Ocular Penetrating and Perforating Injuries

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Article initiated by:
Sayjal J. Patel M.D.
All contributors:
Benton Chuter, Brian T. Fowler, MD, Fabliha A. Mukit, M.D., Brad H. Feldman, M.D., Vinay A. Shah M.D., Anna Murchison, MD, MPH, Grant A. Justin, MD, Paul R Parker, MD, Fabliha A. Mukit, M.D., Jason Hsu, MD, Jennifer I Lim MD, Sayjal J. Patel M.D., Boonkit Purt, MD, Grayson W Armstrong MD MPH
Assigned editor:
Grayson W Armstrong MD MPH, Jason Hsu, MD
Review:
Assigned status Up to Date
 by Grayson W Armstrong MD MPH on November 4, 2025.


Ocular penetrating and perforating injuries, collectively known as open globe injuries, involve full-thickness wounds of the cornea or sclera and can cause severe vision loss or globe loss. They are most often seen in young males and result from sharp or high-velocity objects, with writing instruments emerging as an under-recognized but common cause in children. Risk factors include lack of protective eyewear, substance use, and unsupervised access to sharp objects, while primary prevention centers on education and protective equipment. Prompt diagnosis with careful examination and imaging, followed by surgical repair within 24 hours and appropriate antibiotic prophylaxis, is essential to reduce complications such as retinal detachment, endophthalmitis, and poor visual prognosis

Disease Entity

Disease

Ocular penetrating and perforating injuries (commonly referred to as open globe injuries) can result in severe vision loss or loss of the eye.

  • Penetrating injuries are a sharp object that penetrates into the eye (i.e. laceration) but does not exit.
  • Perforating injuries, enter and exit the globe, and therefore have both an entrance and an exit wound.
    • Typically, to constitute one of these injuries, a full-thickness wound through the cornea and/or sclera must be present.
  • Open globe rupture, in contrast, refers to blunt trauma to the eye causing sudden deformation of the globe at a high velocity impact,  resulting in acutely high pressure in a closed space, resulting in scleral or corneal dehiscence, leading to a globe collapse.

These 3 terms are used to standardize the nomenclature associated with severe ocular trauma.[1] Most ocular injuries occur at the limbus and near the equator behind the recti muscles insertions, where the sclera is thinnest.[2]This can also occur at sites of prior intraocular surgery from iatrogenic lack of tissue integrity at these sites.

Ocular Trauma Classification (zones of globe injury)

Classification of the three zones of globe injury. [3]

  • Zone I involves the cornea up to the limbus.
  • Zone II involves the sclera from the limbus extending up to 5 mm posteriorly.
    • Anatomically, this region is anterior to the ora serrata.
    • Does not involve the retina.
  • Zone III involves any injury more than 5 mm posterior to the limbus.
    • Extends to structures posterior to the ora serrata.
    • Involves the retina.

Epidemiology

Penetrating or perforating ocular injuries can be due to injury from any sharp or high velocity object. Most individuals sustaining eye injuries are male, with an estimated relative risk that is 5.5 times greater than females.[4] The average age at injury is 30.

Etiology

The home and workplace are the most frequent locations for injuries, and the most common situations were domestic assaults, battery assaults, and workplace accidents. The most common blunt objects reported by the United States Eye injury Registry were rocks, fists, baseballs, lumber wood, and fishing weights.[5]

The most common sharp objects were sticks, knives, scissors, screwdrivers and nails. Penetrating injuries from writing instruments such as graphite pencils, colored pencils, and pens are increasingly reported in pediatric populations.[6] Colored pencils have surpassed graphite in frequency in some series, likely due to increased popularity among young children.[7] When one of these objects becomes lodged in the eye, it is referred to as an intraocular foreign body (IOFB), which occurs in up to 40% of ocular penetrating or perforating injuries (see Intraocular Foreign Bodies (IOFB).

