24-year-old with pain and decreasing vision after a motor vehicle accident

The image is consistent with a diagnosis of open-globe injury:

• Open-globe injury is a full-thickness wound that can result from laceration injury but is also classically seen in blunt ocular trauma.
• Laceration injury leads to an outside-in injury, whereas blunt trauma leads to an inside-out injury due to an abrupt, temporary increase in intraocular pressure.
• Areas prone to rupture include the limbus and those posterior to the extraocular muscles.
• Treatment is surgical repair within 24 hours of injury and evaluation.

• Prioritize life-threatening injuries above ocular assessment. Once the patient is stable, an ocular assessment can be performed.
• If globe injury is suspected, do not press on the eye.
• Antiemetics can be given and a protective eye shield can be placed to prevent further expulsion, with emergent referral to the ophthalmologist.

• Most open-globe injuries can be diagnosed with simple penlight examination, but the use of a slit-lamp biomicroscope may be warranted for smaller wounds and identifying foreign bodies.
• Assess visual acuity for prognostication or assess for an afferent pupillary defect if unable to obtain visual acuity in altered patients.
• Order an orbital computed tomography scan to help confirm the diagnosis and evaluate for foreign bodies and surrounding fractures.
• Perform a Seidel test, which may be helpful for determining the depth of a known defect.

The primary goal of treatment is surgical repair within 24 hours of injury/assessment. The eye should be shielded at all times except during assessment, and the patient should be npo (nothing by mouth) in preparation for surgery.

Antiemetics and pain medication can be used as needed. Intravenous broad-spectrum antibiotics such as vancomycin and ceftazidime can be given to prevent postoperative endophthalmitis. Tetanus prophylaxis is appropriate if immunization status is unknown or immunization is overdue.

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