Trauma to the eye is a major cause of vision loss, especially in young people. We refer to the eye as the “globe,” so trauma to the eye is classified as “open globe” versus “closed globe” injury. If the wall of the eye is lacerated or ruptured in any way, that qualifies as an open globe. Below, I will discuss open globe and closed globe trauma.
First, a few words on avoiding eye trauma
Prevention is the best medicine. Some general rules based on my experience seeing a lot of tragic eye trauma:
1. If you’re running around in a wooded area, be careful with regards to the branches.
2. Stay away from BB guns. I have seen little boys shoot their brother or sister in the eye by mistake. I have seen young children shooting at a squirrel on a tree; the BB bounces of the tree and hits the child in the eye, so the child loses that eye. Please steer clear of all types of BB guns.
3. Stay away from paintball guns. Usually it’s a friend or relative that shoots the patient in the eye by mistake. Often the patient put his or her goggles up “for a moment” to wipe away sweat and in that moment disaster happens.
4. When doing any kind of hardware work at home–assembling, hammering, nailing, anything–wear protective goggles the entire time. Don’t be shy and don’t be embarrased by how it looks. A severely traumatized eye looks much worse than a pair of goggles that is worn for a few minutes or a few hours.
5. If your job is a physical job, such as road or car repair, yard work, etc. wear goggles all the time during your work. Hopefully your employer provides safety goggles; if not, buy some from Home Depot for a few dollars.
6. Condition children to respect the eye. In video games and in movies, children see people punched in the eye and it’s “no big deal.” The person who was punched recovers instantly. In reality, a single fistpunch to an eye may functionally blind that eye forever. I have seen 8 year old kids punched in the eye once at school and blinded in that eye forever, through a mechanism known as a choroidal rupture through the macula. The eye is a beautiful and delicate structure and does not withstand trauma well.
7. As an adult, do not punch people in the eye, and avoid situations where people may punch you in the eye. This warning sounds trite, but I have seen lots of nice people involved in a fist fight at a football game, bar, or night club. It happens a lot, especially when alcohol is in the mix.
Now, a discussion on “closed globe” injury
In a closed globe injury, the eye absorbs a force but the eyeball wall is neither lacerated nor ruptured.
Closed globe injury is a very broad spectrum. There may be bleeding in the front of the eye (“hyphema”). There may be dislocation of the lens. Retinal bruising called “commotio retinae” may develop. Bleeding in front of the retina, within the retina, or underneath the retina may occur. Small tears in the retina or giant retina tears may develop, with ensuing retinal detachment. There may be rupture in the “choroid” layer underneath the retina.
Often there is no surgical intervention. We may treat inflammation and bleeding inside the eye with drops to help the eye settle down.
If there is a tear in the retina, we may perform “tack down” laser to prevent retinal detachment. If there is a giant tear or a retinal detachment, we may need to proceed with surgery in the next few days. A traumatized eye may develop a dislocated lens or a cataract and need cataract surgery.
Many, if not most, eyes with blunt trauma and closed globe injury do quite well. It all depends on the severity of the initial trauma.
A special note: any eye that has had closed globe injury is at an increased lifetime risk of glaucoma. So, if you recover successfully from a closed globe injury, please keep a regular once a year appointment with a qualified eye doctor, so if glaucoma developes 5, 10, or 15 years later, it is caught early before causing significant vision loss.
Now, a discussion on “open globe” trauma
Open globe trauma tends to be severe and, to some degree, is a life-changing experience. Open globe trauma often means the patient will have multiple eye surgeries and many, many visits to various eye surgeons over the next 1 to 2 years.
For a laceration or rupture injury that causes a wound or “opening” in the wall of the eye, the critial prognostic factors are:
1. the length of the wound.
2. how”far back” towards the back portion of the eye the wound extends.
3. how much of the intraocular contents of the eye are prolapsing out of the wound.
In addition, the presence of an intraocular foreign body (IOFB) such as a BB gun pellet or piece of shrapnel is critical as well. If the wound is a “dirty” wound–for example, it was caused by a tree branch or other organic material–we must be especially vigilant for infection inside the eye in the days after the injury.
For open globe trauma, urgent surgery is necessary to repair the wound. The integrity of the eye must be restored to prevent additional loss of tissues from within the eye. This first surgery is called “primary repair.” If possible, during the primary repair, we usually avoid entering the eyeball itself. If there is an intraocular foreign body, we may consider removing it at the time of primary repair, or we may wait, depending on the material and circumstances of the foreign body. Data from the Iraq war suggests that there is no disadvantage to delaying the removal of certain types of intraocular foreign bodies.
If there is severe damage to the intraocular contents of the eye, we usually plan on waiting 10 to 14 days and then performing a “secondary repair.” We allow this waiting period after the primary repair for the eye to recover from the initial trauma and the inflammation to settle down. In addition, the “vitreous” gel portion of the eye starts to undergo some structural changes during those 10 days after the initial trauma that often facilitate the secondary repair.
Here are some general principles I tell patients and their families when there has been an open globe eye injury or a severe closed globe injury:
1. This injury will likely necessitate multiple eye surgeries over a 6 to 24 month period.
2. It will take 1-2 years until the patient knows what the final vision in the eye is going to be.
3. Every injury and every eye is different, so we cannot really generalize the experience of one patient to another patient. Every eye “is its own individual story;” there is no cookie-cutter approach.
4. It is unlikely for the eye to go back to seeing 20/20; the goal is to get back as much vision as possible.