History and Presentation
After any life-threatening injuries are addressed, a detailed history and exam of the eye should be obtained if possible. The timing of the injury and mechanism should be noted, especially if there is concern for an open globe injury. Although the mechanism is important, the severity or force of the mechanism is much more important in determining whether an open globe is present. Severe blunt trauma from bungee cords, assaults/fights, paintball injuries, falls, all-terrain and motor vehicular collisions, and sports injuries without protection are of particular risk in causing open globes.
The relative cleanliness of any penetrating injuries and the potential for a retained IOFB should also be investigated. Do not overlook the potential for retained foreign bodies from a wide variety of mechanisms such as hammering metal on metal, sharpening metal, or an explosion. Dirty or contaminated objects, especially if organic (like wood), may increase the risk of concurrent development of endophthalmitis with the open globe injury. In addition to the timing and mechanism of the injury, other important information includes whether the patient is experiencing pain or a decrease in vision and, if so, the timing of the pain or acuity change relative to the time of the injury.
Even with grievous injuries to the eye, a past medical and surgical history is important to obtain. Blunt injuries to the eye can sometimes precipitate or worsen existing systemic eye conditions that can cause vision loss. For example, in a diabetic patient with proliferative diabetic retinopathy, an accidental blow or fall can precipitate a diabetic vitreous hemorrhage, causing sudden vision loss. As noted earlier, a history of previous eye surgeries is important because surgical wounds may be a potential path for extraocular expulsion or wound dehiscence. It is important to know the patient’s level of vision prior to the injury, including whether they wear corrective lenses or contacts. If the patient wears contacts, it is important to know if the patient had them on during the injury. Knowing the overall visual potential of the eye prior to the injury is helpful in setting expectations for the visual prognosis.
Careful exam for a possible open globe injury is crucial, and, notably, this may include limiting the exam. On external exam, close visual inspection of the eyelids, orbit, and surrounding facial structures should first be performed, paying specific attention to any bruising pattern or lacerations on the eyelids and any injury to the lid margins and adnexa.
TABLE 45.1 Terminology for Open Globe Injuries
Sclera and Cornea
Closed globe injury
No full thickness eyewall injury
Open globe injury
Full thickness eyewall wound present
No full thickness wound present
Partial thickness eyewall wound present
Full thickness wound present from blunt trauma
Full thickness wound present from sharp object
Intraocular foreign body
Entrance wound without exit wound
Entrance and exit wound present from same agent
Entrance wound with retained foreign object in eye (no exit wound)
It is not uncommon for the eyelids to be swollen shut owing to periorbital edema after blunt trauma. An attempt to open the eye may be performed, but extreme care must be taken to avoid applying pressure to the globe during examination, especially in an agitated, frightened, or uncooperative patient. Cavalier handling of the eye during examination in an open globe may result in expulsion of intraocular contents and potentially worsen the injury and prognosis. Measurement of visual acuity, confrontational visual fields, and evaluation of pupillary response and extraocular movements should be performed if possible. Evaluation for a relative afferent pupillary defect (RAPD) is crucial because the presence of an RAPD influences the overall prognosis. A “reverse RAPD” exam can be performed if the pupil is unrecognizable by looking for constriction of the contralateral pupil while light is shone into the injured eye. In a suspected open globe, measurement of IOP via tonometry is not recommended.
Ideally, a standard stationary or portable slit lamp should be used to examine the eye. On anterior segment examination, a full thickness laceration of the cornea or sclera may be readily apparent, with possible wound gaping. Other exam findings that are concerning for an open globe include the following:
Circumferential hemorrhagic conjunctival chemosis (Figure 45.1
Hyphema, especially if 100% “eight ball” hyphema (indicating dark, clotted blood) (Figure 45.1
Iris defects (transillumination defects), which may be caused by an intraocular foreign body (Figure 45.2
, see black arrow)
Expulsed lens or dislocated intraocular lens and external vitreous humor (sticky, gelatinous texture) (Figures 45.3
Black, stringy debris (uvea) subconjunctivally or overlying the conjunctiva (Figure 45.4