01OverviewDefinition, clinical context and the essential points that orientate the chapter.
Open-globe injury is a structural breach of the eye wall and threatens sight through direct tissue disruption, infection and secondary damage. Blunt impact raises pressure within the fluid-filled eye and can split the wall at a weak point, including a previous surgical wound. A sharp object cuts from outside inward. These mechanisms can leave very different external appearances: a large corneal tear may be obvious, whereas a scleral rupture hidden beneath swollen conjunctiva or a sealed metallic entry wound can be difficult to see. The history therefore carries substantial diagnostic weight.
Ask what struck the eye, its velocity and material, and whether work involved grinding, hammering or an explosion. Establish the timing of visual loss and any previous ocular surgery. A small piece of metal can enter with little continuing pain; organic material can introduce aggressive infection. Assess associated head, neck and facial injuries within the trauma approach. Life-threatening problems still take priority, while a colleague protects the injured eye and coordinates ophthalmology involvement.
The safe examination is deliberately limited by the suspected injury. If possible, record acuity using the available chart or the ability to count fingers, see hand movements or perceive light. Observe pupils without pressing the globe. Distortion towards a wound, an abnormal anterior chamber, uveal tissue at the surface, marked subconjunctival haemorrhage or an obvious laceration increases concern. Do not push on the eye to demonstrate that it is soft. Do not repeatedly retract swollen lids or remove tissue that may actually be iris, vitreous or another intraocular structure.
A Seidel test may reveal aqueous leaking through a small wound, but the test is not required to prove an obvious rupture and a negative result does not rule out a sealed injury. Pressure from tonometry or a routine ultrasound probe can worsen tissue extrusion. CT of the orbits is useful for retained foreign material, globe contour and associated fractures, especially when swelling limits inspection. Request appropriate thin sections and explain the suspected mechanism. MRI is unsafe while a metallic foreign body remains possible, and imaging should not postpone urgent specialist communication.
A rigid shield rests on the surrounding bony margin and creates space over the eye. It must not become a tight dressing. Avoid putting a pad beneath it or taping across an embedded object; the aim is protection from accidental touch, not compression. A protruding object should remain in place and be supported without pressure while urgent surgical arrangements are made. Pain, vomiting, agitation and straining can all complicate protection. Provide systemic treatment and calm explanation, monitoring the patient rather than repeatedly handling the globe.
Definitive closure and management of internal injuries belong to the ophthalmic surgical team. The patient should remain nil by mouth pending the anaesthetic plan, with appropriate hydration and management of relevant medicines. Systemic antimicrobial prophylaxis is selected according to the wound, contamination, allergies, local protocol and renal function; there is no single universal regimen for every mechanism. Review tetanus immunisation and contamination risk. Explain that initial vision is important but does not determine the entire eventual outcome: lens damage, retinal injury, infection and subsequent operations may influence recovery.
Key points
- Open globe means a full-thickness wound of the cornea or sclera; blunt rupture and sharp laceration are different mechanisms within this category.
- A penetrating injury has an entry wound; a perforating injury has entry and exit wounds, and an intraocular foreign body may remain after penetration.
- Use a rigid eye shield, not a pressure pad, and avoid placing gauze against a protruding wound or object.
- Do not measure intraocular pressure, press the lids open, perform routine ocular ultrasound or remove an impaled object when an open globe is suspected.
- Record safe visual and pupillary observations, but stop further examination when the diagnosis is clinically evident.
- CT with thin orbital sections can identify foreign material and associated fractures; a normal scan cannot safely exclude every small eye-wall injury.
- Prevent vomiting and straining, obtain urgent surgical review, assess tetanus protection and arrange specialist-directed systemic antimicrobial prophylaxis.
02AetiologyUnderlying causes, associations and risk factors, with why each one matters.
Blunt globe rupture
A sudden pressure rise after impact can split the cornea or sclera at a structurally weak site, including a previous operative scar.
Sharp penetrating injury
Knives, wire, glass and fast-moving fragments can create a full-thickness entry wound and may damage the iris, lens, vitreous or retina.
Retained intraocular material
Metallic or organic debris can remain within the eye after penetration, adding chemical toxicity, contamination or ongoing mechanical damage to the original wound.
03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.
- 1Loss of wall integrity
A breach allows aqueous, vitreous or internal tissue to move through the wound; external pressure and straining can increase this displacement.
- 2Direct internal disruption
The injury track may disrupt the lens capsule, retina or choroid, while blunt deformation can damage structures distant from the apparent impact.
- 3Contamination and immune exposure
Organisms can enter normally protected intraocular spaces, and exposed ocular antigens may rarely initiate an inflammatory response affecting both eyes.
04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.
A pupil drawn towards a corneal wound or dark tissue at the surface suggests disrupted internal structures and requires protection rather than further manipulation.
Metal-on-metal work, power tools or explosive fragments create a credible route for penetration even when the surface mark seems trivial.
Extensive subconjunctival haemorrhage, an abnormal chamber or visual loss after a blunt impact may conceal a scleral wound beneath apparently intact conjunctiva.
Facial fractures, loss of consciousness or neck pain can accompany the eye injury and need coordinated trauma assessment without abandoning globe protection.
05InvestigationsWhat to request, why it matters and how to interpret it.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Limited acuity and pupillary examinationFirst step - Why
- Document visual function without placing pressure on the injured globe.
