EM@3AM: Open Globe Injury

Author: Joshua J. Oliver, MD (EM Attending Physician, San Antonio, TX) // Edited by Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)  

Welcome to EM@3AM, an emDocs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.

A 26-year-old male groundskeeper is sharpening a rusty lawnmower blade without eye protection when he feels a sudden pain and loss of vision in his right eye.

What is the diagnosis, and what are your next steps?

Answer: Open Globe

Background:

• Open globe injuries represent a large public health concern with an incidence of over 200,000 annually.
• It occurs most commonly in male patients between the age of 10 and 30.
• These injuries most often result from violence and occupational injuries.¹

Presentation:

• An open globe can present subtly with no obvious external injury. If a patient’s history and mechanism are consistent with the injury, maintain a high index of suspicion.
• Some common signs and symptoms are:
  • Markedly decreased visual acuity
  • Relative afferent pupillary defect
  • Teardrop pupil
  • Change in anterior chamber depth compared to contralateral eye
  • Tenting at the site puncture
  • Prolapse of ocular structures
  • Seidel sign
  • Injury to surrounding structures²

Evaluation:

Unless the patient requires emergent resuscitation for other injuries or has an obvious open globe, the initial evaluation should consist of the same examinations as any patient with a potential eye injury.  These include:

• Visual Acuity
• Visual fields
• Pupil exam
• Fluorescein staining
• Intraocular pressure measurement (defer to Ophthalmology in this instance)³

A CT scan of the brain and orbits should also be performed to evaluate for open globe and intraocular foreign body.  Preferably it should be 1mm slices.²

Management:

• Consult Ophthalmology emergently.
• Place an eye shield over the affected eye.
• Avoid manipulating the eye.
• Bed rest, as exertion may increase intraocular pressure resulting in extrusion of eye contents.
• Antiemetics should be provided, as vomiting increasing intraocular pressure and could cause extrusion of eye contents.
• Pain medication should be provided, but avoid NSAIDs due to their antiplatelet properties.⁴
• Antibiotics:
  • Prophylactic broad spectrum intravenous antibiotics should be started immediately to prevent endophthalmitis. A possible regimen includes:
    • MRSA coverage with Vancomycin (15mg/kg). Consider Linezolid or daptomycin if allergic.
    • Ceftazidime 50mg/kg for broad spectrum. If allergic consider a fluoroquinolone such as Moxifloxacin or Ciprofloxacin.⁵
  • Tetanus Prophylaxis if last tetanus was more than 5 years ago.

If the patient requires intubation or sedation, be aware that there is controversy surrounding the use of ketamine, as it is believed to increase intraocular pressure.  However, in doses less then 3mg/kg IV, ketamine has been shown to be safe.  An antiemetic is recommended with any sedative to avoid emesis which will also increase intraocular pressure potentially causing extrusion of intraocular contents.⁶

References:

1. Babar TF, Khan MT, Marwat MZ, Shah SA, Khan MD. Patters of ocular Trauma.  Journal of the College of Physicians and Surgeons—Pakistan.    Mar;(3):148-53.
2. Tintinalli JE et al. Eye Emergencies. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 2011; 7.
3. Stone CK, Humphries RL. Eye Emergencies. CURRENT Diagnosis & Treatment Emergency Medicine (7th edition). McGraw-Hill, 2011.
4. Gerstenblith AT, Rabinowitz MP. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease (6th edition). Lippincott Williams & Wilkins, 2012.
5. Ahmed Y, Schimel AM, Pathengay A, Coyler MH, Flynn HW. Endophalmitis following open globe injuries.    2012(26):212-217.
6. Nagdeve NG, Yaddanapudi S, Pandav SS. The effect of different doses of ketamine on intraocular pressure in anesthetized children. J Pediatr Ophthalmol Strabismus 2006; 43:219.