Open Globe Management

Alessandro A. Castellarin, MD; Dante J. Pieramici, MD


Compr Ophthalmol Update. 2007;8(5):111-124. 

In This Article

Ophthalmic Evaluation

External inspection is essential prior to starting the ophthalmic inspection. One should inspect the head, the scalp, and the periorbital tissue along with the inspections of the globes.

The initial visual acuity, a crucial prognostic indicator, is measured in each eye separately using an occluder or eye patch. If vision is too poor to be measured with standard charts, a gross assessment of the visual acuity should be obtained with the use of light and counting fingers. Near charts are also helpful for the trauma patient.

An important indicator of the visual function is the presence/ absence of an afferent pupillary defect, as it may indicate optic nerve or significant retinal damage. Peripheral visual field testing and color vision testing may also provide additional information about the overall visual function.

The assessment of ocular motility is most relevant in cases of known or suspected cranial nerve and/or orbital injury. Significant periorbital edema, hemorrhage, or lack of patient cooperation often prohibit formal motility testing.

Conjunctiva. Fornix should be carefully examined, looking for foreign bodies sequestered in redundant folds. Hemorrhagic chemosis could be secondary to orbital fractures and/or open globe injuries. Laceration of the conjunctiva may be gently manipulated in order to rule out an underlying scleral wound or a subconjunctival foreign body.

Cornea. The corneal examination begins on the surface and proceeds more deeply. For epithelial defects, utilize topical fluorescein when necessary. If wounds are present, these must be carefully evaluated to determine if they are full thickness. A full-thickness wound leaks aqueous; this can be highlighted using 2% fluorescein (Seidel positive). If a foreign body extends into the anterior chamber (AC) (open globe), it should be removed in the operating room.

Sclera. The conjunctiva may remain intact overlying a full-thickness scleral wound; similarly, a full-thickness scleral wound may be distant from the conjunctival wound. Hemorrhage in or under the conjunctiva may also hide the scleral defect and/or prolapsed uveal tissue. Exploratory surgery is indicated when a scleral wound cannot be ruled out.

Anterior Chamber. The AC should be examined with the slit-lamp, looking for cells, flare, fibrin, hypopyon, and possible IOFBs. The depth of the chamber can also provide additional information; deepening can be seen with posterior dislocation or subluxation of the crystalline lens, iridodialysis, and scleral rupture. Shallowing can occur with anterior dislocation or subluxation of the crystalline lens, vitreous prolapse, leaking corneoscleral wound, suprachoroidal hemorrhage, serous choroidal detachment, aqueous misdirection, and angle closure.

Iris and Angle. Using direct illumination and retroillumination techniques, the iris should be examined for sphincter tears, iridodialysis, full-thickness laceration (stromal defect), and iridodonesis (indicative of lens subluxation). Gonioscopy can be useful in identifying an IOFB in the angle or, with gentle pressure, an occult wound.

Lens. The lens should be examined for phacodonesis, dislocation, defects in the anterior capsule with or without leakage of cortical material, posterior capsular defects or feathering, sectoral cataract, intralenticular foreign body,and zonular rupture (signaled by vitreous prolapse into the AC). Intraocular pressure should be deferred in eyes with obvious open globe injuries.

The posterior segment must be examined before the view is compromised by developing media opacity. All topical medications should be administered from fresh, unopened, sterile bottles to avoid iatrogenic intraocular infection or, in the case of antibiotics, drug toxicity. In open globe injuries with iris prolapse, the dilated examination should be deferred until the wound is surgically closed. If unable to perform ophthalmoscopy, computed tomography (CT) scan or ultrasound should be carefully performed.


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