Residency · Residency · Ophthalmology

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

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.

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)

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.

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.

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