Penetrating and Perforating Ocular Trauma

Key Points at a Glance

1. What are penetrating and perforating eye injuries?

Penetrating injury and perforating injury are classified as open globe injuries involving full-thickness wounds of the cornea or sclera. They are defined as full-thickness defects of the eye wall caused by laceration or rupture ¹⁾.

Penetrating injury

Definition: A condition in which a sharp object penetrates the eyeball but does not exit.

Only an entry wound is present.

Penetrating Injury

Definition: A condition in which an object passes through the eyeball, with both an entry wound and an exit wound.

Also called double perforation.

Globe Rupture

Definition: A condition in which the sclera or cornea is separated due to a sudden increase in intraocular pressure caused by blunt external force.

Blunt trauma is the cause.

Injury Zone Classification

The injury site affects prognosis and is classified into the following three zones¹⁾.

Zone	Range	Characteristics
I	Cornea to limbus	Limited to anterior segment
II	Up to 5 mm posterior to the limbus	Anterior to the ora serrata
III	5 mm or more posterior to the limbus	Posterior segment including the retina

Epidemiology

The incidence of ocular trauma is estimated to be approximately 3.5–4.5 per 100,000 population¹⁾. The majority of patients are male, with a relative risk about 5.5 times higher than females. The mean age at injury is approximately 30 years.

In cases of globe rupture, the rupture site is often in the posterior region near the extraocular muscle insertions. However, in eyes with an intraocular lens, ruptures more frequently occur anteriorly, including the wound from cataract surgery.

2. Main Symptoms and Clinical Findings

Subjective Symptoms

Eye pain: Occurs immediately after injury. Severity varies depending on the size and location of the perforation.
Vision loss: Caused by corneal damage, hyphema, lens damage, vitreous hemorrhage, etc.
Diplopia: Appears when there is associated damage to the extraocular muscles or orbit.
Foreign body sensation and blurred vision: In minor injuries, these may be the only complaints.
Hyperemia, photophobia, and lacrimation: Common symptoms associated with open globe injury.

Clinical Findings (Findings Confirmed by Physician Examination)

Subconjunctival hemorrhage: If extensive, suspect globe rupture. The rupture is often located posterior to the hemorrhage.
Shallow anterior chamber or flat anterior chamber: An important sign suggesting aqueous humor leakage.
Hyphema (anterior chamber hemorrhage): May be associated with angle recession or cyclodialysis.
Peaked pupil: Occurs when the iris is incarcerated in the wound.
Uveal prolapse: If the laceration is anterior, the uvea prolapses and becomes incarcerated in the wound.
Hypotony: Suggests perforating ocular injury. Differentiation from cyclodialysis is also necessary.
Traumatic cataract: Anterior subcapsular cortical opacity or Vossius ring may be observed. It may be accompanied by lens subluxation or dislocation.
Vitreous hemorrhage: Indicates extension of injury to the posterior segment.
Traumatic retinal tear: More common in the superonasal or inferotemporal quadrant. It may not be present immediately after injury but can appear later as a dialysis at the ora serrata.

The Seidel test using fluorescein staining is useful for evaluating full-thickness wounds. Under cobalt blue light, the dye is washed away by aqueous humor leakage (Seidel positive), confirming a full-thickness wound.

Q Should open globe injury be suspected even if anterior segment findings appear normal?

In cases of blunt trauma, even if the eye appears normal, extreme hypotony, severe subconjunctival hemorrhage, or hyphema should raise suspicion for open globe injury. If the patient reports any history of something hitting the eye, CT should be performed even if anterior segment findings are normal.

3. Causes and Risk Factors

Mechanism of Injury

Home and workplace are the most frequent locations of injury. The main causes are listed below.

Sharp objects: knives, scissors, screwdrivers, nails, sticks, etc. In children, writing instruments such as pencils and pens are an important cause.
High-speed projectiles: metal fragments (from grinders or welding), hammer strike fragments, concrete chips, glass shards, etc.
Sports-related: baseball/softball (hit balls, irregular bounces), golf balls (same size as the eyeball and prone to rupture), shuttlecocks, BB pellets, etc.
Assault/fights: fists, iron pipes, bats, etc.

Intraocular foreign bodies (IOFB) complicate up to 40% of penetrating injuries. Metal fragments are the most common, followed by wood and glass fragments.

Risk Factors

Male sex: The relative risk of ocular trauma is approximately 5.5 times higher than in females.
Lack of protective equipment: Not wearing eye protection during high-risk work or sports.
Drug and alcohol use: Increases the risk of injury.
Children’s writing instruments: Pencils and pens are often perceived as harmless but can cause serious eye injuries.

