Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Suspect open globe; avoid pressure; place shield and keep NPO; control pain and nausea.
- Give broad IV antibiotics and tetanus booster; obtain CT orbit.
- Urgent ophthalmology consult for operative repair; avoid drops/tonometry/US.
- Post-op: shield, activity restriction, infection prophylaxis; monitor for complications.
Clinical Synopsis & Reasoning
Penetrating ocular trauma with peaked pupil, low IOP, or Seidel sign. Avoid any pressure on the eye, place a rigid shield (no patch), give antiemetics and analgesia, start broad IV antibiotics, update tetanus, obtain CT orbit (no tonometry/US), and take urgently to the OR for repair.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|
| Visual acuity/pupillary exam (gentle) | Baseline function | RAPD, peaked pupil | Avoid pressure |
| CT orbits (no contrast) | Foreign body/fracture | IOFB, intraorbital air | Surgical planning |
| Seidel test (if safe) | Leak detection | Positive aqueous leak | Confirm open globe |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| Positive Seidel test, peaked pupil, low IOP | Open globe likely | Shield, NPO, IV antibiotics; urgent OR |
| Organic/dirty mechanism or IOFB | Endophthalmitis risk | Add antifungal consideration; CT orbit |
| Vomiting/Valsalva | Extrusion risk | Antiemetics; avoid pressure/eye drops |
| Delayed presentation | Poor prognosis | Expedite surgery |
| Tetanus not up to date | Infection risk | Give booster |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Rigid eye shield + NPO + antiemetics | Mechanical/support | Immediate | Prevent extrusion | No patch/pressure |
| IV Vancomycin + Ceftazidime (or fluoroquinolone if allergic) | Antibiotics | Hours | Endophthalmitis prevention | Tailor post-op |
| Tetanus booster and analgesia | Prevention/support | Hours | Immunization update and comfort | — |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- AAO trauma guidance on open globe injuries — Link