See also

Acute eye injury
Eye examination

Key points

1. An open globe, or penetrating eye injury is a serious threat to vision
2. In penetrating eye injury, avoid any pressure on the eyeball through examination or padding, as eye contents may be extruded
3. Ensure prompt and adequate analgesia. Do not give any eye drops
4. If identified or suspected, stop examination, place an eye shield over the eye, keep nil by mouth and urgently refer to ophthalmology. Urgent imaging may also be required

Background

• An open globe injury is defined as a full thickness injury to the cornea or sclera resulting in either globe rupture or laceration
• Globe rupture is more common in blunt injury, and laceration as a result of trauma from a sharp object or high velocity projectile
• Most injuries occur at home away from parental supervision
• Open globe injuries are associated with poor visual outcomes
• Open globe injuries may accompany multiple trauma or serious head injury

Assessment

History

• Full history of event including timing and witnesses
• Mechanism of injury eg blunt force/sharp object/projectile
• Composition of any possible intraocular foreign body eg soil/dirt/metal
• Pain
• Decrease in vision
• Associated injuries (may accompany multiple trauma or serious head injury)

Examination

• Examination may only need to be cursory but should include an attempt at determining visual acuity and assess for a Relative Afferent Pupillary Defect
• Primary survey
• Avoid pressure on the globe if perforation is suspected and examine with the utmost care
• In young children examination facilitated by procedural sedation or general anaesthesia should be performed by an ophthalmologist whenever the mechanism of injury is highly suggestive of an open globe
• See Eye Examination

Signs suggestive of globe perforation

• Missile protruding from the eye: do not remove it or touch it
• Severe loss of vision
• Loss of red reflex
• Relative Afferent Pupillary Defect
• Squashed or distorted appearance to globe
• Swollen, haemorrhagic eyelids
• Chemosis (bulging of the conjunctiva)
• 360 degree subconjunctival haemorrhage
• Distorted, irregular or peaked pupil
• Ocular contents extruding from globe (iris and retina are pigmented, vitreous is a clear jelly)
• Increased or decreased anterior chamber depth

Penetrating eye injury with 360 degree subconjunctival haemorrhage, irregular shaped iris, hyphaema and extrusion of ocular contents

Penetrating eye injury with prolapse of iris

Reproduced with permission from The Royal Australian College of General Practitioners from: Lu SJ, Lee GA, Gole GA. Acute red eye in children: A practical approach. Aust J Gen Pract 2020;49(12):815–22 doi: 10.31128/AJGP-02-20-5240. Available here

Management

Suspected penetrating eye injury

• Do not force eyelids open - pressure on the lids may cause extrusion of ocular contents
• Do not attempt to remove a protruding foreign body from the globe
• Urgently notify ophthalmology for all suspected penetrating eye injuries
• Place an eye shield
• Fast the child from the time they are seen
• Do not give any eye drops
• Use appropriate analgesia. Consider NSAIDs. Consider concurrent antiemetic (eg ondansetron) as vomiting increases intraocular pressure and may cause expulsion of ocular contents
• Place the child on bed rest with head of bed elevated to 30 degrees if haemodynamic condition allows
• Check tetanus status
• Give antibiotics:
• If prophylaxis without signs of infection: oral ciprofloxacin 20mg/kg (maximum 750mg) BD
• If endophthalmitis is suspected or signs of infection: give IV ceftazidime 50mg/kg (maximum 2g) 8 hourly and vancomycin 15mg/kg (maximum 750mg) 6 hourly

After discussion with ophthalmology, image the orbit (X-ray or CT) in cases where an intraocular foreign body is suspected

Consider consultation with local paediatric team when

A child with suspected child abuse

Consider transfer when

A child with penetrating/open globe injury and management beyond the capability of local services

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider discharge when

• Penetrating or open globe injury has been treated or excluded AND
• The child is symptom free, or clear follow up plan in place with criteria for early review identified

Last updated October 2022