Open Globe Injury — Evaluation & Emergency Management

Clinical Signs

Open globe injury doesn't always announce itself with an obviously gaping wound. The single most useful clinical sign to recognize is a teardrop-shaped, or peaked, pupil: iris tissue gets pulled toward and incarcerated in a corneal or scleral wound, distorting the pupil into a point aimed at the site of the breach. Seeing this sign on an otherwise unremarkable-looking eye should immediately raise suspicion for occult globe rupture with iris incarceration, even without an obviously visible laceration.

Other findings that should prompt the same suspicion include a visible corneal or scleral wound, a shallow or flat anterior chamber, hyphema, marked chemosis, or extrusion of dark uveal tissue through the ocular surface. The mechanism of injury is diagnostic in its own right — a high-velocity projectile or hammering metal-on-metal history should be treated as an open globe until proven otherwise, since the entry wound from a fast-moving metal fragment can be small enough to miss on a casual look while still fully breaching the eye wall.

The Seidel Test

The Seidel test uses fluorescein dye under a cobalt blue light to detect active aqueous leakage from a corneal or scleral wound. Concentrated fluorescein dye is applied to the ocular surface; where it pools intact, it fluoresces bright green, but a positive test shows a visible stream of diluted, darker fluorescein — leaking aqueous humor washing a track through the concentrated dye — confirming a full-thickness wound that is actively leaking. It is a fast, low-risk bedside test used specifically to detect an aqueous leak from a penetrating corneal injury when the diagnosis is in question.

Exam Precautions

Once open globe injury is suspected, the examiner's job shifts from "characterize the injury fully" to "avoid making it worse." Anything that applies pressure to the eye can force intraocular contents — iris, vitreous, even retina — out through the open wound, so several otherwise-routine parts of the eye exam must be deliberately skipped or deferred:

• Visual acuity, pupil size/shape/reactivity, and lid inspection for lacerations remain appropriate and should still be performed — they don't touch the globe itself.
• Intraocular pressure measurement (tonometry) must never be performed on a suspected open globe — any contact pressure from the tonometer tip risks extruding intraocular contents through the wound.
• No firm pressure patching, no forceful lid retraction, and no further manipulation of the eye beyond what's needed to confirm the diagnosis.

Prehospital Care and Initial Protection

The correct immediate action while awaiting ophthalmology transfer is to place a rigid protective shield (a "fox shield" or similar rigid eye shield) over the injured eye. A rigid shield rests on the surrounding bony orbital rim rather than the globe itself, protecting it from external pressure and accidental contact without compressing the eye the way a soft pressure patch or firm gauze wrap would. Patching an open globe firmly is specifically the wrong move — it transmits pressure directly onto a wall that can no longer resist it.

In mass casualty or multi-patient triage settings, open globe injuries exposing uveal tissue are prioritized for the earliest ophthalmic intervention, ahead of stable or resolving injuries like a healed subconjunctival hemorrhage or a resolving corneal abrasion — the risk of infection (endophthalmitis) and permanent vision loss climbs the longer an open wound goes unrepaired.

RAPD and the Ocular Trauma Score

A relative afferent pupillary defect (RAPD) found on the initial pupillary exam is one of the strongest available predictors of poor final visual outcome after open globe injury — it signals significant optic nerve or extensive retinal damage, rather than an isolated anterior-segment problem that repair alone might fully reverse. Sudden vision loss with a new RAPD after trauma should be triaged as an emergent referral (same-day evaluation), not merely "urgent" (within 24 hours).

This prognostic weight is formalized in the Ocular Trauma Score (OTS), a validated scoring system that combines the initial visual acuity with several injury characteristics to estimate the probability of a given visual acuity outcome at six months. The variables scored by the OTS are: initial visual acuity, presence of globe rupture, endophthalmitis, perforating injury, retinal detachment, and RAPD. Notably, preoperative intraocular pressure is not one of the OTS variables — a detail worth knowing specifically because it's an easy distractor on exam questions listing OTS components.

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