Infection Risk

The incidence of endophthalmitis in open globe injuries is 2–7%. Infections, especially those from plants or soil, frequently lead to blindness. Unlike post-cataract endophthalmitis, there is endophthalmitis caused by virulent bacteria such as Bacillus species. For intraorbital foreign bodies, anaerobic infections (e.g., tetanus) should also be considered.

Q In which sports are eye injuries likely to occur?

Typical examples include baseball/softball (hit by own ball, irregular bounces), golf (high-speed ball easily fits into the orbit and tends to cause globe rupture), badminton (shuttlecock), and physical contact in martial arts and ball games. For details, see the section “Causes and Risk Factors”.

4. Diagnosis and Examination Methods

Diagnosis of open globe injury is made through a combination of detailed history taking, careful examination, and imaging studies.

History Taking

Obtain detailed information on the time, mechanism, and causative object of the injury. Also check for use of protective or prescription glasses, tetanus immunization status, and time of last meal (due to possible general anesthesia). In patients with decreased consciousness, collecting information from family members or relevant personnel is important. If emergency surgery under general anesthesia is anticipated, secure peripheral intravenous access and instruct the patient to fast.

Ophthalmic Examination

Visual acuity test: Visual acuity at the initial visit after injury must be measured for prognosis and documentation.
Pupillary examination: Check for relative afferent pupillary defect (RAPD). Important for detecting traumatic optic neuropathy.
Slit-lamp examination: Evaluate corneal and conjunctival lacerations, hyphema, and lens damage. Perform Seidel test with fluorescein staining to check for aqueous humor leakage.
Fundus examination: Check for traumatic retinal tears, subretinal hemorrhage (suggesting choroidal rupture), and vitreous hemorrhage. If view is poor, use imaging as alternative.

Imaging Studies

Examination method	Main indications	Precautions
Orbital CT	Foreign body detection, ocular deformation	1mm thin-slice recommended
Ultrasound B-mode	Posterior segment evaluation when media opacity	Caution with pressure
X-ray	Detection of metallic foreign bodies	Visible if ≥2mm

CT scan: Indicated in all ocular trauma cases. It can simultaneously evaluate the location of intraocular foreign bodies, globe deformation, orbital fractures, and intracranial lesions. Plant foreign bodies may be difficult to visualize if they have low water content.
Ultrasound B-scan: Useful when fundus cannot be visualized due to hyphema, vitreous hemorrhage, or traumatic cataract. However, if globe rupture is suspected, avoid pressing the probe firmly or choose CT scan instead.
X-ray: Useful for detecting metal within the eye or orbit. Metal fragments can be identified if they are at least 2 mm in length and 0.4 mm in thickness.
Anterior segment OCT: Useful for detecting corneal lacerations and lens dislocation.
MRI: Contraindicated if a metallic foreign body is suspected. Only use when a non-metallic foreign body is confirmed; useful for detecting wood fragments or deep fluid collections.

Q Why is CT scan necessary in all cases?

Intraocular foreign bodies are associated with up to 40% of penetrating injuries. Even if anterior segment findings appear normal, an intraocular foreign body may be present. CT can simultaneously evaluate the presence and location of the foreign body, ocular deformation, and orbital fractures; missing it can lead to delayed surgery or blindness.

5. Standard Treatment

The priority in treating penetrating or perforating ocular injuries is wound closure (primary repair) to prevent infection and extrusion of ocular contents.

Emergency Treatment

If ocular contents are prolapsed, they should be completely repositioned into the eye.
If the eyelid wound or conjunctival sac is contaminated, thoroughly irrigate with normal saline.
Do not remove foreign bodies at the bedside. Apply a rigid eye shield and plan for controlled removal in the operating room.

Primary Repair (Wound Closure)

Primary repair within 24 hours of injury is recommended. Repair within 24 hours has been reported to reduce the risk of endophthalmitis by 0.30 times compared to delayed repair¹⁾.

General anesthesia is typically chosen. Local anesthesia may be selected only when the posterior segment is confirmed to be normal, such as with anterior chamber foreign bodies.

Corneal Suturing

Use 10-0 nylon. Aim for watertight closure, but avoid overtightening sutures to prevent corneal astigmatism or irregular astigmatism; take longer bites. Ensure all sutures are tightened equally to prevent aqueous leakage.

Scleral Suturing

Use 6-0 to 8-0 nylon. First, secure the four rectus muscles and locate the wound. If the wound is deep and the rectus muscles obstruct, temporarily detach the tendon. Once a part of the rupture wound is found, suture sequentially from the easiest-to-suture area to ensure closure.

For wounds at the limbus, first suture with 9-0 nylon, then perform end-to-end suturing of the corneal wound with 10-0 nylon and the scleral wound with 9-0 nylon.

Antibiotic Prophylaxis

Administer systemic broad-spectrum antibiotics covering gram-positive and gram-negative bacteria. Combination of vancomycin and a third-generation cephalosporin (e.g., ceftazidime) is associated with reduced incidence of endophthalmitis. Prophylactic intravitreal antibiotic administration during surgical repair further reduces risk.

