1. Open Globe Injuries
Maddy Alexeeva PGY-1

2. Be Suspicious….

3. Case:
26 year old male
Was out with friends drinking, on the way home from the bar he decided to urinate in the woods
Tripped over a log and fell forwards onto a tree – a small stick went into his eye

4. Case: 19 year old mechanic
Today at work, spring “popped into his eye” and then fell to ground
All you see is a defect in the cornea

5. Trauma to the eye: what to think about
Corneal abrasion
Intraocular foreign body
Retrobulbar hemorrhage
Vitreous hemorrhage
Open globe injury
Rupture
Laceration

6. Globe Injuries: Any disruption of the outer membranes of the eye
Trauma can be blunt, penetrating, or combined
Blunt
Usually at structurally weakest part of the eye – near equator, behind rectus muscle insertion points
Laceration: think foreign object
Penetrating: entry, no exit
Perforating: both entry and exit
Full thickness – sclera or cornea

7. Can be described by anatomical location, type of trauma, and grade (visual acuity), and pupil involvement
Location
-Cornea
-Limbus
-Insertion site
Pupil
Grade
I. Cornea
II. Limbus to 5mm posterior into sclera
III. Posterior to 5mm from limbus
Relative afferent pupillary defect or none
>20/40
20/50 to 20/100
19/100 to 5/200
4/200 – light perception
No light perception

8. Globe Rupture Compression on an A-P axis
Intraocular pressure increases – tearing of sclera
Suspect in MVCs, sports, paintball injuries, assaults, trauma
Cause diffuse injury, hemorrhagic choroidal and retinal detachment – secondary injury with diffuse healing response
tearing of the sclera at thinnest areas
Insertions of EOMs
Limbus
Prior surgical sites

9. Uveal prolapse
Rupture

10. Globe Laceration Sharp or quickly-traveling objects
Metal on metal (hammer and chisel), grinding
BBs, pellet guns
Worse outcomes with PERFORATING
Exit wound can be around optic nerve, macula, etc.
Better outcomes with PENETRATING
More localized, less structures affected

11. Perforating injuries
Penetrating injuries

12. Testing <2mm may be small enough to seal themselves Seidel testing
Pass: no need for surgical intervention if no other factors present (IOFB, cataracts, endophthalmitis
Be suspicious! If surgery needed: hr window
Start antibiotics
10% fluorescein strip applied to eye
Cobalt blue filter with slit lamp

13. Seidel test

14. Poor outcome is associated with:
Initial vision after injury that only perceives light, or no light at all
Injury involving the area posterior to the insertion of the rectus muscles
Wounds >10mm
Blunt injuries
Missile penetration – high velocity foreign object

15. Appears as layered WBCs - Hypopyon
Endophthalmitis
10 to 100 times more common following trauma than surgery
Rapid, irreversible vision loss
Systemic antibiotics then topical antibiotics after repair
Can take a few days to start
Appears as layered WBCs - Hypopyon

16. What needs to be asked? What happened? When? How?
Possible foreign objects?
Contact lenses or glasses? Protective devices?
Vision complaints?
PMHx
Prior eye surgery
Medications (eye drops)
Tetanus status
Allergies and other medical issues

17. Physical exam DO NOT APPLY PRESSURE TO EYE Initial inspection
Distracting injury
Vision testing – injured and non-injured eye
Evaluate for diplopia and orbital floor fracture
Prolapsing uveal tissue
Misshapen eye
Visible foreign object

18. Cornea and Sclera – defects, buckling Pupil – tear drop, iris prolapse
Eyelid
Orbits:
Bony deformity, crepitus
Foreign body – leave in place until surgery
Exophthalmos
Conjunctiva:
Conjunctival hemorrhage – severe (360 degrees) associated with rupture
Cornea and Sclera – defects, buckling
Pupil – tear drop, iris prolapse
Anterior Chamber: hyphema, red reflex

19. Exophthalmos Retrobulbar hemorrhage
Iris prolapse
Exophthalmos Retrobulbar hemorrhage

20. What else? CT of orbits and any other affected areas
Collapsed globe – “flat tire” or “mushroom”
Hazy appearance around globe
Increased chamber size
AVOID TESTING PRESSURE or using ultrasound
MRI is contraindicated if metallic objects involved
Wait to repair eyelid or conjunctival lacerations until globe rupture is determined

21. Management Emergent Ophthalmological evaluation  to the OR
Head of the bed to 30 degrees
Rigid shield or cup to protect eye
Sedatives, pain control, antiemetics – prevent Valsalva
Update tetanus, Antibiotics – Ceftazidime, Ciprofloxacin, Gentamicin, Vanco
No solid evidence for prophylactic benefit, but still recommended
Ceftaz – 3rd gen; gram neg, pseudomonas
Cipro – staph and pseudomonas (not good strep, anaerobes) can add clinda – eye IV form good penetration
Gent – pseudomonas, synergy with betalactamase
Vanco – alternative to ceftaz; gram +, bacillus
Endophthalmitis after globe injury is estimated at an occurrence rate of 6.8%
Staph aureus, staph epi, Bacillus, and strep species most common
Consider Eikenella, Pasteurella for animal injuries, gram-negatives and fungi in farming injuries

22. Be suspicious.

23. References
Ocular injuries: New strategies in emergency department management; Messman, A.; Emergency Medicine Practice, Volume 17, number 11, November 2015.