Open globe injuries – A case report and literature review on initial evaluation and management in a district hospital

Introduction

The prevention of blindness programme of the World Health Organization (WHO) indicates that ocular trauma has led to monocular blindness in approximately 19 million people worldwide and bilateral blindness in 1.6 million people over the past three decades. ¹ Open globe injuries (OGIs) are more prevalent in men and mostly happen at the workplace. OGIs by blunt trauma are more frequent among women and are usually caused by falls. This gender-specific trend is similarly observed in children, where most OGIs are primarily caused by lacerations, and occur in boys.^2,3 Without prompt intervention, OGI may lead to permanent visual impairment and blindness.

Case report

A 34-year old man who had a history of a left frontal craniotomy performed ≥20 years previously for a benign brain tumour, which left him blind in both eyes, presented as an emergency at a district hospital with a painful left red eye with bleeding. He recounted that he had been struck on the left side of his face by his one-year old niece's head when he was bending down and she was concurrently jumping up.

A left ocular subconjunctival haemorrhage with total hyphaema and a blood clot adherent to the conjunctiva was diagnosed at the initial assessment (Fig. 1). Siedel's test was negative. A skull radiograph revealed a non-displaced left lateral orbital wall fracture.

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Figure 1.

Initial assessment revealing left eye subconjunctival haemorrhage with blood clot adherent to conjunctiva and total hyphaema.

An eye shield was placed, and the patient was kept propped up. OGI was not initially suspected but he was referred to a tertiary centre ophthalmologist for further evaluation. This revealed a full-thickness scleral laceration with uveal prolapse and total hyphaema (Fig. 2).

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Figure 2.

Left eye total hyphaema and full-thickness scleral laceration over supero-nasal region with uveal prolapse.

Intravenous vancomycin, ceftazidime and intramuscular tetanus vaccine were administered, and a primary scleral repair performed, with iris repositioning under intravitreal ceftazidime and vancomycin intraoperative cover as prophylaxis to prevent endophthalmitis.

Post-operatively, topical moxifloxacin and dexamethasone were continued for 3 days. A contrast-enhanced CT brain and orbit scan on the next day revealed no optic nerve or extraocular muscle nerve entrapment.

During subsequent follow-ups in the first and second months, his hyphaema gradually resolved with minimal inflammation. At 5 months post-operative, there was complete resolution with a well-healed scleral wound, but with minimal scleral thinning. The pupil was displaced supero-nasally due to iridodialysis from 9 to 12 o’clock.

Discussion

The Ocular Trauma Classification Group guidelines and the Birmingham Eye Trauma Terminology (BETT) define OGI as a full-thickness defect of the eyewall caused either by a laceration or an occult rupture.^1,2 Ruptures result from blunt trauma causing a full-thickness defect at the weakest point of the eye wall. Lacerations, on the other hand, result from a sharp object entering the globe, and are classified as penetrating (only an entrance wound or same entrance/exit wound) or perforating (separate entrance and exit wounds) injuries. Another distinct category in this classification system identifies cases with an intra-ocular foreign body (IOFB). Injury is further categorised by zone of injury: Zone 1 involves only the cornea, including the corneo-scleral limbus, Zone 2 up to 5 mm posterior to the corneo-scleral limbus, and Zone 3 extending beyond.^2,3

A comprehensive history and thorough clinical examination play a pivotal role in diagnosing OGI. Certain indicative historical details such as sudden eye pain and visual loss after foreign body insertion by glass or metal fragments, wood shavings from wood grinding should raise the suspicion of penetrating OGI. Blunt trauma may result from mechanical falls, syncope, motor vehicle accidents with airbag deployment, or assaults with blunt objects.

The mechanism of injury may not initially raise suspicion of an IOFB. Consequently, its possibility may not be considered when Siedel's test is not performed or yields negative results. However, it is crucial to note when the impact of an injury could be substantial enough to cause blunt trauma, potentially resulting in an OGI, despite the lack of initial suspicion based on the test results.

In primary or emergency care settings, direct visual inspection of the eye using a pen torch and a Siedel's test will easily identify significant anterior OGIs. Attention should be paid to specific physical findings such as a teardrop pupil, irregular or unreactive pupil, hyphaema, flattened globe and haemorrhagic chemosis. The presence of a suspicious mass of brownish blood clot should raise suspicion of OGI with uveal prolapsed. Even in patients without any apparent eye findings, OGI should always be suspected if there is sudden visual loss and eye pain, especially when coupled with a history of trauma, as a posterior globe injury could be concealed.

If there is an evident OGI, further manipulation of the eye should be avoided to reduce the risk of further extravasation of intra-ocular contents. An eye shield should be used to protect the affected eye, and tetanus vaccination given if not covered.

A CT scan is helpful in detecting an orbital wall fracture and IOFB, or to confirm and assess the extent of OGI. However, conventional plain radiographs are often as useful. ⁴

The risk of infection following an OGI is considerable. While there is no standardised prophylactic antibiotic regimen, broad-spectrum intravenous antibiotic treatment should be initiated and continued for at least 48 h. Vancomycin in combination with a third-generation cephalosporin such as ceftazidime are recommended.^5,6 In high-risk cases involving organic IOFBs or soil, intravitreal antibiotics may be given and prophylactic antifungal coverage may be considered.^6,7 If an OGI is suspected during initial presentation at emergency centres, intravenous antibiotics should be started empirically, and intramuscular anti tetanus toxoid given prior transfer to tertiary centre.

In cases of OGIs, emergency surgical exploration and primary closure are recommended whenever feasible. Primary enucleation or evisceration is not recommended even in blindness unless the globe is not salvageable and primary repair is not possible. ⁸ The absence of light perception or the presence of severe relative afferent pupillary defect alone should not serve as sole indications for enucleation. ⁹ After initial closure, secondary surgery and revision may be needed to improve visual outcomes, followed by extensive follow-up in view of the risk of sympathetic ophthalmia. Regular monitoring is essential to detect and manage any potential complications arising from the injury.