If endophthalmitis is suspected, early surgical intervention is recommended. If inflammation is confined to the anterior chamber, perform anterior chamber washout and inject vancomycin 1 mg/0.1 mL and ceftazidime 2.25 mg/0.1 mL into the anterior chamber and vitreous. If vitreous opacification is extensive, perform emergency vitrectomy.

Secondary Surgery (Vitrectomy)

Depending on the extent of damage to intraocular tissues, lensectomy and vitrectomy may be performed as secondary surgery. However, in the following cases, performing them as a single-stage procedure immediately after primary repair may also be considered.

When lens swelling has already progressed
When the wound extends posteriorly beyond the rectus muscle insertion
When an intraocular foreign body remains
When vitreous hemorrhage is severe and the fundus cannot be visualized

After restoring the eyeball shape as much as possible, perform three-port vitrectomy to remove the cloudy vitreous and release incarcerated vitreous, then perform gas tamponade or silicone oil tamponade to ensure transparency.

Intraocular Foreign Body Removal

Once the presence of an intraocular foreign body is confirmed, remove it as soon as possible. Currently, it is mainly removed via pars plana vitrectomy using micro forceps or diamond forceps.

Q How long is the acceptable time from injury to surgery?

Primary repair within 24 hours of injury is strongly recommended. Systematic reviews have shown that repair within 24 hours significantly reduces the risk of endophthalmitis¹⁾. However, no significant difference in final visual acuity has been found based on repair timing within 24 hours.

6. Pathophysiology and Detailed Mechanisms

Mechanisms of Injury

Penetrating trauma occurs when a sharp object passes through the eye wall at high speed. It tends to occur at the thinnest parts of the sclera, such as the limbus and the equator behind the rectus muscle insertions. Previous intraocular surgery sites are also vulnerable due to iatrogenic tissue weakness.

In globe rupture, a sudden increase in intraocular pressure due to blunt force is the cause. The pressure rise in a closed space causes the sclera or cornea to rupture, leading to globe collapse. Rupture wounds are often near the extraocular muscle insertions.

Mechanism of retinal detachment associated with open-globe injury

There are two mechanisms of retinal detachment in open-globe injury.

Direct hole formation: The external force directly creates a retinal break, from which retinal detachment progresses.
Secondary traction: Vitreous gel incarcerated at the corneoscleral laceration site pulls on the opposite retina, causing a retinal tear and retinal detachment.

Open injuries often also involve elements of blunt trauma. In the latter, relatively large retinal tears may occur at the vitreous base, sometimes appearing as a dialysis of the ora serrata.

Secondary Complications

The following secondary changes may occur after initial treatment of the injury.

Proliferative vitreoretinopathy (PVR): One of the main causes of poor functional and anatomical outcomes after trauma.
Traumatic cataract: Caused by penetrating injury or blunt impact to the lens.
Secondary glaucoma: Resulting from hyphema, angle recession, or anterior synechiae.
Endophthalmitis: Occurs in 2–7% of open globe injuries.
Sympathetic ophthalmia: Suspect if inflammation or redness in the anterior chamber of the fellow eye is noted later.

7. Latest Research and Future Prospects (Investigational Reports)

Systematic review on the timing of primary repair

Blanch et al. (2025) conducted a systematic review and meta-analysis on the timing of primary repair after open globe injury and its association with visual outcomes and endophthalmitis incidence ¹⁾. Repair within 24 hours of injury reduced the risk of endophthalmitis by 0.30 times compared to repair after 24 hours. However, no significant difference in final visual acuity was observed based on repair timing. The authors strongly recommend repair within 24 hours, but note that all included studies were retrospective and non-randomized, resulting in low certainty of evidence.

Furthermore, there is insufficient data to compare earlier time windows within 24 hours (e.g., emergency nighttime surgery vs. next-morning surgery), and prospective studies are needed.

Ocular Trauma Score (OTS)

The Ocular Trauma Score (OTS) is a prognostic tool that estimates the probability of visual outcomes based on initial visual acuity, presence of globe rupture, endophthalmitis, penetrating injury, retinal detachment, and relative afferent pupillary defect (RAPD). In a study of 93 combat-related ocular injuries, the sensitivity for predicting visual survival (light perception or better) was 94.8%, and the specificity for predicting no light perception was 100%.

8. References

Blanch RJ, et al. Early versus Delayed Timing of Primary Repair after Open-Globe Injury: A Systematic Review and Meta-Analysis. Ophthalmology. 2025;132:431-441.
Kaur K, Gurnani B. Lens Abscess. . 2026. PMID: 36512661.
Blair K, Alhadi SA, Czyz CN. Globe Rupture. . 2026. PMID: 31869101.

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