What is the priority intervention for a patient with a penetrating eye injury and asymmetry of the globe?

Management of Penetrating Eye Injury with Globe Asymmetry

For a patient with a large piece of metal penetrating the eye and globe asymmetry, the nurse should immediately apply a protective shield over the eye without removing the foreign object and arrange for emergency ophthalmological evaluation. 1, 2

Initial Assessment and Priority Interventions

• Apply a hard plastic eye shield, paper cup, or plastic cup over the affected eye without applying pressure to the globe or attempting to remove the foreign object 1
• Do not manipulate the eye or attempt to remove the impaled metal object as this could cause further damage to ocular structures 2
• Position the patient with the head slightly elevated to reduce intraocular pressure 1
• Avoid having the patient rub or touch the affected eye 1
• Recognize that globe asymmetry with a penetrating object is a sign of severe ocular trauma requiring immediate intervention 1, 2

Clinical Significance of Globe Asymmetry

• Globe asymmetry in the setting of penetrating trauma indicates potential full-thickness injury to the eyewall (open globe injury) 3
• Asymmetry may result from:
  • Disruption of the normal globe contour due to penetration 1
  • Displacement of intraocular contents 3
  • Orbital compartment changes from hemorrhage or edema 1
• Irregular pupil often accompanies globe asymmetry and indicates uveal damage, which is present in 94% of penetrating eye injuries 4

Secondary Interventions

• Assess visual acuity without manipulating the eye if possible 5
• Document the mechanism of injury and time since injury occurred 3
• Administer tetanus prophylaxis if indicated based on immunization history 3
• Arrange for non-contrast thin-section orbital CT with multiplanar reconstructions to assess the extent of injury 2
• Avoid MRI when metallic foreign bodies are suspected as the magnetic field could cause movement of the object 2

Rationale for Intervention Priority

• Penetrating eye injuries with globe asymmetry have a high risk of permanent vision loss, with studies showing 28% resulting in enucleation and 10% in no light perception 4
• Secondary injury can occur from manipulation of the penetrating object, which can cause further damage to intraocular structures 3, 6
• The risk of infection is high in open globe injuries, with complications occurring in 25% of cases 4
• Proper protection of the eye with a shield prevents inadvertent pressure on the globe that could extrude intraocular contents 1, 2

Common Pitfalls to Avoid

• Never attempt to remove an impaled object from the eye as this could cause further damage and vision loss 1, 2
• Avoid applying direct pressure to the eye or globe 1
• Do not delay ophthalmological consultation as time to treatment affects visual outcomes 4
• Avoid administering topical medications before ophthalmological assessment 2
• Do not allow the patient to eat or drink in preparation for possible emergency surgery 3

By following these guidelines, the nurse can help preserve vision and improve outcomes in this ocular emergency that requires immediate and careful management.