Risk Factors

As noted from the epidemiological studies above, male gender is a large risk factor for ocular trauma[4]. Failure to wear adequate eye protection while performing high risk activities such as baseball, basketball and use of power tools in the home environment have also been noted to be risk factors for eye injuries.[4][8][9] Substance abuse, including alcohol and marijuana, is also known to increase the risk of eye trauma.[9] Additionally, the ubiquitous presence of writing instruments in children’s environments are an under-recognized risk factor for serious ocular injury. This is because pencils and pens are often perceived as innocuous and often used by children without supervision. A national surveillance study in the UK estimated roughly 892 pencil-related and 748 pen-related eye injuries annually, underscoring the need for caution even with everyday objects.[6]

Primary Prevention

Appropriate and adequate eye protection when performing visually threatening activities is the most effective method to prevent ocular trauma. Avoiding high-risk activites is also an effective method of prevention. The American Academy of Ophthalmology Eye Injury Snapshot is a yearly survey designed to collect data and educate the public about the causes and prevention of eye injuries. Through educational programs such as this, potential eye injuries may be prevented.[8] Specifically, parents and teachers should be educated about the serious risk of ocular injury from sharp point writing instruments such as pencils and pens. Close supervision of young children when they handle these objects can prevent many of these injuries, and furthermore, clinicians to understand the extent of an injury to determine next steps for management. [7]

Diagnosis

History

It is important to obtain a thorough history from the patient to help identify the timing of the injury and mechanism. Any injuries other than the eye should be ascertained. Questions such as what the patient was doing during the injury and what potential objects could have caused the injury are important prior to physical evaluation. It is important to note whether safety glasses or prescription eyeglasses were being worn at the time of the injury. Also, make sure to ask the patient if he/ she has a history of limited vision in either eye (amblyopia or other prior cause of visual loss).

A pertinent medical history including current medications, allergies, tetanus status, and timing of last meal can help with diagnosis and management. Prior ocular history and ocular surgical history is also important to obtain. Ask specifically about writing instruments (graphite pencil vs. colored pencil vs. pen), whether the object was thrown or held in the mouth at the time of injury, and any delayed pigment colored discharge, which raises suspicion for retained colored core material. Writing instrument injuries in children frequently require admission and surgery,[7] and colored pencil injuries show distinct inflammatory and infectious behavior that warrants early vigilance.[10]

Symptoms

Patients with penetrating or perforating injuries usually complain of pain, vision loss, or double vision. In more subtle injuries, there may be minor symptoms such as foreign body sensation or blurred vision. Severe redness, light sensitivity, and foreign body sensation are also symptoms of open globe injuries. Colored pencil injuries may present days to weeks later with blue or orange pigmented discharge (‘sludge’) and eyelid swelling/ptosis, reflecting dissolution of wax/pigment binder and secondary inflammation. [11][10]

Signs

Subconjunctival hemorrhage, shallow or flat anterior chamber, hyper-deep anterior chamber, peaked pupil, corneal or scleral discontinuity, hyphema, iris deformities, uveal prolapse, lens disruption, or posterior segment findings such as vitreous hemorrhage, retinal tears, or retinal hemorrhage are concerning when seen in a patient with suspected ocular trauma.  It is essential to evaluate for a small puncture wound (often medial), periocular edema, and pigment tracks or ‘tattoo’ from graphite. Colored pencil material may appear as friable, colored granulation tissue or pigmented discharge.[12][11][10]

Physical Examination

Ophthalmic examination after severe trauma can be difficult but a thorough examination is necessary. Ocular vital signs of Vision and Pupillary exam is essential. Intraocular pressure can be deferred if there is obvious globe deformity or extrusion of intraocular contents. [13] Obvious trauma requires careful handling of the eye with care taken to prevent any pressure on the globe if an open globe is suspected; exam maneuvers commonly conducted that exert such pressure are contraindicated, such as forced ductions, gonioscopy, scleral depression, and B-scan.

Once an extraocular muscle and external examination is complete, a thorough conjunctival and anterior segment examination must be completed if penetrating or perforating injury has occurred. A posterior exam should be done to look for intraocular damage as long as there is a view through the pupil or if no wound entry site is found. Nuances to B-scan, and pupillary dilation in such case is service and surgeon dependent.

Moreover, eyedrops should be avoided in cases of obvious penetrating or perforating injury. The adnexa should be carefully examined with delicate palpation of the orbital rim.

