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Clinical Summary

Penetrating globe injuries can be subtle and easily overlooked. All are serious injuries. Signs to look for are loss of anterior chamber depth caused by leakage of aqueous humor, a teardrop-shaped (“peaked”) pupil, a dark area on the bulbar conjunctiva, or prolapse of choroid through the wound.

Management and Disposition

Open globe injuries require urgent specialty consultation. Immediately protect the affected eye with a rigid eye shield. If a specifically designed shield is unavailable, the bottom of a Styrofoam cup may be used. Do not use a pressure patch. Tonometry to measure pressures is strictly contraindicated. It is imperative to avoid inadvertent pressure on the globe with resulting irreversible expulsion of choroid through the wound. Intravenous antibiotics appropriate to cover gram-positive organisms are indicated. Consider adding gram-negative coverage for injuries that involve organic FBs. Prophylactic antiemetics, sedation, and aggressive pain management are crucial to prevent or decrease expulsion of intraocular contents caused by crying, activity, or vomiting. Update tetanus status. Other significant blunt trauma may accompany penetrating globe. Always consider the possibility that FBs may have penetrated through the globe into the posterior orbit and possibly extend into the cranial vault.

FIGURE 4.27

Open Globe. This injury is not subtle; extruded ocular contents (vitreous) can be seen; a teardrop pupil is also present. (Photo contributor: Alan B. Storrow, MD.)

FIGURE 4.28

Open Globe. An obvious penetrating globe injury is seen once lids are carefully retracted. The lower lid laceration makes this a high risk for globe penetration. Intraocular foreign body should be suspected. (Photo contributor: David Effron, MD.)

FIGURE 4.29

Penetrating Globe. (A) This penetrating injury shows an “eight-ball” hyphema. (B) Bedside ultrasound shows both intraocular and anterior chamber hemorrhage. (Photo contributor: Kevin J. Knoop, MD, MS.)

Vedio Graphic Jump Location
Video 04-07: Eyelid Laceration

A careful exam shows an intact anterior chamber and laceration through the lid margin and tarsal plate. Ophthalmology consultation is indicated for complete assessment and repair. (Video contributor: Kevin J. Knoop, MD, MS)

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Pearls

  1. Stabilize protruding FBs without manipulation until definitively treated in the operating room.

  2. Control of pain, activity, and nausea may be sight saving and requires proactive use of appropriate medications.

  3. Use of lid retractors is preferred to open the eyelids of trauma victims with blepharospasm or massive swelling when such examination is indicated. Attempts to use fingers can inadvertently increase the pressure on the globe.

  4. Emergency department ultrasound with a high-frequency probe using no pressure technique can be a ...

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