Systemic evaluation in open globe injuries: An "eye opener".

Dear Editor,

Open globe injury (OGI) is an emergency that requires immediate ophthalmic intervention. OGI in children is typically caused by handheld sharp objects like pencils/pens or while playing.[1] In these cases, early wound repair performed is associated with better visual outcomes.[2] Hence, many clinicians prefer to perform primary wound repair as early as possible, even at odd hours.

We present two interesting cases of OGI in children. The first patient was a 3-year-old male who presented with a corneal tear due to a pencil tip injury. The site of the tear was inferior to the visual axis in the right eye. He was uncooperative for vision assessment. In the right eye, he had hyphema, and anterior chamber details were obscured. The child was otherwise healthy and had no prior systemic symptoms. However, on referral to a pediatrician for preoperative evaluation, he was diagnosed to have a complete heart block with atrioventricular dissociation. The child was referred to a pediatric cardiologist, under whom he underwent temporary pacing before primary wound repair under general anesthesia (GA). He has been advised a permanent pacemaker before further ophthalmic surgical intervention. This patient carried very high risk to life, had GA been induced without cardiac pacing.

The second patient was a 11-year-old male patient who had suffered injury to the left eye from a bicycle handle, 16 h before presentation. He had severe lid edema and was unable to open the eye. He denied perception of light, and an examination was not possible due to edema. He was well oriented with time, place, and person. The patient was advised computed tomography (CT) scan of the orbit before primary wound repair under GA. The scan showed that the left eye had collapsed and appeared unsalvageable [Fig. 1a]. Additionally, a displaced orbital roof fracture with injury to the frontal lobe and caudate nucleus was also noted [Fig. 1b]. The patient was referred to a neurosurgery unit, where he underwent orbital roof fracture repair along with primary enucleation of eyeball.

Figure 1

(a) Axial CT scan image showing distorted ocular details (asterisk) in the right eye following trauma. (b) A coronal slice showing the displaced fragment (yellow arrow) from an orbital roof fracture. CT = computed tomography

These two cases demonstrate importance of a thorough preoperative evaluation of every patient of ocular trauma not just from an ophthalmic perspective, but also from a systemic point of view. Majority of these cases, pediatric or adult, require GA. Undetected systemic issues can have catastrophic outcomes, especially given the limited resources available in the operating rooms in stand-alone ophthalmic centers. Through this communication, we wish to emphasize that even in emergent cases, it may be appropriate to delay the ophthalmic surgery for a few hours in order to ensure a thorough systemic preoperative evaluation of the patient.

Financial support and sponsorship

AGN: HelpMeSee Inc., Carl Zeiss Meditec Inc.

Conflicts of interest

There are no conflicts of interest.