Penetrating Eye Injury (Open Globe Injury)

First aid: what to do right now

1. Call 911 or go straight to an emergency department, ideally one with an eye specialist.
2. Protect the eye with a rigid shield. Tape a paper cup, the bottom of a plastic bottle or a commercial eye shield over the eye so it rests on the bones around it, not on the eyeball.
3. Do not remove any object stuck in the eye.
4. Do not press, rub or rinse the eye. Do not apply ointment or drops.
5. Keep the person still, ideally with the head raised about 30 to 45 degrees. Discourage bending, straining and coughing.
6. Cover the other eye lightly if possible, to reduce eye movement.
7. Do not give food or drink, as surgery is likely.
8. Treat nausea and pain only as advised by emergency services, because vomiting raises pressure in the eye.

Types of open globe injury

Causes

• hammering metal on metal and using power tools without eye protection
• lawn mowers and string trimmers throwing debris
• broken glass in car crashes or falls
• sticks, pencils, fishhooks and other sharp objects
• fireworks, BB and paintball guns
• assaults
• sports injuries

Symptoms

• eye pain
• sudden blurred vision or vision loss
• a visible cut, puncture or object
• a teardrop-shaped or irregular pupil
• blood in the front of the eye (hyphema) or under the conjunctiva
• the eye looks deflated or collapsed
• clear fluid leaking
• double vision, if eye muscles or the orbit are injured

Small metal fragments can enter the eye with surprisingly little pain. Anyone who felt something hit the eye while hammering or grinding should be examined, even if vision seems normal.

Diagnosis

An ophthalmologist examines the eye carefully without pressure. Tests may include:

• visual acuity and pupil reactions
• slit lamp examination
• Seidel test: a dye shows fluid leaking from a wound
• CT scan of the orbits to locate foreign bodies and fractures. MRI is avoided if a metal fragment is possible.

Eye pressure is not measured with a device that touches the eye when an open globe is suspected.

Treatment

• Emergency surgery: repair of the eye wall, usually within 24 hours, to close the wound, restore the eye's shape and remove foreign bodies when possible.
• IV antibiotics to prevent infection inside the eye (endophthalmitis), which can destroy sight.
• Tetanus shot if not up to date.
• Anti-nausea medicines and pain relief to prevent straining.
• Later surgery for cataract, retinal detachment, scar tissue or a remaining foreign body.
• Removal of the eye is rarely needed for a severely damaged eye with no chance of vision, sometimes to reduce the risk of sympathetic ophthalmia.

Complications

• permanent vision loss
• endophthalmitis
• traumatic cataract and glaucoma
• retinal detachment and proliferative vitreoretinopathy (scarring)
• sympathetic ophthalmia: a rare immune reaction that inflames the uninjured eye weeks to years later
• loss of the eye

Outlook

Outcomes depend on the initial vision, the size and location of the wound, whether the retina is involved, and how quickly the eye is repaired. Some eyes regain good vision; others are left with limited sight. Regular follow-up is essential, and any symptoms in the uninjured eye should be reported promptly.

Prevention

Most eye injuries are preventable:

• wear safety glasses or goggles meeting ANSI Z87.1 standards for hammering, grinding, power tools, lawn work and chemicals
• use sports eye protection with polycarbonate lenses for racquet sports, basketball, hockey and paintball
• keep fireworks away from children and stand well back
• supervise children with sharp objects and projectile toys
• wear seatbelts

Frequently asked questions

What should I do if something is stuck in my eye?

Do not remove it or rub the eye. Cover the eye with a rigid shield such as a paper cup taped in place, without touching the object, and go to an emergency department or call 911 immediately. Keep still and avoid bending over.

Can you recover from a penetrating eye injury?

Some people recover useful or even good vision, particularly when the wound is small, at the front of the eye, and repaired quickly. Injuries involving the retina or with poor vision at the start have a worse outlook. Early surgery and infection prevention are critical.

Should I rinse my eye after it is cut?

No. Rinsing can push fluid into the eye or worsen damage. Rinse only for chemical splashes. If the eye might be cut or punctured, cover it with a rigid shield and get emergency care.

What is sympathetic ophthalmia?

It is a rare condition in which the immune system attacks the uninjured eye after a penetrating injury to the other eye, sometimes weeks or years later. It causes pain, redness, light sensitivity and blurred vision in the good eye and needs urgent treatment.