Open globe injuries from garage door springs

Abstract

We describe seven patients who were attempting to repair their garage doors when a spring dislodged at high velocity resulting in open globe injury (OGI). All patients were seen at Massachusetts Eye and Ear (MEE) between the years of 2008 and 2023. The final visual acuities ranged from 20/125 to no light perception (NLP). OGI appears to be a risk of attempting to fix a garage door in people who are inexperienced in doing so.

Introduction:

Eighty percent of US homes have a garage¹. Around 35,000 people get injured due to garage doors each year, and some of these injuries are fatal². When garage doors close, energy is stored in a spring that is under compression due to the heavy weight of the door which can weigh up to 400 pounds^2,3. The energy is released as the door opens, but if that energy is misdirected, it can cause minor injuries like bruises or abrasions, more severe injuries such as lacerations to the limbs or eyes or in some cases death^2,4.

This case series describes seven patients who suffered open globe injuries (OGI) from high velocity garage springs seen at MEE. All patients were attempting to fix a jammed garage door. These injuries were severe, all resulting in significant loss of vision. Chart review was done using the Research Patient Data Registry (RPDR) at Massachusetts General Hospital. A search was performed using the terms [“garage door” and “spring” and [“OGI” or “open globe” or “ruptured globe” or any ICD9 or ICD10 code for OGI]] for patients seen prior to January 1, 2023. Institutional review board approval was obtained (protocol #2022P001017), and the study complied with the Health Insurance Portability and Accountability Act of 1996 and adhered to the tenets of the Declaration of Helsinki. As this was a retrospective study, informed consent is not indicated.

Case Reports

Case 1:

A healthy 37-year-old male presented after a spring dislodged and struck his left eye while he was working on a garage door. On examination, the patient had light perception (LP) vision, there was a relative afferent pupillary defect (RAPD) and a zone I-II lacerating OGI. Computed tomography (CT) revealed no intraocular foreign body (IOFB) or orbital fracture. The patient underwent same-day OGI repair, but at 1-week follow-up a B-scan revealed a retinal detachment (RD). 18 days later, he underwent temporary keratoprosthesis (TKP), pars plana vitrectomy (PPV), retinectomy, insertion of silicone oil and corneal transplantation. At final follow-up (7 months), the visual acuity (VA) was hand motions (HM), the eye was soft, and the corneal graft had opacified; the patient declined further surgery.

Case 2:

A 59-year-old female with a history of laser-assisted in situ keratomileusis (LASIK) presented after a spring-loaded one-foot metal plate dislodged and struck her left eye while working on her garage door. The eye was LP only and had a stellate zone I-II-III lacerating OGI (Figure 1). No RAPD was present. CT showed a lateral orbital wall fracture but no IOFB. She underwent same-day OGI repair, but due to subsequent RD she underwent PPV with TKP, retinectomy, insertion of silicone oil and corneal transplantation 21 days later. Post operatively, the patient achieved counting fingers (CF) vision, but the eye subsequently became phthisical. At final follow-up (4 years), the vision was LP, the corneal graft was hazy, and the eye was soft.

Figure 1. External photograph of a patient upon presentation.

Photograph shows a severely deformed globe with extrusion of intraocular contents through a zone I-II-III wound.

Case 3:

A 43-year-old healthy male presented to MEE after a metal spring dislodged and struck his left eye while working on his garage door. Preoperative VA was LP and he was found to have a reverse RAPD and a stellate zone I-II lacerating OGI. CT showed no IOFB nor fracture. The patient underwent OGI repair the next day. B-scan on follow-up showed kissing hemorrhagic choroidals and the patient deferred further intervention. At final follow-up (4 months), the eye was pre-phthisical, intraocular pressure (IOP) was 10mmHg, VA was HM and he had a closed funnel RD on ultrasound.

Case 4:

A 57-year-old male with a distant history of retinal detachment in the left eye repaired with scleral buckle presented after a garage door spring attached to a metal bracket dislodged and struck his left eye while working on his garage door. On presentation his VA was LP, he had a reverse RAPD and examination showed a zone III globe rupture with several facial lacerations. CT showed multiple facial fractures and no IOFB. He underwent same-day OGI surgery and 14 days later underwent PPV, pars plana lensectomy (PPL), retinectomy and silicone oil placement for a total incarcerated RD. His visual acuity at final follow-up (2.5 years) was 20/125 following secondary IOL placement and silicone oil removal. His retina remains attached.

Case 5:

A 43-year-old male with no ocular history sustained an OGI after a garage door spring dislodged and struck his left eye. Examination revealed LP vision, an RAPD and a zone I-II-III lacerating OGI. CT revealed no IOFB and non-displaced maxillary sinus fractures. After OGI repair, vision remained bare LP, but 14 days later he underwent PPV, PPL, retinectomy and placement of silicone oil for an RD. At final follow-up (1 month), VA was LP and IOP was soft with the retina remaining attached.

Case 6:

A 25-year-old male with no past ocular history presented after a garage door spring dislodged and struck his left eye. His vision was no light perception (NLP) and examination revealed a zone I-II-III lacerating OGI and a lid laceration. RAPD was not documented at the time of presentation. CT revealed no IOFB and a floor and a medial wall fracture. The globe was repaired on the same day, but one week post-operatively, VA remained NLP with a reverse RAPD and total hyphema and no view to the posterior chamber. At final follow-up (3 months), the eye remained NLP and became phthisical.

