Open-globe emergency management

Open Globe Injury: Emergency Principles & Surgical Repair

Immediate Emergency Triage & Stabilization

When an open globe injury is diagnosed or suspected, primary clinical management adheres to strict trauma protocols to avoid secondary ocular extrusion:

1. Rigid Protection: Place a rigid shield supported by the orbital rim without pressure on the globe. Avoid pressure dressings and unnecessary manipulation, which can worsen extrusion through an open eyewall wound. Arrange urgent specialist repair.
2. Systemic Stabilization: Keep the patient fasting for anticipated surgery, provide appropriate analgesia and antiemetic treatment, and address other injuries. Drug selection and dose depend on age and clinical context. Review tetanus status and provide prophylaxis according to the wound and immunisation history; not every patient needs an automatic booster.
3. Prophylactic systemic antibiotics: Start prompt broad-spectrum cover using the local open-globe protocol, considering soil/organic contamination, foreign body, allergy, age and renal function. Selected intravitreal prophylaxis or treatment is a specialist decision. A fixed adult dose is not suitable for every injured patient.
4. Diagnostic Imaging: Obtain a non-contrast orbital CT scan with 1 mm thin axial and coronal cuts. CT is the gold standard modality to delineate globe collapse, scleral contour irregularity, and radiopaque intraocular foreign bodies (IOFBs). MRI is strictly contraindicated if a metallic ferrous IOFB is suspected. Diagnostic B-scan ultrasonography is contraindicated prior to surgical closure due to the mechanical transducer pressure exerted on the unsealed globe.

Anesthetic Considerations

• Emergency general anesthesia requires rapid sequence induction (RSI).
• Anaesthesia: Non-depolarising alternatives may be preferred to minimise ocular pressure changes. Airway and aspiration safety take priority; induction choice requires the anaesthetist rather than an absolute prohibition on life-saving treatment.

Microsurgical Repair Principles

Surgical repair should be undertaken within 24 hours to minimize endophthalmitis risk. The overarching primary objective is achieving a watertight, anatomically aligned globe closure that restores normal intraocular architecture and pressure without inducing excessive tissue distortion.

1. Exploration & Exposure:

   • Perform a $360^\circ$ conjunctival peritomy at the limbus.
   • Dissect Tenon capsule blunt-dissection style to expose all four quadrants.
   • Carefully isolate and sling each rectus muscle with $2-0$ or $3-0$ silk or vessel loops. Systematically inspect the sclera under direct visualization, especially beneath the muscle insertions where sclera is thinnest ($0.3\text{ mm}$).

2. Corneal Laceration Closure:

   • Suture Material: $10-0$ monofilament nylon with an operative spatula needle.
   • Technique: First, place landmark sutures at the limbus or identifiable angular landmarks to re-establish anatomical orientation. Sutures must penetrate $90\%$ of corneal stromal depth (or full-thickness to Descemet membrane without penetrating the anterior chamber) to prevent posterior wound gaping and internal fluid leakage.
   • Suture Length & Tension: Follow the principle of compression sutures: longer sutures are placed in the corneal periphery where scar-induced flattening does not impair the central visual axis; shorter, tighter sutures are placed centrally to minimize irregular astigmatism.
   • Knot Management: All knots must be buried completely into the corneal stroma away from the visual axis, pointing toward the limbus, to facilitate re-epithelialisation and minimize postoperative suture-induced inflammation.
   • Tissue Reposition vs. Excision: Prolapsed iris presenting within 24 hours without gross purulent infection or necrosis is gently reposited into the anterior chamber using a cohesive ophthalmic viscoelastic device (OVD; e.g., sodium hyaluronate) and an iris spatula through a separate paracentesis. Iris that is visibly necrotic, depigmented, macerated, or exposed for $>24-48$ hours with bacterial contamination should be conservatively excised.

3. Scleral Laceration Closure:

   • Suture Material: $8-0$ or $9-0$ non-absorbable nylon, polyester, polypropylene (Prolene), or absorbable polyglactin ($7-0$ or $8-0$ Vicryl) on a spatulated needle.
   • The "Close-as-You-Go" Technique: Posterior scleral lacerations must be closed progressively from anterior (limbus) to posterior. As each suture is tied, the wound edge is secured and the globe stabilized, allowing the surgeon to gently retract adjacent tissues and advance further posteriorly. This prevents sudden expulsion of intraocular contents that would occur if the entire posterior scleral wound were exposed simultaneously.

• Prolapsed vitreous is cut with an appropriate vitrector without traction rather than pulled or trimmed under tension.

Immediate Priorities and Procedure Safety

Irrigate a chemical splash immediately with copious available clean fluid; use water rather than delaying for saline. Remove retained particles and recheck pH after a pause, continuing until stable. A stated litre count is not a stopping rule. Assess limbal and conjunctival involvement, sensation, pressure and evolving epithelial defects; treat severe burns with specialist monitoring and appropriately selected anti-inflammatory, epithelial-support and anticollagenolytic therapy.

With suspected open globe, avoid pressure, tonometry and unnecessary manipulation. A negative CT does not exclude every wound or organic foreign body; MRI is avoided until a ferromagnetic foreign body is excluded. Stabilise systemic injury, shield, give analgesia/antiemetics and appropriate systemic antibiotic prophylaxis, keep nil by mouth and arrange urgent repair. Peritomy extent, posterior exposure and iris preservation depend on the wound and tissue viability, not a fixed clock rule. Protect the airway; the anaesthetist selects induction to minimise pressure while managing aspiration and life-threatening risks.