Urgent Management of Penetrating Ocular Injury: A Case Report and Review of the Literature

Abstract

Ocular globe injury is a severe ophthalmic emergency that requires immediate attention in the emergency department. In this case report, we present a 35-year-old male who suffered a penetrating ocular injury and globe rupture caused by a nail puncture. The patient presented with severe pain and visual loss and was treated with tetanus vaccination, empirical antibiotics, and pain control, followed by an urgent orbital computed tomography (CT) scan and consultation with an ophthalmologist. The CT scan revealed a retained nail in the ocular space, and an urgent operation was performed to repair the eyeball rupture, remove the intraocular foreign body, and perform an anterior vitrectomy. The patient was discharged 6 days after the operation with a visual acuity of 20/400 and an ocular trauma score of 34. This case highlights the importance of initial emergency physician decision-making and the need for a thorough history-taking and examination when encountering penetrating ocular injuries.

Introduction

Ocular globe injuries are a severe form of ophthalmic trauma that require immediate attention in the emergency department. These types of injuries often result in multiple mechanisms of trauma, ranging from damage to the anterior structures of the eye to posterior structures and the post-ocular space. The treatment plan and evaluation considerations are crucial when encountering this type of ocular trauma. In this case report, we present a patient with a penetrating ocular injury and globe rupture caused by a nail puncture. We discuss the management strategy and considerations when encountering this type of ocular trauma.

Case Report

A 35-year-old male presented to the emergency department with a right eye injury caused by a nail puncture that occurred 30 minutes prior. The patient was striking a nail with a hammer when the nail rebounded and hit his right eye. He reported severe pain and visual loss. Upon examination, no comorbid organ injuries were found. The patient received tetanus vaccination, empirical antibiotics, and pain control, and was referred for an urgent orbital computed tomography (CT) scan and consultation with an ophthalmologist. Ophthalmic examination revealed a cornea penetration wound measuring 3 × 3 mm at the 8 o’clock peripheral with iris protrusion, hyphema, and lens drusen blocking the fundus exam. ( Fig. 1 ) Extraocular motor function was limited in all directions due to pain, and visual acuity was limited to counting fingers at a 20-cm distance. The CT scan revealed a retained nail with in-and-out penetration in the ocular space, and the orbital floor was intact. ( Fig. 2 ) An urgent operation was performed to repair the eyeball rupture, remove the intraocular foreign body, and perform prophylactic intra-vitreous injection of vancomycin plus ceftazidime and anterior vitrectomy. The patient was discharged 6 days after the operation without any major complications. At discharge, visual acuity was 20/400, and the ocular trauma score was 34.

Fig. 1 . Globe ocular injury by the penetrated nail.

Fig. 2 . Computed tomography scan of the penetrating nail injury.

Discussion

Penetrating ocular injuries have a significant impact on ocular function. Damage can occur to delicate structures such as the cornea, iris, and lens, as well as the anterior chamber, vitreous, and retina. Additionally, orbital floor fractures and brain parenchymal injuries may also occur. 1 It is important to consider the risk of endophthalmitis, retinal detachment, and wound leaks following initial injury. ( Fig. 3 ) Therefore, prompt and effective decision-making by emergency physician is vital. The management strategy for ocular trauma follows the A-B-C rule (Airway-Breathing-Circulation) and aims to stabilize the patient’s vital signs. 2 Medications that increase intra-orbital pressure (IOP) should be avoided during intubation or sedation. A thorough history should be taken, including information about the injury timing, mechanism, foreign body content, last meal timing, and past medical history including ocular surgery, tetanus status, and current medications. If possible, the wound should be protected with a Fox shield and the foreign body should not be removed except during surgery. Vaccination and prophylactic antibiotics may be used for tetanus-prone dirty wounds, but no strong evidence suggests optimal prophylaxis agents. Emergent consultation with an ophthalmologist should be prompted if the patient’s condition allows for surgery. Emergency physician should be aware that some ophthalmic examinations may be harmful and increase ocular pressure, and should be avoided. Fluorescein staining may be useful when there is no obvious foreign body visible but it should be avoided if foreign body penetration is suspected. Ocular imaging, including orbital CT, can be helpful but it should not replace a thorough ophthalmic examination.

Fig. 3 . Potential injury separating by anatomy.

Orbital magnetic resonance imaging is generally contraindicated only if the ocular CT scan does not show any metal foreign body and the clinician still suspects the presence of a radiolucent one. In general, the treatment of traumatic globe injuries can be divided into two main parts: (1) trauma repair and foreign body removal, and (2) infection control. The gold standard treatment strategy is surgery; however, in Taiwan, due to inconsistent expectations between physicians and patients’ families, the Ocular Trauma Score, which predicts the initial visual acuity post-trauma and the visual acuity at 6 months follow-up, can be used to help physicians explain the potential outcome to patients. 3 The eye is considered the window to the soul and ocular globe trauma can be a devastating experience. Emergency physicians should be proficient in dealing with these injuries, from assessment to final treatment plan.