It is imperative to not remove a dislodged foreign body at the bedside. Instead, apply a rigid eye shield and plan-controlled removal in the OR given vascular risk and uncertainty of critical structures involved. Involve oculoplastics, neurosurgery, and/or ENT early for medial–superior entries or suspected transorbital trajectories. [10][14][15]

Full thickness corneal lacerations often result in leakage of aqueous humor from the anterior chamber. Applying fluorescein dye to the suspected corneal wound is called a 'seidel test' and can be used to assess for full thickness lacerations in cases where it may not be obvious. In these cases, the fluorescein dye under cobalt blue light will be 'washed away' by the aqueous humor leaking from the full thickness wound and confirms the presence of a full thickness wound. If the fluorescein dye is washed away, the wound is considered 'seidel positive', while lack of fluid coming from the wound means it is 'seidel negative'. An example video of a 'seidel positive' exam can be found here. Similar testing can sometimes be performed on the sclera and conjunctiva, though vitreous may plug scleral wounds and cause a lack of seidel positivity.

Diagnostic Procedures

  • Computed tomography (CT) scans of the orbits are indicated in all cases of ocular trauma to assess the presence of any intraocular foreign body, especially in cases of poor views to the vitreous and retina. It is important to obtain orbit cuts, which are thin 1 mm CT cuts in the axial, coronal, and sagittal planes to rule out IOFB, which can be present in up to 40% of penetrating ocular injuries.[16] In suspected vegetative trauma (ex. Wood), alerting the radiologist to assess the Houndsfield units and relaying concern for vegetative matter can aid in proper diagnosis.
    • Hounsfield Units (HUs) measure CT density and help radiologists identify foreign bodies based on characteristic values.
      • Negative HU values: less dense materials such as wood, which may resemble fat or air.
      • High positive HU values: dense materials such as metal or stone.
      • Clinical importance: Determining a foreign body’s HU is critical, but interpretation depends on proper CT window adjustments to prevent misdiagnosis.
  • Challenges
    • Wood may increase in density over time as it absorbs water.
    • Imaging artifacts can distort HU measurements.

When direct visualization is not possible, gentle ultrasound can be considered to evaluate the globe, though extreme caution should be used as the pressure from the ultrasound device and cause extrusion of intraocular contents.

  • B-scan Ultrasonography can be helpful when the media preclude a posterior exam, and has been shown to have a 100% positive predictive value for diagnosing retinal detachment and IOFB.[17]
  • In a case of unknown IOFB or potential posterior rupture (with deep chambers), it may be prudent to gently place a small tegederm on the injured globe before performing a B-scan.

Contraindication of MRI

Additionally, if there is a suspicion for an IOFB, magnetic resonance imaging (MRI) is contraindicated due to risk of the foreign body being metallic.

For non-metallic writing instrument injuries, thin cut CT may show only indirect signs (air, fat stranding, phlegmon) and fragments are often not retrieved at surgery. Consider MRI when metal is not suspected to identify wood or deep collections, and obtain CT/MR angiography if a transorbital–intracranial path is possible. [10][14][15]

Management

General treatment

Penetrating and perforating ocular injuries require immediate evaluation and management, as the material and site of entry can result in severe vision loss. The Ocular Trauma Score (OTS), developed in 2002 from a cohort of 2,500 eye injuries, provides a prognostic tool for visual recovery following trauma. The OTS is calculated by assigning a raw score (0–100) based on initial post-injury visual acuity (VA), globe rupture, endophthalmitis, penetrating injury, retinal detachment, and presence of a relative afferent pupillary defect; this score is then categorized from 1 to 5 to estimate the probability of visual outcomes. [18]

  • In a study of 93 patients with combat-related penetrating and perforating ocular trauma, the OTS predicted visual survival (light perception or better) with a sensitivity of 94.8%, and predicted no light perception (NLP) with a specificity of 100%.[19]
  • The risk of post-traumatic endophthalmitis must also be carefully assessed, particularly in rural settings or in the presence of an intraocular foreign body (IOFB). Prophylaxis should include systemic, topical, and/or intravitreal broad-spectrum antibiotics with Gram-positive and Gram-negative coverage. [20]Systemic therapy with vancomycin plus a third-generation cephalosporin such as ceftazidime has been associated with reduced rates of endophthalmitis. Additionally, prophylactic intravitreal antibiotics at the time of surgical repair have been shown to further lower the risk.[21]

