What is the best next step in management for a patient with a potential penetrating eye injury after trauma?

Management of Suspected Penetrating Eye Injury After Tree Branch Trauma

Cover the eye with an eye shield immediately to protect the globe from further injury and arrange urgent ophthalmology consultation. 1

Immediate Priority: Globe Protection

• Do not manipulate or apply pressure to the eye – any suspected penetrating injury requires immediate protection with a rigid shield (hard plastic eye shield, paper cup, or plastic cup taped over the eye without touching the globe itself) 1
• The patient must be instructed not to rub the eye, as this can exacerbate globe rupture and worsen outcomes 1
• A ruptured globe should be protected by an eye shield before any other interventions 2, 3

Why Eye Shield Takes Priority Over Other Options

Checking Intraocular Pressure is Contraindicated

• Never perform tonometry (IOP measurement) on a suspected open globe – applying pressure to measure intraocular pressure can cause extrusion of intraocular contents and irreversible damage 3
• This is a critical pitfall that can convert a potentially salvageable eye into one with poor visual outcomes 2

Ocular Ultrasound is Contraindicated

• Ultrasound probe contact with a ruptured globe can cause further trauma and should be avoided until globe integrity is confirmed 3
• While ultrasound may eventually be useful for evaluating posterior segment injuries, it is not the immediate next step when penetrating injury is suspected 2

Orbital CT Scan Comes After Initial Protection

• CT imaging is valuable for identifying intraocular foreign bodies, trajectory assessment, and evaluating extent of injury, but the eye must first be protected with a shield 3
• Imaging should not delay globe protection or ophthalmology consultation 2, 3
• CT is typically performed after initial stabilization and shield placement 3

Clinical Context Supporting This Approach

• High-velocity or sharp object mechanisms (like tree branches) carry significant risk for globe penetration ranging from corneal laceration to full-thickness perforation 1
• The 2024 American Heart Association/American Red Cross guidelines explicitly state that penetrating eye injury from a sharp object requires immediate medical attention 1
• Signs suggesting penetrating injury include: irregular pupil after trauma, eye bleeding, loss of vision, or visible globe disruption 1

Subsequent Management Algorithm

After eye shield placement 1:

1. Immediate ophthalmology consultation – do not delay for imaging if clinical suspicion is high 2, 3
2. Systemic antibiotics should be prescribed if penetrating or perforating injury is suspected to prevent endophthalmitis 2
3. NPO status – the patient should be kept nothing by mouth in anticipation of urgent surgical repair 2
4. Avoid antiemetics if possible – vomiting increases intraocular pressure and can worsen globe rupture 3
5. Primary surgical repair should be performed in a timely fashion once the diagnosis is confirmed 2

Important Prognostic Considerations

• Poor initial visual acuity does not guarantee poor final outcome – definitive prognosis typically cannot be determined until 3-4 weeks post-injury 2
• Penetrating injuries reported to the National Eye Trauma System Registry showed that 62% had initial visual acuity of hand motion or worse, but many improved with appropriate management 4
• The outcome depends critically on timely recognition, appropriate initial management (eye shield), and prompt surgical intervention 2, 3