- Interpretation and limitations
- Record what can be assessed safely and any relative afferent pupillary defect; inability to complete examination should be stated, not treated as a normal result.
- 02
Careful external and anterior segment inspection - Why
- Recognise a full-thickness wound or indirect signs of rupture.
- Interpretation and limitations
- Observe without forcing the lids or touching prolapsed tissue; an obvious open globe is sufficient to stop routine further examination.
- 03
Thin-section CT of the orbits - Why
- Locate suspected foreign material and define associated orbital injury.
- Interpretation and limitations
- CT supports surgical planning but may miss a small wound or some non-metallic material; persistent clinical suspicion overrides a reassuring scan.
- 04
Preoperative assessment and tetanus history - Why
- Identify anaesthetic, antimicrobial and wound-protection requirements before urgent repair.
- Interpretation and limitations
- Check allergies, relevant comorbidity, last intake, anticoagulants and immunisation history; these should be obtained alongside referral rather than delaying it.
06Differential diagnosisRealistic alternatives and the features that help distinguish them.
Closed-globe contusion
Blunt trauma can cause hyphaema, lens injury or retinal damage while the eye wall remains intact; internal severity may still be substantial.
Lamellar corneal laceration
A partial-thickness cut damages corneal layers without a complete wall breach, although its depth may be difficult to determine during an initial examination.
Orbital compartment syndrome
Bleeding in the confined orbit can cause proptosis and rapidly impaired vision through compression, a different mechanism from leakage through a globe wound.
07ManagementImmediate care, first-line treatment, alternatives and escalation.
01Immediate protectionPrevent secondary mechanical damageFirst stepMechanism or examination raises a credible suspicion of a full-thickness ocular wound.+
- 1Stop contact procedures, leave adherent or protruding material in place and apply a rigid shield without gauze or pressure against the globe.
- 2Call the ophthalmic emergency service immediately and communicate mechanism, visual findings, wound concern and any associated major trauma.
- 3Treat pain and nausea systemically, reduce straining and keep the patient nil by mouth while urgent operative and transfer arrangements are clarified.
02Imaging and preparationSupport definitive surgical planningDefinitiveThe eye is protected and specialist assessment requires information about a foreign body or associated injuries.+
- 1Arrange orbital CT with suitable thin sections when requested, avoiding MRI until metallic material has been excluded and avoiding routine ocular ultrasound.
- 2Obtain relevant blood tests and medication information, assess tetanus prophylaxis and start the specialist-approved systemic antibiotic plan without unnecessary delay.
- 3Maintain the shield and monitor comfort and general physiology during transfer, ensuring the receiving team has accepted responsibility for the injury.
03After repairPreserve function and detect complicationsPrimary wound closure has been completed and the patient enters postoperative recovery.+
- 1Follow the surgeon's instructions for topical treatment, protection and activity, explaining which drops are being used and when review is required.
- 2Assess emerging infection, retinal complications, pressure changes and lens damage through the specialist follow-up pathway, rather than assuming closure completes treatment.
- 3Discuss visual rehabilitation, work and driving implications, psychological support and protection of the fellow eye according to the final level of function.
08ComplicationsImportant consequences, why they occur and why they matter clinically.
Traumatic endophthalmitis
Microbial contamination can produce destructive intraocular infection, particularly after dirty wounds or retained material, with substantial risk of permanent visual loss.
Retinal and lens sequelae
Retinal detachment, vitreous haemorrhage, traumatic cataract or lens displacement can impair sight and complicate recovery after the wall has closed.
Sympathetic ophthalmia
A rare immune-mediated bilateral uveitis can follow penetrating injury, so inflammation in the previously uninjured eye is clinically significant during follow-up.
09Monitoring and follow-upTreatment response, safety checks and longer-term review.
- Check the shield remains clear of the wound and that nausea or agitation is controlled during observation and transport.
- Communicate changes in visual perception or pain promptly, balancing useful reassessment with avoidance of repeated pressure-producing examination.
- After surgery, follow the planned review of wound integrity, inflammation, pressure and posterior segment status; several problems may become apparent sequentially.
- Provide immediate return advice for increasing pain, redness or vision loss, and explain the rare need to report inflammation or visual symptoms in the other eye.
10Special situationsVariants, exceptions and circumstances that change the usual approach.
A shield creates space
The protective device works by preventing contact with the eye; padding beneath it defeats that purpose by transmitting force to the damaged globe.
A sealed wound remains significant
Temporary closure by tissue or a tiny entry site can prevent visible leakage while an intraocular foreign body and internal damage remain.
Previous surgery changes vulnerability
A remote surgical scar may be a weak point during blunt impact, so apparently modest trauma can still produce rupture.
Visual prognosis needs time
Early acuity reflects multiple factors and should be communicated honestly without premature certainty about recovery or irreversible loss.
11Common pitfallsFrequent interpretation and management errors.
- 01
Pressing the eye or using tonometry to establish whether a suspected rupture has lowered the pressure.
- 02
Removing a protruding fragment or trimming dark material before recognising that it may be prolapsed intraocular tissue.
- 03
Using a negative Seidel test or normal CT alone to dismiss a high-risk penetrating mechanism.
- 04
Covering the injury with a tightly taped pad or allowing nausea and vomiting to continue untreated.