Writing instrument–specific considerations

  • Start IV broad spectrum antibiotics with anaerobic coverage (e.g., ampicillin–sulbactam ± vancomycin), and obtain aerobic, anaerobic, fungal cultures when discharge or cellulitis is present. Colored pencil injuries have yielded Clostridium bifermentans, Penicillium, and Exophiala. [10][11][22]
    • If no improvement by 24–48 h of IV therapy, proceed to operative exploration, debridement, and irrigation per the published algorithm. If improving, complete 48 h IV then transition to oral therapy with close follow up.[10]
  • A plan for prompt surgical repair within 24 hours of the injury is crucial whenever possible, as this has been shown to have a lower risk of endophthalmitis compared to delayed repair.[18][19]However, timing of surgery within the 24 hour window has not been found to be associated with visual outcomes.[20]

Surgery

In cases with a high suspicion for penetrating or perforating eye trauma, globe exploration should be performed with possible vitrectomy if vitreous hemorrhage with an intraocular foreign body or retinal detachment is present.[13] In cases of confirmed penetrating or perforating eye trauma, prompt closure of the open globe is recommended primarily focusing on anterior segment structures, with all attempts made to restore the entire wall of the eye to its pre-trauma state.

Lacerations of the cornea require careful reapproximation of corneal tissue with care to reform the anterior chamber to its prior state while minimizing astigmatism and scar. Tips on addressing corneal wound repair can be found in this video-based open globe curriculum in the chapters dedicated to corneal repair.[21] Typically, corneal tissue should be repaired with 10-0 nylon sutures in an interrupted fashion using slip knots (video here).[23] Limbal wounds can be repaired with 9-0 nylon sutures on a spatulated needle.

Scleral lacerations also require care and attention and are repaired using 8-0 nylon sutures tied using surgeons knots (video here)[23]. Tips on addressing scleral wound repair can be found in this video-based open globe curriculum in the chapters dedicated to scleral wound repair[24]. Care to reposit uveal and retinal tissue without further iatrogenic damage is critical when repairing scleral wounds.

Surgical considerations for writing instruments:

  • Expect fragmentation or dissolution of colored cores.
  • Exploration may reveal pigmented ‘sludge’ requiring thorough debridement and irrigation rather than discrete foreign body removal.
  • Retrieve intraocular graphite and/or plastic with forceps
  • Inspect the entire tract, as medial entries frequently violate the lamina papyracea and may extend to the skull base, and involve neurosurgery for suspected intracranial paths. [14][10]

Any subsequent procedures needed to restore the anterior segment (e.g. penetrating keratoplasty, secondary intraocular lens) are performed at a later date when the eye is stable. Any eyelid trauma should be repaired after repair of the globe injury, as pressure placed on the eyelids during repair can extrude globe contents. In addition, eyelid trauma can sometimes improve exposure of the globe injury.

Postoperatively, the eye should be monitored carefully with exams and ultrasound until any vitreous hemorrhage resolves or indications for pars plana vitrectomy occur (tractional and/or rhegmatogenous retinal detachment). For eyes in which the vitreous cavity has been violated on presentation, pars plana vitrectomy is frequently performed to avoid tractional retinal detachment when vitreous organization is seen.

Complications

One important consideration is the risk of retinal detachment, both in the immediate timeframe and following presentation. In one retrospective chart review, retinal detachment (RD) occurred in 29% of open globe injuries.[25]Of these eyes with RD, 27% detached within 24 hours of primary open globe repair, 47% detached within 1 week, and 72% detached within 1 month. Risk factors for RD post open globe repair included presence of vitreous hemorrhage, higher zone of injury, and worse presenting visual acuity.[25] The same cohort of patients were used to devise a low, moderate, and high risk scoring system for predicting this risk, the Retinal Detachment after Open Globe Injury (RD-OGI)[26].

