Pediatric emergency medicine trisk 3671 3671

CLINICAL PEARLS AND PITFALLS
In order to avoid extrusion of intraocular contents, open-globe injury
requires rapid recognition and emergent evaluation by an
ophthalmologist.
Clinical findings include teardrop pupil, 360 degrees of bullous
subconjunctival hemorrhage, or enophthalmos ( Fig. 114.3 ).
If any of the above is present, immediately place an eye shield and
minimize disturbing the child.

Current Evidence
The visual prognosis in pediatric open-globe injury may be poor. The following
factors seem to be most predictive of poor visual outcome: blunt injury, injury
resulting from a gun, age <5 years, large wounds (>5 mm), wounds involving the
sclera and associated injuries such as hyphema, vitreous hemorrhage, or retinal
detachment. Prompt recognition and immediate referral to an ophthalmologist,
ideally one with pediatric expertise, is the accepted standard of care.

Goals of Treatment
Open-globe injury is an ominous trauma that warrants emergent ophthalmology
consultation. The goal of treatment in the emergency department (ED) is to avoid
causing extrusion of contents from the eye, while awaiting definitive surgical
repair. Further ocular examination should be stopped immediately when an openglobe injury is suspected and pain control and antiemetics should be initiated.

Clinical Considerations
Clinical Recognition
An open-globe injury is defined by the presence of a full-thickness break in the
cornea or sclera ( Fig. 114.4 ). This condition can occur following trauma by
sharp implements, projectiles, or blunt trauma. Sharp objects can directly
penetrate the globe. In the case of blunt trauma, significant force causes
compression of the globe, raising intraocular pressure and leading to rupture.
Although severe intraocular disruption may occur, the globe has a remarkable

ability to maintain its integrity. Upon injury, the iris or choroid may move and
plug the wound. Blue, brown, or black material on the surface of the sclera may
be visible as the iris or choroid forms a plug ( Fig. 114.5 ). With small lacerations
that are plugged by iris or choroid, the globe may maintain a remarkably normal
external appearance. Alternatively, with the movement of the iris or choroid in