Ocular Trauma: Open Globe Injuries: Incidence and Treatment

Written By: Dr. Sarah Mireles Jacobs

It was Prom season.  Every time-honored dramatic narrative was playing out in the high school hallway—roses, crushes, jealousy, heartbreaks, creative invitations, swoons.  Amelia*came home from school to find a fruit bouquet with a card inside.  Excited, she grabbed scissors from the kitchen drawer and started cutting the ties that held the plastic packaging in place.  In one awful split-second, the tip of the scissor blade slipped off the ties, recoiled back, and stabbed into her right eye.  The rest of the day was a chaotic blur.  Her mother screaming and getting her to the car.  An emergency room.  A surgery to save the eye.  A fruit bouquet left half-unwrapped, with an unread invitation to Prom.

Open Globe Injuries

Eye injuries span a wide range, from minor issues like a black eye (periocular hematoma) or broken superficial blood vessels (subconjunctival hemorrhage), to moderate issues like bleeding within the eye (hyphema or vitreous hemorrhage), to the most severe issues in which the wall of the eye is torn open by a sharp object or a blunt trauma (open globe injury).  In the United States, approximately 15,600 people (4.49 per 100,000 people) experience an open globe injury each year.  The most common mechanism of injury is assault in patients under age 40, whereas falls from standing height are the most common mechanism in patients over age 70.

While many eye injuries can be managed with medications and close clinical follow-up, open globe injuries require surgery.  A patient with an open globe typically presents to an Emergency Department, where they are evaluated by an ophthalmologist (a medical doctor specializing in eye surgery).  Within 24 hours of arrival to the ER, the patient undergoes surgery to address their injuries.

• In 90-95% of cases, the injured eye is reparable.  The surgeon removes any embedded debris and washes out the wounds with antibiotic solution. If the lens inside the eye was violated by the injury, the remainder of the lens is removed. Tears or cuts through the cornea and sclera are sutured closed.
• In approximately 5-10% of cases, the eye has been damaged beyond repair and must be surgically removed (enucleation or evisceration).  Whenever possible during an eye removal surgery, the eye socket is reconstructed with an implant to replace the volume the eye had formerly occupied, and the extraocular muscles are reattached around the implant to restore movement.  Weeks later, when the socket has healed, the patient can opt to have a custom prosthesis made that is worn on the surface of the socket to give the appearance of having a normal eye.

Patients are typically kept in the hospital for several hours-to-days after their ruptured globe repair surgery, depending on their other injuries.  After that, they are followed very closely in an outpatient eye clinic.  Medical care for open globe injuries accounts for nearly $100 million in healthcare expenses in the U.S. each year.

Visual Deficits after an Open Globe Injury

Recovery of visual function after an open globe injury varies tremendously.  Some patients regain 20/20 vision, while others may lose vision in the injured eye entirely.  Most patients fall somewhere in between those two extremes.  Outcomes generally depend on the location of the injury, the severity of the injury, and the potential for healing or restoration of the tissues involved.

• Location:  Certain regions of the eye have a large impact on visual clarity, especially the central cornea, the lens, and the macular region of the retina.  Injuries in those regions can substantially distort the central vision that people need for reading, driving, and other tasks. Other regions of the eye have less visual impact, such as the peripheral cornea, the sclera (white of the eye), and the peripheral retina, where an injury may only result in one region of the peripheral visual field being foggy, warped, or missing.
• Severity:  Injuries that only affect a limited amount of eye tissue tend to have a limited impact on vision.  For example, if Bob were struck by a single metal bristle from a spinning grinder, he would require surgery to remove the bristle and close the tiny entry wound.  He would only have a small scar at the wound site, and would likely retain intact vision otherwise.  In contrast, if John were struck with a broken bottle that cut across the cornea, sclera, and lens, he would require surgery to extract the injured lens from the eye, return any viable prolapsed iris or retinal tissue into the eye, and several microscopic stitches to repair the external cuts in order to reform the eye.  John would have a very guarded visual prognosis, likely ending with just enough vision to see light or motion.
• Potential for healing or restoration:  Some eye tissues heal readily, such as the conjunctiva covering the surface of the eye, which typically forms a simple scar without compromising vision.  Some eye tissues do not heal well but they can be replaced.  For example, if the natural lens was damaged and had to be removed, an ophthalmologist can implant a new plastic lens inside the eye.  If a corneal injury caused a foggy scar blurring the vision, it can be replaced with a corneal transplant.  Some eye tissues cannot be replaced.  An injured retina forms a permanent scar that will not regain vision.  Similarly, it is rare for an injured optic nerve to recover significantly.

Amelia came through globe repair surgery with 3 stitches to her peripheral cornea and no damage to her natural lens.  With close follow up, antibiotic and anti-inflammatory eyedrops, and time, she recovered most of her vision back.  She went to Prom a week later, with a shield to protect her eye and a promise to avoid any scissors.

As with so many things in life, an ounce of prevention is worth a pound of cure.  Eyecare professionals recommend that people wear safety glasses whenever there is potential for exposure to metallic fragments, fast-moving debris, sharp or blunt trauma to the face, or heat/sparks/explosions.  Minimize the risk of falls by providing good lighting, maintaining level walking surfaces without trip-hazards, and using assistive devices such as a walker or cane if necessary.  Overall, treasure the wonderful and fragile gift of sight, and seek out a skilled ophthalmologist immediately if your eye has been injured despite your best preventive efforts.

Meet the Author Dr. Sarah Mireles Jacobs
Dr. Sarah Mireles Jacobs is an Oculoplastic Reconstructive Surgeon who graduated from Mayo Clinic School of Medicine, completed Ophthalmology residency at Washington University in St Louis, then Oculoplastic Surgery fellowship at the University of Washington in Seattle.  She is on faculty at the University of Alabama Birmingham Callahan Eye Hospital. Learn More About the Author.

References:

1. Mir TA, Canner JK, Zafar S, et al.  Characteristics of Open Globe Injuries in the United States from 2006 to 2014. JAMA Ophthalmol. 2020;138(3):268-275.
2. Haochi Ho, Foo J, Li YC, et al.  Prognostic factors and epidemiology of adult open globe injuries from Western Sydney: a twelve-year review. BMC Ophthalmology. 2021;21:173.
3. Wai Man CY, Steel D.  Visual outcome after open globe injury: a comparison of two prognostic models—the Ocular Trauma Score and the Classification and Regression Tree.  Eye. 2010;24:84-89.

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