednisolone acetate 1 percent, atropine 1 percent; monitor endophthalmitis, intraocular pressure, retinal detachment, proliferative vitreoretinopathy.
• Amblyopia treatment in children (patching, refractive correction after repair).
• Counselling: guarded outcomes when posterior, and long term follow up for glaucoma and retinal detachment.