Eyes must also be assessed for wound leak post operatively. In one review, 16% of eyes developed wound leak post-operatively. Factors associated with higher risk of wound leak post-repair were delayed presentation as well as a stellate shaped wound.[27] Wound leak was also found to be a risk factor for endophthalmitis, which is another important complication post-operatively that can be minimized with the use of prophylactic antibiotics and repair within 24 hours of injury.[28]

Colored pencil injuries are linked to polymicrobial and atypical infections. Reported organisms include Clostridium bifermentans (panophthalmitis described after penetrating trauma), Exophiala jeanselmei, and Penicillium spp.[22][10][11] Rare intracranial vascular injury has occurred with transorbital pencils, carrying poor neurologic prognosis. [15]

Prognosis

There are a number of risk factors on initial presentation that can be used to predict ultimate visual prognosis following an ocular penetrating or perforating injury. By far the most predictive prognostic factor is the initial visual acuity on presentation, as well as injury to zone III, history of corneal transplantation, presence of RAPD, time from injury, and presence of retinal detachment and/or vitreous hemorrhage, and crystalline lens dislocation[29][30]. The OTS is also a useful tool to get an idea of visual recovery potential.

Prognosis in writing instrument injuries

Many anterior injuries recover well with timely repair.[14] By contrast, orbitocranial trajectories can be devastating with lasting neurologic deficits despite foreign body removal.[15] Prognosis also worsens with endophthalmitis or posterior segment involvement. [10]

It is important to be clear with patients regarding degree of visual recovery and future options depending on the type of injury. Corneal transplantation, traumatic cataract extraction with insertion of an intraocular lens implant, or further posterior segment procedures may be required following the initial operation repair. Sympathetic ophthalmia, a bilateral diffuse granulomatous uveitis that often follows ocular trauma due to violation of the eye's immune privilege, is an important though rare consequence to consider (see Sympathetic Ophthalmia). In eyes with pain where visual recovery is unlikely, enucleation or evisceration should be considered to prevent injury to the non-injured eye[31].

