see also:

• ophthalmology
• chemical injuries and burns to the eyes
• welder flash burns - UV keratopathy (photo keratitis)
• corneal abrasions
• retrobulbar haemorrhage
• RCH guideline - acute eye injuries in children
• RCH guideline - penetrating eye injury
• RCH guideline - the acute red eye

• Vic DHS - Eye injury - Flash burns (pdf)
• Vic DHS - Eye injury - Foreign body (pdf)

• patients with a possible open globe injury should be examined with extreme caution, and clinicians must avoid placing pressure on the globe (eg, with lid eversion or foreign body [FB] removal) or using eye drops until this injury is ruled out.

• 18-41% are caused by intraocular foreign bodies (IOFBs) of which 90% are metallic such as from motor vehicle accidents, lawn mowers, weapons, hammering on metal or stone, or machine tool use.
• most IOFB's are found in the vitreous cavity.
• lacerations may also be caused in young children from falling onto sharp objects such as scissors, pens, thorns or knives.
• lacerations involve the cornea in ~2/3rds with the remainder involving the sclera
• the globe may rupture from blunt trauma - usually at its weakest spot where the sclera is thinnest near the equator directly behind the insertion of the rectus muscles, or at sites of previous ocular surgery.

• extrusion of ocular contents
• endophthalmitis
  • occurs in 2-7%, but higher in those with IOFBs (up to 13%), and particularly a risk if retained FB, organic FB (eg thorn) or delay in primary closure
• traumatic cataract (late)
  • the most common late complication that limits vision
• corneal scarring (late)
• retinal detachment (late)

• intraocular or protruding foreign body
• obvious scleral or corneal laceration
• volume loss to the eye
• uveal prolapse (iris of ciliary body)
• eccentric or peaked pupil
• 360 degree, bullous subconjunctival haemorrhage suggesting posterior rupture
• decreased visual acuity
• relative afferent pupillary defect by swinging penlight technique

• keep nil orally
• assess other injuries as per usual
• do NOT remove any protruding foreign bodies
• minimise increasing intraocular pressure:
  • avoid suxamethonium or ketamine if rapid sequence induction (RSI) for emergency intubation needed
  • avoid eye manipulation such as lid eversion, tonometry, or ocular ultrasound
  • elevate head of bead to 30deg if haemodynamics allows (ie. not hypotensive)
  • aggressively Mx nausea or vomiting eg. ondansetron iv
  • avoid crying hence analgesia such as opiates and opioids iv eg. fentanyl or morphine
• do NOT use eye drops (eg. LA's, flourescein, cycloplegics]]
• place eye shield after initial eye examination
• begin iv antibiotics:
  • vancomycin + ceftazidime (or ciprofloxacin if penicillin sensitive)
• immediate ophthalmology consult
• CT scan of orbits with 1-2mm slices
  • CT findings of open globe injury include IOFB, intraocular air, eye wall deformity, volume loss of the eye, and irregular scleral contour
  • ocular CT has limited ability (sensitivity 56-75%) to demonstrate an occult open globe injury and should not be used as the sole determining factor for decisions regarding surgical exploration
• tetanus
• urgent surgical repair, preferably within 24hrs of injury.

• UpToDate - open globe injuries