Case 7:

A 60-year-old male with no past ocular history presented after a spring dislodged and struck his right eye while working on his garage door. On examination, the patient had bare LP vision, and he had a zone I-II-III lacerating OGI with uveal prolapse. An RAPD was not initially documented but was found to be present on exam post-operatively. CT showed no IOFB and a left nasal bone fracture with minimal displacement. The patient underwent OGI repair the next day. One day post operatively, the VA was NLP. B-scan showed disorganized contents and minimal choroidals. One month postoperatively, the VA remained NLP and the IOP was soft. At final follow-up (5 months), the patient had undergone enucleation for blind painful eye.

Discussion

Garage door spring-related OGIs are rare but devastating forms of ocular trauma. This case series describes seven patients who sustained OGIs while attempting to fix their garage door. While most ophthalmologists are familiar with more common mechanisms of OGI (falls, sharp objects, small projectile foreign bodies), high velocity garage door springs only came to our attention as a repeating mechanism of OGI after we saw five patients in the span of 3 years with the same injury (2019 – 2022).

For most homes, the garage door is the heaviest mechanical device². On average, a garage door will be opened and closed over 3-5 times a day, which results in strain during the 6-10 years life span of garage doors⁶. Experts recommend yearly garage door inspections to maintain the health of the garage⁷. The underlying theme in the seven patients seen in this case series is that they were all attempting to fix their garage door without experience in doing so.

There are two types of spring systems that can be found in garage doors: extension springs and torsion springs (Figure 2). Extension springs are mounted on both sides of the garage door track and are necessary for when the garage door is in motion to help with the movement of the cables and pulleys⁵. Torsion springs, on the other hand, are tightly wound springs with cable drums on both ends that are mounted to the header wall above the garage door³. The main mechanism of action of both garage door springs involves the springs gaining tension when the garage door lowers and then releasing tension upon the lifting of the garage door³.

Figure 2: Schematic of a garage door with two springs.

Diagram shows the torsion spring and the extension spring which can both cause injury, though garage doors typically have one or the other. This diagram is simplified for schematic purposes and does not represent all components of a garage door.

Mechanical globe injuries affect 3.5 per 100,000 persons yearly⁸ and garage door-related injuries are just one of the many ways by which these types of ocular injuries could occur. After analyzing the 2002 National Health Interview Survey data, about 29.3% of individuals were found to be engaging in activities that could cause eye injury⁹. However, only about 32% of those individuals reported wearing eye protection during those activities. The younger population (age 18-24 years) was the least likely to be wearing eye protection⁹.

The injuries sustained by patients in this series were severe (Table 1). Six out of seven involved zone III, five developed an RD that required subsequent extensive surgeries, and two did not recover any vision. For all but one patient, the final VA was HM or worse. Many studies have looked at presenting OGI features that correlate with final prognosis. These studies repeatedly demonstrated that the strongest predictors are poor initial visual acuity, blunt rupture (versus laceration or perforation), zone III wound, RAPD, retinal detachment and endophthalmitis^11–17. The overall poor prognosis of patients in this series is likely due to many factors: all but one involved zone III, most presented with or developed a retinal detachment and most had an RAPD. RAPD refers to a relative afferent pupillary defect that indicates less light is transmitted to the optic nerve in the affected eye compared to the fellow eye as evidenced by a relative difference in the concentric pupillary light response depending on which eye receives light (and in this setting is thought to be due to either traumatic injury to the optic nerve or choroidal hemorrhage or both). The presence of an RAPD portends a poor prognosis, and it is crucial to test for it at the time of presentation to be able to provide the patient with realistic expectations regarding visual outcome.

Table 1:

Overall Timeline of Each Case from Arrival to the Emergency Room to after the Open Globe Surgery.

	Case 1	Case 2	Case 3	Case 4	Case 5	Case 6	Case 7
Age (years)	37	59	43	57	43	25	60
VA Pre-operatively	LP	LP	LP	LP	LP	NLP	LP
Zone	I-II	I-II-III	I-II	III	I-II-III	I-II-III	I-II-III
Length of defect (mm)	17	16	10 (stellate)	ND	13	ND	14
Subsequent retinal detachment (yes/no)	Yes	Yes	Yes	Yes	Yes	No	No
Subsequent corneal transplant (yes/no)	Yes	Yes	No	No	No	No	No
Time of final follow-up (months)	7.5	58	4	31	1.5	3.5	92
VA at final follow-up	LP	LP	HM	20/125	LP	NLP	Prosthetic
Phthisis	Yes	Yes	Yes	No	No	Yes	Yes

HM = hand motions; LP = light perception; ND = not documented; NLP = no light perception.

Of note, the chance of suffering an OGI from garage door spring if one is struck in the eye appears to be about 50%. In a search of patients at MEE between the years of 2008 and 2023 using the Research Patient Data Registry (RPDR), we identified 6 other patients who had mention of an injury from a garage door spring in their chart. These injuries included traumatic cataract with 360-degree angle recession, traumatic hyphema with iris disinsertion and angle recession, orbital floor fracture, orbital roof fracture, eyelid laceration and traumatic iritis.

All but one of the patients in this series were found to have a lacerating OGI rather than a blunt posterior rupture. Though one may expect such force to lead to a blunt rupture, we suspect that the spring itself will have a sharp edge if it breaks or dislodges and therefore a laceration will supersede a rupture if the sharp edge is in contact with the eye. Unfortunately, while all patients reported a large “spring” that dislodged at high speed, none of them collected the material for inspection.

In conclusion, we describe seven patients who were attempting to fix their garage door and suffered a severe OGI due to a high velocity spring that dislodged. Most injuries involved zone III and developed a retinal detachment or resulted in NLP vision or enucleation. This mechanism of OGI appears to be severe.