Trauma (penetrating)

Contents

Aetiology

Full-thickness injury of outer wall of eye caused by sharp object
Common causes include: assault, industrial or work-related accident, DIY injury

Predisposing factors

Male: female = 3-5:1

Failure to wear suitable eye protection while involved in high risk activities

Symptoms of penetrating trauma

History of trauma
Pain
Visual loss

Signs of penetrating trauma

Variable presentation including:

Periocular tissue injury e.g. lid laceration: 

  • assess depth, contamination and whether canaliculi involved

Conjunctiva

  • hyperaemia and chemosis
  • subconjunctival haemorrhage
  • look for foreign bodies
  • assess depth of any conjunctival laceration

Corneal laceration

  • check depth
  • check for signs of perforation (shallow or flat AC, Seidel test +ve)

Anterior chamber

  • possible iris damage (iridodialysis) ± iris prolapse into wound
  • shallow or flat anterior chamber
  • hyphaema
  • AC inflammation
  • irregular pupil (may be pointing towards the wound)

Lens

  • may be subluxated, dislocated, absent, or cataractous

Scleral laceration
Iris prolapse
Commotio retinae
Vitreous haemorrhage (absent or poor red reflex)
Retinal tear/detachment
Relative afferent pupillary defect (RAPD)
Risk of endophthalmitis 

Differential diagnosis

Non-penetrating (blunt) trauma
Chemical trauma

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

Non pharmacological

DO NOT EXERT PRESSURE ON EYE IF EVIDENCE OF PENETRATING INJURY.

Take a careful history

  • patient’s description of events leading to trauma
  • nature of any known foreign body, its speed and size
  • A history of metal striking metal without the use of protective goggles should raise suspicion of an intraocular foreign body (IOFB)
  • in cases of suspected IOFB, or uncertain penetration dilated fundus examination
  • check tetanus status

If there is any suspicion of a full-thickness laceration of the globe

  • do not exert any pressure on the eye (including forcing the lids open)
  • advise patient not to cough or strain

Check VA (important even if pain and swollen lids make that difficult)
Protect eye by taping over it a rigid plastic shield (e.g. cartella)
If penetrating object is still in the eye do not be tempted to remove it
If iris protrudes from wound do not attempt to push it back
Advise patient to take nil by mouth (except as below*)
(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Pharmacological

Topical anaesthetic (to aid examination), systemic pain relief and antiemetic as required
*To assist swallowing of tablets, a small amount of water is permissible
(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Management category

A2: first aid followed by immediate referral; no intervention. Emphasise to the patient the urgency of the condition and instruct them to attend the local hospital eye department or hospital A&E the same day, explaining that you will leave a message so that they are expected. Telephone the department to explain what you have done, preferably leaving your message with a doctor or other health care professional.

Possible management by ophthalmologist

Orbital X-ray, ultrasound, other investigations 
Surgical management of penetrating injury
Tetanus prophylaxis considerations
Endophthalmitis prophylaxis
Follow-up includes examination for possible sympathetic ophthalmia affecting fellow eye (occurs in 0.19% of cases of penetrating trauma in adults and 0.39% in children)

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation  (www.gradeworkinggroup.org)
 

Sources of evidence

Eye trauma. 2023 BMJ Best Practice

He B, Tanya SM, Wang C, KezouhA, Torun N, Ing E. The incidence of sympathetic ophthalmia after trauma: A meta-analysis. Am J Ophthalmol. 2022;234:117-125

Kuhn F, Morris R, Witherspoon CD, Mester V. The Birmingham Eye Trauma Terminology system (BETT). J Fr Ophtalmol. 2004;27(2):206-10

Lecuona K. Assessing and managing eye injuries. Community Eye Health. 2005;18(55):101-4

Zhou Y, DiSclafani M, Jeang L, Shah AA. Open Globe Injuries: review of evaluation, management, and surgical pearls. Clin Ophthalmol. 2022;16:2545-2559

Summary

What is Penetrating Trauma of the eye?

Full or partial penetration of the outer coat of the eye (the clear part, the cornea or the white part, the sclera) can result from industrial, work-related or DIY injuries, or from assaults with sharp objects. Such injuries occur three times as frequently in males as in females. Because they are so close to the eyeball, the eyelids may be injured also.

How is Penetrating Trauma of the eye managed?

The optometrist will check the vision and examine the injured eye to discover the extent of the damage and whether there is full or partial penetration. Any foreign bodies will be noted but not removed. Evidence of damage to the internal structures of the eyeball, such as the lens of the eye, will be looked for.

The optometrist will prescribe or supply pain relief if necessary and make arrangements for the ophthalmologist to see the patient as soon as possible on the same day.

The ophthalmologist, having examined the patient, may arrange investigations such as X-rays or ultrasound and will decide on whether surgery is necessary, and if so how soon. In penetrating injury there is a very rare risk of inflammation in the other eye, a possibility that will be watched for as the patient is followed up.

Trauma (penetrating)
Version 12
Date of search 10.12.23
Date of revision 29.03.24
Date of publication 11.04.24
Date for review 09.12.25
© College of Optometrists

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