Consensus Regarding the Timing and Basic Treatment of Traumatic Open Globe Eye Injuries in Pediatric Patients
Original Date: 04/07/2023 | Last Review Date: 04/07/2023
Purpose: To provide timing and basic treatment recommendations for the surgical correction of pediatric trauma open globe eye injury.
Etiology and Terminology: Open globe injury (OGI) is defined as a full-thickness wound of the eyewall, due to either a laceration or an occult rupture.1
Evaluation of Open Globe:
History:
Time of injury, contamination, and medical co-morbidities are pertinent to management.
Critical to evaluate for Visual Potential: Other factors impactful for management.
Active leak – is the wound self-sealing
Prolapse of intraocular contents
Time of injury to presentation
Presence and nature of foreign body
Evidence of active infection
Concomitant injuries
Need to coordinate with multiple surgeons.
Adjunctive studies include non-contrast CT. Non-contrast orbital CT is the recommended imaging modality for ocular trauma and should be employed for most patients with a suspected OGI. Globe contour, abnormality of the lens, vitreous hemorrhage, retinal detachment, orbital and facial fractures, and obvious orbital volume loss can all be assessed with this modality. CT scans have a reported sensitivity between 56% and 68% in diagnosing patients with an open globe.4 most important, CT is particularly useful if a metallic IOFB is suspected, in which case magnetic resonance imaging is contraindicated.
Pre-operative management:
In anticipation of possible surgery, patients should be kept on NPO status (no food or liquids by mouth). The eye should be covered with a protective shield at all times to prevent further injury. In general, topical ointments should be avoided, although topical nonpreserved antibiotics may be used if there is a delay in getting the patient to the OR. Treatment may be given for nausea (Ondansetron 0.15mg/kg, max of 4mg / dose, max 12 mg/24h; for severe pain morphine 0.05-0.1mg/kg, max 4mg/dose, max 10mg/24h) ideally with IV medications Mild to moderate pain: acetaminophen 15mg/kg/dose q6 (1000mg max/dose), and ibuprofen10mg/kg/dose q6h (800mg max/dose).
Antibiotics. Endophthalmitis is a potentially devastating complication after OGI. The rate of endophthalmitis following OGI has been reported to be higher in patients with IOFBs.5 Anti-biotic prophylaxis to prevent development of posttraumatic endophthalmitis has become common practice. Although standardized guidelines for antibiotic selection and route have not been established, there is strong evidence to support the use of 48 hours of IV therapy.6 Gram-positive cocci, gram-positive and gram-negative bacilli, and fungi are the most common organisms isolated in culture-positive cases of endophthalmitis after trauma.7 Broad-spectrum antibiotics are needed to provide coverage for both gram-positive and gram-negative bacteria. IV vancomycin (15 mg/kg; maximum dose, 1.5 g) and a third-generation cephalosporin such as ceftriaxone (50 mg/kg; maximum dose, 2.0 g) may be given. Unless there are high-risk features such as intraocular organic foreign material, prophylactic antifungal coverage is not routinely given. The use of intravitreal antibiotics is controversial in the absence of endophthalmitis, unless there is delayed primary closure or presence of an organic IOFB.8
Timing:
For cases with visual potential. Operative management should proceed as soon as possible depending on urgency of injury and coordination of surgeon and other injuries. The case should not be delayed later than following day. Surgeon will document urgency and visual potential in medical record. Open Globe without visual potential: Timing to preserve visual function is not as critical. After surgical repair, the patient should be directed to wear a protective shield at all times, including while sleeping, and be given careful instructions to refrain from rubbing or touching the eye. In addition, the patient should not engage in heavy lifting, exercise, or swimming for at least six weeks.
After surgical repair, the patient should be directed to wear a protective shield at all times, including while sleeping, and be given careful instructions to refrain from rubbing or touching the eye. In addition, the patient should not engage in heavy lifting, exercise, or swimming for at least six weeks.
References: 1 Kuhn F et al. Graefes Arch Clin Exp Ophthalmol. 1996;234(6):399-403. 2 Pieramici DJ et al. Am J Ophthalmol. 1997;123(6):820-831. 3 Casson RJ et al. Clin Exp Ophthalmol. 2002;30(1):15-18. 4 Arey ML et al. Ophthalmology. 2007;114(8):1448-1452. 5 Essex RW et al. Ophthalmology. 2004;111(11):2015-2022. 6 Andreoli CM et al. Am J Ophthalmol. 2009;147(4):601608.e2. 7 Long C et al. BMC Ophthalmol. 2014;14:34. 8 Mittra RA, Mieler WF. Surv Ophthalmol. 1999;44(3):215-225. 9 Kuhn F et al. Ophthalmol Clin North Am. 2002;15(2)163-165. 10 Fujikawa A et al. BMC Ophthalmol. 2018;18(1):138.