What is the initial management for suspected retinal trauma or open globe injury?

Initial Assessment and Management of Suspected Open Globe Injury or Retinal Trauma

If an open globe injury is suspected based on mechanism of injury or clinical findings, immediately apply a rigid protective shield without any pressure to the eye, avoid all manipulation, and arrange urgent ophthalmologic consultation with preparations for emergent surgical repair. 1, 2

Immediate Recognition and Protection

High-Risk Mechanisms Requiring Suspicion

• High-velocity projectile injuries (metal working, hammering, grinding) mandate immediate evaluation for open globe injury 3
• Any penetrating trauma with sharp objects or blunt force sufficient to cause full-thickness eyewall defects 2
• Globe asymmetry or disruption of normal globe contour indicates severe ocular trauma requiring immediate intervention 1

Critical "Do Not" Actions

• Never attempt to remove any impaled foreign object from the eye, as this will extrude intraocular contents and cause irreversible vision loss 1
• Do not apply any direct pressure to the globe or attempt to manipulate the eyelids 1, 3
• Do not administer topical medications before ophthalmologic assessment 1
• Do not attempt to "flush" the eye with water—this is not a foreign body on the surface issue 4
• Avoid rubbing or any contact with the affected eye 4

Immediate Protective Measures

• Apply a hard plastic eye shield, paper cup, or rigid protective cover over the affected eye without touching the globe 1
• Position the patient with head slightly elevated to reduce intraocular pressure 1
• Cover the eye during transport to prevent accidental contact 4

Clinical Examination Findings Suggesting Open Globe

Key Diagnostic Signs

• Irregular or peaked pupil pointing toward the site of perforation 3
• Shallow or flat anterior chamber compared to the fellow eye 3
• Hyphema (blood in anterior chamber) 3
• Visible corneal or scleral laceration 3
• Globe asymmetry or abnormal contour 1
• Reduced visual acuity in the affected eye 3
• Extraocular movement restriction 3
• Vitreous hemorrhage or prolapse 2

Examination Limitations

• If open globe is suspected, stop the examination immediately after initial assessment—do not perform detailed manipulation that could worsen injury 1, 2
• Avoid forced duction testing or deep palpation of the globe 2

Imaging Protocol

When to Order CT Orbit

• Non-contrast thin-section orbital CT with multiplanar reconstructions is the imaging modality of choice for suspected open globe with possible intraocular foreign body 1, 3
• CT has 94.9% sensitivity for detecting intraorbital foreign bodies, especially metallic ones 3
• Order CT for any clinical evidence of ocular penetration, high-velocity injury mechanism, or signs listed above 3

Critical Imaging Contraindication

• MRI is absolutely contraindicated when metallic foreign bodies are suspected, as the magnetic field can cause movement of the object and catastrophic damage 1, 3

Imaging Caveats

• Wooden foreign bodies may appear hypoattenuating on CT and be mistaken for air; these are rare exceptions where MRI may be supplementary after metallic foreign body is excluded 3
• Plain radiography is insufficient and should not be used 3

Urgent Management Pathway

Immediate Actions While Arranging Transfer

• Request ophthalmologic consultation immediately upon suspicion—do not delay for additional testing 5, 2
• Initiate empiric systemic antibiotics immediately due to high intraocular infection risk 2
• Keep patient NPO (nothing by mouth) in preparation for emergent surgery 2
• Administer tetanus prophylaxis if indicated 2

Surgical Timing

• Emergent surgical exploration and primary closure is indicated whenever possible and should not be delayed 2
• Without timely intervention, damage is irreversible and leads to permanent vision loss 2
• For retinal detachment associated with open globe injury, outcomes improve significantly when initial vitrectomy repair occurs within 20 days of injury 6

Retinal Trauma Without Open Globe

When Retinal Tear or Detachment is Suspected (Closed Globe)

• Symptoms include sudden flashes of light, floaters, or curtain-like visual field loss 4
• Stop all activities immediately and avoid eye rubbing or pressure 4
• Cover the affected eye with a rigid shield during transport 4
• Arrange urgent (same-day) ophthalmologic evaluation—retinal tears require prompt treatment to prevent progression to detachment 4

Additional Consideration for Older Patients

• Patients over 50 years old presenting with sudden painless monocular vision loss require evaluation for retinal artery occlusion, which necessitates immediate stroke center referral within 4.5 hours 5, 4

Common Pitfalls to Avoid

• Delaying referral to perform additional outpatient testing when open globe is suspected—this is an ocular emergency requiring immediate triage 5, 2
• Assuming topical antibiotics with eye pad and delayed follow-up is adequate for suspected penetrating injury with irregular pupil 3
• Failing to examine the fellow eye thoroughly, as bilateral injuries from blunt trauma can occur with less obvious signs in one eye 7
• Underestimating injuries that may be harbored in the angle recesses or peripheral retina after blunt trauma 7