Management of open globe injury: a narrative review

Abstract

Open globe injuries are a significant global cause of visual loss, including unilateral and bilateral blindness. Prognosis is predicted by injury severity, with lower presenting visual acuity and more posterior injuries associated with poor visual outcomes, although even the most severely injured eyes with no perception of light vision may regain some visual function. In addition to severity of the primary injury, the secondary injuries and complications causing poor outcomes include proliferative vitreoretinopathy (PVR) and endophthalmitis. Endophthalmitis is common after open globe injury, affecting up to 16.5% of patients. Systemic antibiotic prophylaxis is commonly used, with a limited evidence base, while intraocular antibiotics are less commonly used but have stronger supporting evidence of efficacy. Endophthalmitis rates are also reduced by prompt primary repair, which may also support recovery of visual acuity. PVR is not prevented or treated by any pharmacologic interventions in current clinical practice, but the incidence of post-traumatic PVR may be reduced by early vitrectomy within the first 4-7 days after injury. Ocular trauma training is often limited in Western ophthalmic surgical training programmes, and patients with ocular trauma often require the input of multiple subspecialists. In this context, it is important that patients have an overview and coordination of the different aspects of their care, with ownership by one lead clinician.

Fig. 1. Ocular trauma classification systems.

a Birmingham Eye Trauma Terminology System (BETTS), classifying injury type [6]. b International Globe and Adnexal Trauma Epidemiology Study (IGATES), classifying injury by mechanism, type and location [7]. More than one mechanism may apply: sharp injuries include low mass projectiles at high speed and sharp objects; blunt injuries include high mass projectiles at low speed; mixed mechanism includes very high energy injuries such as blast; IOFB, intraocular foreign body with entrance laceration; bite or sting e.g. from an animal; burn may be chemical or thermal. Type: closed globe injury has no full thickness wound of the sclera or cornea; contusion has no visible laceration; lamellar laceration has a partial thickness laceration; open globe injury has a full thickness wound of the sclera and/or cornea; a rupture is caused by a blunt object; a laceration is caused by a sharp object; a perforating injury has an entrance and an exit wound; lens injury and severe adnexal injury, including injury to the lacrimal drainage system, may occur in conjunction with open or closed injuries. Zone I includes the cornea and limbus.