# Open Globe Injury: Assessment and Surgical Management

## Introduction

An open globe injury is defined as a full-thickness wound of the cornea and/or sclera. These injuries represent ophthalmic emergencies requiring prompt recognition, appropriate initial stabilization, and timely surgical repair. The **Birmingham Eye Trauma Terminology (BETT)** system and the **Ocular Trauma Score (OTS)** provide standardized classification and prognostic frameworks.

## Classification (BETT System)

### Open Globe Injuries

**Rupture**: full-thickness wound caused by blunt force; globe gives way at weakest point (often at limbus, prior surgical wounds, or equator) **Laceration**: full-thickness wound caused by a sharp object. **Penetrating injury**: single full-thickness entry wound. **Perforating injury**: through-and-through injury with both entry and exit wounds. **Intraocular foreign body (IOFB)**: retained foreign body within the eye (technically a penetrating injury)

### Zones of Injury

| Zone | Location | Prognostic Implication |
|------|----------|----------------------|
| I | Cornea (including limbus) | Best prognosis |
| II | Anterior sclera (limbus to 5 mm posterior) | Intermediate |
| III | Posterior sclera (>5 mm from limbus) | Worst prognosis |

## Initial Assessment

### History

Mechanism of injury: blunt vs. sharp, velocity, object involved. **Hammering on metal**: high suspicion for IOFB. Use of protective eyewear. Time of injury and last meal (for anesthesia planning) Tetanus immunization status.

### Emergency Department Examination

**Visual acuity**: critical for prognosis and documentation; even light perception vs. no light perception. Pupil examination: **relative afferent pupillary defect (RAPD)** is a strong negative prognostic indicator. Avoid any maneuver that may increase pressure on the globe. External examination: periorbital edema, ecchymosis, lacerations. Inspection (without applying pressure): wound location, prolapsed tissue, flat anterior chamber, hyphema, lens dislocation, vitreous prolapse. **Do NOT perform tonometry** on a suspected open globe.

**Do NOT force open swollen lids**; use a lid speculum carefully or defer to OR examination.

### Protective Measures

Place a rigid **eye shield** (Fox shield); avoid pressure patches. Administer antiemetics (ondansetron) to prevent Valsalva. Pain management (avoid topical medications in known open globe) NPO for anticipated surgery.

![Clinical photograph of a corneal laceration with iris prolapse in an open globe injury](images/open-globe-corneal-laceration.jpg)

### Imaging

**CT orbit (axial and coronal, thin cuts)** without contrast: standard of care. Detects IOFBs (metallic, glass), retrobulbar hemorrhage, fractures. Identifies scleral discontinuity, vitreous hemorrhage, lens dislocation, retinal detachment. **MRI is contraindicated** if metallic IOFB is suspected. Plain X-rays: limited role; can detect radiopaque foreign bodies. B-scan ultrasound: generally deferred until the globe is closed to avoid pressure on the eye.

## Medical Management

### Systemic Antibiotics

**IV broad-spectrum antibiotics** within 6 hours to prevent endophthalmitis. Common regimens: vancomycin + ceftazidime (or fluoroquinolone) Duration: typically 48-72 hours IV, then oral step-down. Risk of endophthalmitis: 3-10% in penetrating injuries; higher with IOFB (especially organic material), delayed repair, rural setting.

### Tetanus Prophylaxis

Administer tetanus toxoid if immunization is not current.

### Corticosteroids

Consider systemic corticosteroids for posterior segment injuries to reduce proliferative vitreoretinopathy (controversial)

## Surgical Repair

### Timing

Primary repair within **24 hours** is ideal. Earlier repair is better, but delaying to optimize conditions (available OR, experienced surgeon) is acceptable. Clean wounds can wait up to 24-36 hours without significantly worsening prognosis.

### Principles of Primary Repair

#### Corneal Laceration

Inspect wound carefully; identify prolapsed tissue (iris, vitreous, lens) Reposition viable iris if injury is less than 24 hours old; excise if necrotic or contaminated. Watertight closure with **10-0 nylon sutures**. Place first suture at the apex of a stellate wound or at the limbus for wounds extending to the limbus. Shelved or beveled wounds may self-seal; still suture for security. Restore anterior chamber depth with balanced salt solution or viscoelastic.

