Open Globe Injury - Causes, Symptoms, and Treatment

Introduction:

Trauma to the eye is considered to be the most common cause of vision loss. Mechanical trauma to the eye can be classified into closed and open globe injuries. Open globe injuries refer to full-thickness injuries of the outer walls of the cornea, sclera, or both. These are generally caused due to trauma or a blunt force to the eyeball, thus resulting in structural tears and sometimes, loss of vision. Advances in the medical field and surgical techniques have prevented vision loss and reduced morbidity to the surrounding structures.

What Are the Causes of Open Globe Injuries?

An open globe injury can be caused due to blunt trauma or a laceration.

Some common causes of this injury include:

• Road traffic accidents are the most common cause of open globe injury.

• Sports like football, tennis, cricket, and boxing increase the risk of open globe injuries.

• Violent actions and physical assaults result in direct trauma to the eyeball structures.

• Sharp or penetrating objects like knives and scissors can probe into the cornea or sclera causing open globe injuries.

• Sudden actions like falls can also result in injury, especially among children and older adults.

In addition, to the above causative factors, previous surgery to the eye like corneal transplantation surgery or cataract surgery can increase the risk of open globe injuries.

What Is the Pathophysiology of Open Globe Injuries?

A blunt force to the eye leads to a rupture of the cornea and sclera. This rupture occurs at the weakest and thinnest sites of the sclera located behind the attachment of recti muscles. In individuals with a previous history of eye surgery, the weakest site is the surgical site.

Damage to the cornea and sclera causes an increase in the intraocular pressure, which leads to loss of contents of the eye including vitreous humor, retinal damage, and choroidal hemorrhage.

What Are the Signs and Symptoms of Open Globe Injury?

People with open globe injuries can experience

• Severe eye pain.

• Redness in the eye.

• Complete or partial loss of vision.

• Blurred or double vision (Diplopia).

• Bleeding (Conjunctival hemorrhage).

• Extreme sensitivity to light.

• Swelling in and around the eyes.

These signs and symptoms should be evaluated and treated immediately to improve the prognosis and reduce the risk of complications.

How Are Open Globe Injuries Evaluated?

Open Globe injuries are medical emergencies that require prompt diagnosis and treatment. A thorough physical examination is done to assess the location and extent of the injury.

Some investigations done to evaluate the patients include:

• Visual Acuity Test: It is done to evaluate the clarity of vision and determine the prognosis of the injury. Lower visual acuity indicates a poor prognosis. Pupillary examination indicates a peaked pupil in cases of a ruptured globe.

• Inspection of the Eyes: Assessment of the eye and surrounding structures (head, face, and perioral regions) should be done to look for lacerations and edema. Swelling of the face could indicate multiple fractures of bones.

• Measurement of Intraocular Pressure (IOP): Intraocular pressure is low in an open globe injury and low IOP can lead to loss of vision.

• Slit Lamp Studies: Narrow beam of light is used to study the structures of the eye like the cornea, sclera, and iris. This may indicate edema, laceration, abrasion, and hemorrhage.

• Imaging Studies: Radiographic examination is a vital tool to assess the extent of the injury and acts as an aid for surgical preparation. It also helps to eliminate the possibility of the presence of a foreign object.

Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) are commonly used modalities for structural examination. MRI is contraindicated in case the foreign object is suspected to be metal.

How Are Open Globe Injuries Treated?

Open globe injuries require immediate assessment and management to prevent further complications and loss of vision.

The prognosis for open globe injuries is determined by the extent or zone of injury.

• Zone I - Injury is limited to the cornea.

• Zone II - Injury occurs in the region of the lens.

• Zone III - Injury occurs in the region of the choroid, retina, and optic nerve.

The farther the zone of injury, the poorer the prognosis. Open globe injuries require comprehensive medical and surgical management.

Medical Management:

• Administration of Antibiotics:

Antibiotics are administered to prevent infection and reduce the incidence of endophthalmitis.

• Anti-inflammatory Medications:

Anti-inflammatory medicines are given to reduce the pain and swelling around the site of injury.

• Prophylactic Immunization:

If the injury is caused due to a foreign object, tetanus vaccination is recommended.

Surgical Management:

Surgery is performed in single or two phases to treat the injury site and correct the deformities caused.

• Repair of the Wound: The primary goal of surgical intervention is to repair the damaged structures of the eye and restore its normal anatomy. This may involve suturing the wound or performing more complex procedures, such as a vitrectomy or retinal detachment repair.

• Intraocular Pressure Control: If the intraocular pressure is elevated, surgical interventions such as a scleral buckle or drainage of the vitreous humor may be required to control the pressure and prevent further damage.

• Correction of Any Associated Injuries: If the injury is associated with other injuries, such as orbital fractures or corneal lacerations, these will also need to be treated surgically.

After the treatment, patients will require close monitoring by an ophthalmologist to ensure proper healing and address any complications. Early diagnosis and appropriate treatment are the keys to improving the outcome of surgery and minimizing complications.

What Are the Post Operative Instructions to Follow After Surgery?

Common guidelines to follow after surgery include:

• Wearing a protective mask or glass to the eye to prevent infection and promote the healing process.

• Using prescribed eye drops and ointments to prevent inflammation of the surgical site.

• Keeping the eyes safe from dust and environmental pollutants.

• Avoiding stress to the eyes like prolonged exposure to bright light.

• Following a proper nutritious diet aids in healing.

It is important to report any changes experienced to the surgeon immediately to prevent further risk of complications.

What Are the Complications of Open Globe Injuries?

Some possible complications of open globe injuries include:

• Infection: Open wounds increase the risk of infection in the eye, which can lead to further damage and vision loss if not treated promptly.

• Intraocular Hemorrhage: Bleeding within the eye can lead to increased intraocular pressure, which can damage the optic nerve and cause vision loss.

• Retinal Detachment: The retina can detach from the back of the eye due to trauma, which can cause significant vision loss if not repaired promptly.

• Cataract: Trauma to the eye can cause the development of cataracts, which can cause cloudiness and decreased vision.

• Glaucoma: Increased intraocular pressure resulting from an open globe injury can lead to the development of glaucoma that can cause irreversible damage to the optic nerve and lead to vision loss.

• Endophthalmitis: This is a severe infection of the eye that can result from an open globe injury and can cause significant vision loss or even blindness.

• Corneal Scarring: The cornea can become scarred as a result of injury, which can cause vision distortion or loss.

• Foreign Body Retention: Sometimes, small foreign objects may remain in the eye after an open globe injury, which can cause further damage or infection if not removed.

Conclusion:

Open globe injuries are life-threatening and require immediate medical attention. Prompt management can always minimize the risk of complications and improve the prognosis.