Open Globe Injuries and Lacerations Management (222)

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A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments.

Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.

If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good practice to record these and communicate them to others involved in the care of the patient.

Management of Open Globe Injuries and Conjunctival, Corneal and Scleral Lacerations

Suspected open globe injury requires prompt assessment to identify all significant ocular trauma and any extraocular injury. Prompt treatment is required to minimise the risk of acute complications and prepare the patient for presumed theatre. Care should be taken to exclude intracranial / non-­ocular injury requiring urgent treatment and referral.

History

History:

Details of Injury

Other non ocular injuries

Pre-­injury VA

Past ophthalmic history

Past medical

Drug history

Tetanus status

Time of last meal

Details of Injury:

•Object causing trauma

  • Size, shape, velocity & direction of injury   
  • Composition of object
  • Consider if intraocular foreign body (IOFB) possible

•Number of times globe was struck

•Use of protective eye wear

Symptoms:

Change in VA – may be unchanged

Pain – variable

Pain on eye movement

Photophobia

Diplopia

Redness / swelling

Associated visual disturbance

Examination

Some open globe injuries may be obvious with the appearance of a misshapen or collapsed globe, protrusion of uveal tissue from a scleral or corneal wound or a visible IOFB. A systematic approach to assessment is necessary if the diagnosis is uncertain.

Orbits

Evidence of fracture, muscle entrapment, orbital foreign body or enophthalmos

Lids

Assess deep injuries for possible extension to involve globe

Conjunctiva

Lacerations may hide scleral injury.  360° subconjunctival haemorrhage may represent globe rupture

Cornea / Sclera

Prolapse of uveal tissue. May be partial or full thickness.  Positive Seidel Test

Anterior Chamber 

Shallowing compared to other eye, hyphaema 

IOP

May be low – only perform if uncertain globe is intact as contraindicated in definite open globe injury. Avoid compression

Pupil

Peaked or distorted, poor reactivity, RAPD, iris transillumination or iridodialysis

Lens

Traumatic cataract or dislocation

Retina

Dilated fundal examination essential. Reduced red reflex from vitreous haemorrhage, retinal or choroidal tear. Blunt trauma can cause posterior segment rupture and leave anterior segment intact

Investigations

CT scan – 1mm slices

Can demonstrate globe rupture if adequate examination not possible due to periorbital oedema. Can also demonstrate optic nerve injury

Will show possible unvisualised IOFB. Caution -­ CT may miss small IOFBs or plastic

B-­scan Ultrasound

Contraindicated if globe obviously ruptured or AC collapsed. Avoid globe compression

Examine for retinal detachment, subluxed lens, IOFBs

Small IOFBs / wood / vegetation may be missed. Gas / air may be mistaken for IOFB

Plain X-­rays

  • are of no value in assessing globe injury and are poor at identifying and locating IOFBs

MRI

  • can assess globe but is contraindicated when metallic IOFB can not be excluded

Management

Conjunctival Laceration – no orbital or globe injury with clear visualisation of sclera

Chloramphenicol ointment QDS up to 1 weeks.

Large lacerations may need sutured. Consult with senior. Otherwise discharge

Conjunctival Laceration – unable to clearly visualise sclera but no features of open globe injury seen

•Chloramphenicol ointment QDS for 1 weeks

•Primary care review clinic 1 week / SOS for adequate examination to exclude open injury

Conjunctival Laceration – unable to visualise sclera but features of open globe injury

Treat as open injury – see below and discuss with senior

Small, self-­sealing full thickness corneal laceration with formed anterior chamber

•Bandage contact lens

•Preservative free chloramphenicol QDS

•Daily review

•Consult with senior regarding further management and appropriate follow up

Obvious open globe injury / scleral or corneal full thickness laceration

•Inform consultant / on call team

•Admit to ward 1C, Gartnavel General, and prepare for planned primary surgical repair (GA)

•CT scan as above if indicated

•Rigid eye shield to protect globe

•Analgesia and antiemetic as required

•Preservative free chloramphenicol 0.5% eye drops QDS

•Intravenous antibiotics may be necessary – consult with senior

•Anti-­tetanus toxoid if indicated

Last reviewed: 07 June 2022

Next review: 21 June 2025

Author(s): Kanna Ramaesh

Version: 5

Author Email(s): [email protected]

Co-Author(s): Douglas Lyall

Approved By: Medicines Utilisation Subcommittee of ADTC

Document Id: 222