High Risk, Low Prevalence: Open Globe

Brit Long, MD and Matthew DeLaney, MD, FACEP, FAAEM

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The summary below is from an episode of ERcast: Clinical Perspectives

Open globe injury is a vision-threatening full-thickness eye injury that is often missed when exam findings are subtle. Blunt orbital trauma is the most common mechanism, and a normal-appearing CT does not reliably exclude the diagnosis when suspicion remains high.

Open Globe Recognition and Management

Blunt trauma risk pattern: Blunt trauma is the leading mechanism for open globe injury, so any eye or facial strike from MVCs, fights, or sports should keep rupture on the differential even without dramatic external findings.
Classic gross exam clues: Uveal prolapse, extruded orbital contents, a peaked teardrop pupil, hyphema, and a 360-degree subconjunctival hemorrhage are the named findings that should make you assume an open globe until proven otherwise.
Bedside vision assessment: Visual acuity is a key prognostic marker, so document Snellen testing or fallback measures like counting fingers, motion, and light perception before transfer when feasible. We get into the charting priorities in the episode.
RAPD and Seidel testing: A relative afferent pupillary defect raises concern for associated optic nerve injury and worse outcomes, while a Seidel test can help when the presentation is not obvious.
Imaging limits and controversy: Non-contrast orbital CT with thin cuts can help find globe contour changes, foreign body, or fracture, but sensitivity is only 56-68%, and ocular ultrasound remains operator-dependent and controversial.
Immediate protective steps: Avoid removing large foreign bodies, place a rigid eye shield, control nausea, and start broad-spectrum coverage such as vancomycin plus a third- or fourth-generation cephalosporin; the transfer and consultant nuances are worth hearing in the chapter.

Subscribe to ERcast: Clinical Perspectives to listen to the episode.

References:

Ojaghihaghighi S, et al. Diagnosis of Traumatic Eye Injuries With Point-of-Care Ocular Ultrasonography in the Emergency Department. Ann Emerg Med. 2019;74(3):365-371. PMID: 30905470
Blaivas M, et al. A study of bedside ocular ultrasonography in the emergency department. Acad Emerg Med. 2002;9(8):791-799. PMID: 12153883
Arey ML, et al. Computed tomography in the diagnosis of occult open-globe injuries. Ophthalmology. 2007;114(8):1448-1452. PMID: 17678689
Pelletier J, Koyfman A, Long B. High risk and low prevalence diseases: Open globe injury. Am J Emerg Med. 2023;64:113-120. PMID: 36516669

Faculty

Brit Long, MD
Dr. Brit Long is a Professor of Emergency Medicine at the University of Virginia and an emergency medicine physician with experience in both a community ED and at a military academic center ED. He is the Clinical Editor-in-Chief of emDOCs.His professional interests include medical education, evidence-based medicine, and the FOAMed movement. Outside of work, he enjoys spending time with his wife and two daughters
Matthew DeLaney, MD, FACEP, FAAEM
Dr. Matthew DeLaney is an emergency medicine physician and educator based in Birmingham, Alabama. A native of Mobile, he earned his medical degree from the University of South Alabama and completed his emergency medicine residency at Maine Medical Center.Dr. DeLaney has experience in both community and academic emergency medicine and is known for his commitment to teaching and medical education. He lives in Birmingham with his wife, Erin, who is also a physician, and their two daughters.