What is the treatment for a young individual with a history of trauma who has suffered an open globe injury?

Open Globe Injury Treatment

Immediately protect the eye with a rigid eye shield (hard plastic shield, paper cup, or plastic cup) without applying any pressure to the globe, avoid any manipulation or attempts to remove foreign objects, and obtain urgent ophthalmology consultation for emergent surgical exploration and primary closure. 1, 2

Immediate Management Priorities

Eye Protection and Stabilization

• Apply a rigid eye shield over the affected eye without touching or applying pressure to the globe to prevent extrusion of intraocular contents 1, 2
• Position the patient with head slightly elevated to reduce intraocular pressure 2
• Never attempt to remove any impaled objects from the eye as this causes further damage and vision loss 2
• Avoid administering topical medications before ophthalmological assessment 2
• Do not rub or manipulate the eye in any way 3

Critical Assessment Elements

The initial examination should focus on identifying life-threatening and vision-threatening conditions before addressing other injuries 3, 1:

• Measure visual acuity (though this may be difficult in young children and should not delay treatment) 1
• Perform pupillary examination 1
• Measure intraocular pressure 1
• Assess for active bleeding from the eye, which is a hard sign of penetrating ocular injury 1
• Check for globe asymmetry, which indicates severe disruption of normal globe contour 2
• Monitor vital signs for bradycardia, heart block, dizziness, nausea, vomiting, or loss of consciousness, which may indicate oculocardiac reflex requiring urgent intervention 1, 4

Urgent Ophthalmology Consultation

Request immediate ophthalmology consultation for urgent surgical exploration and primary closure - this is the definitive treatment for open globe injury 1, 5. Do not delay surgical consultation for imaging if the diagnosis is clinically obvious 1.

Antibiotic Prophylaxis

Administer immediate empiric systemic antibiotics to prevent endophthalmitis, as intraocular infection risk is relatively high in open globe injuries 5, 6.

Imaging Considerations

When to Image

• CT orbit without contrast with thin cuts and multiplanar reconstructions is the imaging study of choice if the patient is stable enough for imaging 1
• CT has 94.9% sensitivity for detecting intraorbital foreign bodies 1
• Never perform MRI if metallic foreign body is suspected as the magnetic field could cause movement of the object and worsen injury 1, 2

Timing of Imaging

A critical nuance: CT scan has limited value in immediate clinical decision-making for primary closure 7. In a 10-year study of 125 open globe cases, CT results did not influence immediate treatment decisions in any case 7. CT can be performed after initial globe exploration and suturing rather than delaying definitive repair 7, though it remains valuable for managing the case in subsequent days and identifying intraocular foreign bodies 7.

Surgical Management

Primary Repair

• Emergent surgical exploration and primary closure is indicated whenever possible 5
• The main goals are to repair the open globe and remove intraocular foreign bodies 6
• 43% of pediatric patients require lensectomy in addition to primary repair 8
• Secondary surgery and revision may be needed after initial closure to improve visual outcomes 5

Prognostic Factors

Poor Visual Prognosis Indicators

The following factors predict worse outcomes and should guide counseling 1, 6, 8:

• Lesions not due to mechanical causes 1
• Ciliary body detachment 1
• Lacerations ≥5-6 mm 1, 8
• Intraocular foreign bodies 1
• Vitreous hemorrhage 1, 6
• Endophthalmitis 1, 6
• Young age (particularly in children 0-6 years) 6
• Poor initial visual acuity 6
• Posterior eye involvement 6
• Globe rupture 6
• Lens involvement 6
• Retinal detachment 6
• Complicating cataract 8

Expected Outcomes

In pediatric orbital blowout fracture series, 86% had diplopia preoperatively and 37% postoperatively 4. Severe vision decline is most commonly due to traumatic cataracts 6.

Critical Pitfalls to Avoid

• Do not apply direct pressure to the eye or globe 2
• Do not attempt foreign body removal 2
• Do not delay ophthalmology consultation for imaging if diagnosis is clinically obvious 1
• Do not perform MRI when metallic foreign body is suspected 1, 2
• Do not administer topical medications before ophthalmological assessment 2
• Remember that 5.5% of patients with facial fractures have complete loss of vision in one eye, and 24% of blow-out fractures present with severe eye injury, so treat vision-threatening conditions before addressing other manifestations of trauma 1