Open Globe Injury
This patient has an open globe injury (Option A), and requires immediate ophthalmology consultation, rigid eye shield placement without any pressure, systemic antibiotics, and urgent surgical exploration and primary closure. 1
Clinical Diagnosis
The presentation is pathognomonic for open globe injury:
- Teardrop pupil indicates full-thickness defect of the eyewall with iris prolapse through the wound 2
- Cloudy anterior chamber suggests disruption of normal ocular anatomy with possible aqueous humor leak, hemorrhage, or inflammatory response 3
- Metallic foreign body mechanism creates high-velocity penetrating trauma with high risk for intraocular foreign body retention 3
Open globe injuries are full-thickness defects of the eyewall and represent true ocular emergencies requiring immediate intervention to prevent irreversible vision loss 2.
Immediate Management Algorithm
Step 1: Protect the Eye
- Apply a rigid eye shield without applying any pressure to prevent extrusion of intraocular contents 1
- Avoid any manipulation of the eye, including lid eversion or pressure application 3
- Keep patient NPO for urgent surgery 2
Step 2: Immediate Ophthalmology Consultation
- Request immediate ophthalmologic consultation for urgent surgical exploration and primary closure 1
- Do not delay surgical consultation for imaging if the diagnosis is clinically obvious 1
Step 3: Systemic Antibiotics
- Administer immediate empiric systemic antibiotics due to relatively high intraocular infection risk 2
Step 4: Imaging (if patient stable)
- Order CT orbit without contrast with thin cuts and multiplanar reconstructions to detect metallic intraocular foreign body (94.9% sensitivity) 3, 1
- MRI is absolutely contraindicated when metallic foreign body is suspected due to potential movement of the object from the magnetic field 3, 4
Step 5: Emergent Surgical Repair
- Emergent surgical exploration and primary closure is indicated whenever possible 1, 2
- Primary closure should be performed as soon as feasible to minimize complications 2
Why Other Options Are Incorrect
- Corneal abrasion (Option B): Would not present with teardrop pupil or cloudy anterior chamber; these findings indicate full-thickness injury, not superficial epithelial defect 3
- Iritis (Option C): While inflammation may be present, the teardrop pupil and mechanism of metallic object penetration indicate structural disruption requiring surgical repair, not medical management alone 3
Prognostic Factors
Poor visual prognosis is associated with:
- Blunt mechanism of injury (though this case involves penetrating trauma) 5
- Initial visual acuity worse than 6/60 5
- Presence of relative afferent pupillary defect 5
- Absence of red reflex 5
- Lacerations ≥5mm, intraocular foreign bodies, vitreous hemorrhage, and endophthalmitis 1
Critical Pitfall to Avoid
Never attempt topical treatment with eye pad and delayed review for suspected penetrating injury with irregular pupil—this is inadequate and risks permanent vision loss 3. The presence of a teardrop pupil mandates immediate surgical intervention, not conservative management.