Open Globe Injuries1

Corneal laceration.

Corneoscleral laceration.

Globe rupture.

Intraocular foreign body (IOFB).

Reassure the patient—make them comfortable and handle them gently.

Check visual acuity first.

Use sterile disposable gloves for examination.

Clean ooze/discharge/external contamination carefully with sterile gauze.

Lids to be separated very gently for slit lamp examination.

For paediatric cases—minimal manipulation/torch light examinations. Rest of the details to be evaluated under GA.

Look for any associated facial asymmetry/lid and adnexal trauma/enophthalmos/proptosis.

Look for any evidence of infections—lid edema, purulent discharge etc.

Examine the pupils and check for RAPD in all cases.

Inform trauma/duty consultant for help if required.

Check for extraocular movement—In open globe state, do not check for ocular motility, since this can lead to raised intraocular pressure and extrusion of ocular contents.

Always look for the posterior extent of the laceration, if possible.

Determine whether the laceration is full thickness or partial thickness. If in doubt look for anterior chamber depth/perform forced Siedel's test.

Measure the dimensions of the laceration and represent the same with a diagram.

Record other anterior segment details like, anterior chamber reaction, blood in anterior chamber, status of the lens, uveal prolapse, vitreous prolapse, etc.

Do not perform intraocular pressure measurement in open globes.

Defer fundus examination in open globes (in self-sealed injuries fundus examination can be done with minimal manipulation and no scleral indentation).

USG can be done in self-sealed lacerations. Defer in open globes.

Suspect globe rupture in cases with dense subconjunctival hemorrhage, subconjunctival pigment and soft eye.

Examination is the same as in corneal laceration except that the patient may be advised CT scan to rule out foreign body and associated orbital injuries where appropriate.

History regarding the dimension of the foreign body, composition (magnetic or non-magnetic).

Patients with penetrating trauma with the history of injury with flying objects should be advised CT scan to rule out the presence of foreign body and perforating orbital injuries.

Ask for thin orbital overlapping cuts with axial and coronal cuts in the CT scan (2 mm cuts).

MRI should not be advised if metallic foreign body is suspected.

Reassurance.

Ensure that the patient does not strain in any way.

Shield the eye at the earliest.

Nil per orally till advised, otherwise.

Tetanus prophylaxis—Tetanus toxoid/Tetanus immunoglobulin (Tet.glob).

Inform the Trauma Consultant/Duty Consultant, Anaesthetist and Operative Theatre staff.

Urgent Physician fitness/Anaesthetist fitness for GA to be obtained.

Hospitalise the patient immediately.

Prophylactic parenteral antibiotics (usually a combination of cefazolin and gentamycin)—tailored to the individual case.

Surgery to be scheduled at the earliest.

All open globe injuries to be repaired under GA.

Peribulbar/parabulbar/retrobulbar anaesthesia should be strictly avoided.

If there is any life-threatening contraindication for GA, facial akinesia by O'Brien's/Van Lint technique can be combined with topical anaesthesia.

Iris tissue when abscised to be sent for microbiological examination.

In case of retained intraocular foreign body with open globe VR surgeon to be informed urgently.

Cases of open globe injury repaired elsewhere with retained intraocular foreign body to be seen by VR consultants.