Avoid entrapping iris or vitreous in the wound.

#### Scleral Laceration

360-degree conjunctival peritomy to explore the full extent of the wound. Gentle exploration; do not pull on prolapsed tissue. Close with **8-0 or 9-0 nylon** or polyglactin (Vicryl) sutures. If uveal tissue is prolapsed and viable, reposit; if contaminated, excise. If vitreous is incarcerated, use cellulose sponge and scissors to cut flush (avoid traction) Posterior wounds may be difficult to access; close what is accessible; mark the posterior extent.

#### IOFB Removal

Timing: primary repair first; IOFB removal at the time of primary repair or as a planned secondary procedure (within 24-72 hours) Pars plana vitrectomy with IOFB removal using intraocular forceps or rare-earth magnet. **Organic IOFBs** carry higher endophthalmitis risk and should be removed urgently. Metallic IOFBs: iron causes **siderosis** (progressive retinal toxicity); copper causes **chalcosis** (severe inflammation)

![Intraoperative photograph showing primary suture repair of a corneal-scleral laceration](images/open-globe-primary-repair.jpg)

### Secondary Surgery

**Vitrectomy**: for non-clearing vitreous hemorrhage, retinal detachment, IOFB removal, endophthalmitis. Typically performed 7-14 days after primary repair (allows for corneal clearing and inflammation to subside) Earlier vitrectomy if endophthalmitis is suspected (intravitreal antibiotics + vitrectomy) Lensectomy for traumatic cataract or lens dislocation. Scleral buckle and/or silicone oil tamponade for retinal detachment.

## Ocular Trauma Score (OTS)

### Calculation

Based on initial visual acuity, globe rupture, endophthalmitis, perforating injury, retinal detachment, RAPD. Assigns a score from 1 to 5 predicting likelihood of various final visual acuity outcomes.

### Variables and Points

Initial VA: NLP = 60, LP/HM = 70, 1/200-19/200 = 80, 20/200-20/50 = 90, 20/40+ = 100. Subtract points for: rupture (-23), endophthalmitis (-17), perforating injury (-14), retinal detachment (-11), RAPD (-10)

### Prognostic Value

OTS provides an evidence-based framework for counseling patients and families. Should not be used in isolation to determine whether to attempt repair.

![Ocular Trauma Score calculation chart and prognostic categories](images/ocular-trauma-score-chart.jpg)

## Complications

**Endophthalmitis**: most feared complication; intravitreal antibiotics (vancomycin + ceftazidime) **Traumatic cataract**: very common; plan for IOL placement at secondary surgery. **Retinal detachment**: rhegmatogenous or tractional (proliferative vitreoretinopathy) **Sympathetic ophthalmia**: bilateral granulomatous panuveitis; risk with penetrating injuries involving uveal tissue. **Phthisis bulbi**: end-stage atrophic globe from severe injury. **Corneal scarring** and irregular astigmatism.

## Key Clinical Pearls

Never apply pressure to a suspected open globe; place a rigid shield and arrange urgent surgical consultation. CT orbit without contrast is the imaging modality of choice; MRI is contraindicated when metallic IOFB is possible. Systemic IV antibiotics should be administered within 6 hours of injury to reduce the risk of endophthalmitis. The Ocular Trauma Score provides a validated prognostic tool but should not be the sole determinant of the decision to operate.

## References

1. Kuhn F, Morris R, Witherspoon CD. Birmingham Eye Trauma Terminology (BETT): terminology and classification of mechanical eye injuries. *Ophthalmol Clin North Am*. 2002;15(2):139-143.
2. Scott R. The Ocular Trauma Score. *Community Eye Health*. 2015;28(91):44-45.
3. Andreoli CM, Andreoli MT, Kloek CE, et al. Low rate of endophthalmitis in a large series of open globe injuries. *Am J Ophthalmol*. 2009;147(4):601-608.
4. Colyer MH, Weber ED, Weichel ED, et al. Delayed intraocular foreign body removal without endophthalmitis during Operations Iraqi Freedom and Enduring Freedom. *Ophthalmology*. 2007;114(8):1439-1447.