References

  1. ↑ Kuhn F, Morris R, Witherspoon CD, et al. A standardized classification of ocular trauma. Graefes Arch Clin Exp Ophthalmol. 1996;234(6):339-403.
  2. ↑ Kuhn F, Morris R, Witherspoon CD, Heimann K, Jeffers JB, Treister G. A standardized classification of ocular trauma. Ophthalmology. 1996 Feb;103(2):240-3.
  3. ↑ Pieramici DJ, Sternberg P Jr, Aaberg TM Sr, et al. A system for classifying mechanical injuries of the eye (globe). The Ocular Trauma Classification Group. Am J Ophthalmol. 1997;123(6):820-831.
  4. ↑ 4.0 4.1 4.2 May DR, Kuhn FP et al. The epidemiology of serious eye injuries from the United States Eye Injury Registry. Graefes Arch Clin Exp Ophthalmol. 2000; 238: 153-7.
  5. ↑ Andreoli MT, Andreoli CM. Geriatric traumatic open globe injuries. Ophthalmology. 2011 Jan;118(1):156-9.
  6. ↑ 6.0 6.1 Kelly, S. P. and G. M. Reeves (2012). "Penetrating eye injuries from writing instruments." Clin Ophthalmol 6: 41-44.
  7. ↑ 7.0 7.1 7.2 Fisher, S. B., M. S. Clifton and A. M. Bhatia (2011). "Pencils and Pens: An Under-Recognized Source of Penetrating Injuries in Children."  77(8): 1076-1080.
  8. ↑ 8.0 8.1 American Academy of Ophthalmology, The 6th Annual Eye Injury Snapshot Project.
  9. ↑ 9.0 9.1 Wong T, Klein B, Klein R. The Prevalence and 5-year incidence of Ocular Trauma-The Beaver Dam Eye Study. Ophthalmology. 2000; 107: [[1]].
  10. ↑ 10.0 10.1 10.2 10.3 10.4 10.5 10.6 10.7 10.8 10.9 Mukit, F. A., C. M. Noguera, N. Sullivan, B. D. Smith, J. C. Fleming and B. T. Fowler (2025). "Penetrating colored pencil injury with Clostridium bifermentans pre-septal cellulitis: case report, literature review, and treatment algorithm." Orbit 44(1): 90-95.
  11. ↑ 11.0 11.1 11.2 11.3 Hwang, C. J., A. C. Maltry, A. R. Harrison and A. Mokhtarzadeh (2023). "A Case of the Blues-Colored Pencil Orbitopathy in an 18-Month-Old Boy." Ophthalmic Plast Reconstr Surg 39(1): e4-e8.
  12. ↑ Han, E. R., W. R. Wee, J. H. Lee and J. Y. Hyon (2011). "A Case of Retained Graphite Anterior Chamber Foreign Body Masquerading as Stromal Keratitis." Korean J Ophthalmol 25(2): 128-131.
  13. ↑ 13.0 13.1 Mittra RA, Mieler WF. Controversies in the Management of Open-Globe Injuries Involving the Posterior Segment. Survey of Ophthalmology. 1999; 44: 215-225.
  14. ↑ 14.0 14.1 14.2 14.3 Huang, T., J. Ling, M. Liu, C. Qiu, G. Ding, J. Huang, B. Krischek, S. Yang and F. Zheng (2020). "Penetrating transorbital injury by a coloring pencil in a 3-year-old child: A case report."  48(3): 0300060519886210.
  15. ↑ 15.0 15.1 15.2 15.3 Brenke, C., J. Fontana, K. Schmieder and M. Barth (2013). "Surgical Management of Basilar Artery Laceration Caused by Transorbital Penetrating Injury: Case Report." J Neurol Surg A Cent Eur Neurosurg 74(S 01): e239-e241.
  16. ↑ Kuhn F, Maisiak R, Mann L, Mester V, Morris R, Witherspoon CD. The Ocular Trauma Score (OTS). Ophthalmol Clin North Am. 2002 Jun;15(2):163-5
  17. ↑ Islam QU, Ishaq M, Yaqub MA, Mehboob MA. Predictive Value Of Ocular Trauma Score In Open Globe Combat Eye Injuries. J Ayub Med Coll Abbottabad. 2016 Jul-Sep;28(3):484-488.
  18. ↑ 18.0 18.1 Ahmed Y, Schimel AM, Pathengay A, et al. Endophthalmitis following open-globe injuries. Eye (Lond). 2012;26:212–217
  19. ↑ 19.0 19.1 Uppuluri A, Zarbin MA, Bhagat N. Risk factors for post–open-globe injury endophthalmitis. J Vitreoretin Dis. 2020;4:353–359.
  20. ↑ 20.0 20.1 Makhoul KG, Bitar RA, Armstrong GW, et al. Effect of time to operative repair within twenty-four hours on visual acuity outcomes for open globe injuries. Eye (Lond). 2023;37(11):2351-2355.
  21. ↑ 21.0 21.1 Bal S, Laíns I, chiou C, Patel N, Rudnik ND, Kim CB, Ma KK, Tone SO, Begaj T, Lu Y, Armstrong GW. Video-based surgical curriculum for open globe injury repair, IV: corneal wounds. Digit J Ophthalmol. 2022;28(4):86-99. doi:10.5693/djo.01.2022.08.003
  22. ↑ 22.0 22.1 Rehany, U., Y. Dorenboim, E. Lefler and E. Schirer (1994). "Clostridium bifermentans Panophthalmitis after Penetrating Eye Injury." Ophthalmology 101(5): 839-842.
  23. ↑ 23.0 23.1 Siddiqui A, Weinert MC, Marando CM, Begaj T, Lu Y, Armstrong GW. Video-based surgical curriculum for open-globe injury repair, III: surgical repair. Digit J Ophthalmol. 2022;28(4):74-85. doi:10.5693/djo.01.2022.08.002
  24. ↑ Chang EK, Begaj T, Lu Y, Armstrong GW. Video-based surgical curriculum for open-globe injury repair, V: scleral wounds. Digit J Ophthalmol. 2023;29(2):14-19. doi:10.5693/djo.01.2022.02.001
  25. ↑ 25.0 25.1 Stryjewski TP, Andreoli CM, Eliott D. Retinal detachment after open globe injury. Ophthalmology. 2014 Jan;121(1):327-333.
  26. ↑ Brodowska K, Stryjewski TP, Papavasileiou E, Chee YE, Eliott D. Validation of the Retinal Detachment after Open Globe Injury (RD-OGI) Score as an Effective Tool for Predicting Retinal Detachment. Ophthalmology. 2017 May;124(5):674-678.
  27. ↑ Kong GY, Henderson RH, Sandhu SS, Essex RW, Allen PJ, Campbell WG. Wound-related complications and clinical outcomes following open globe injury repair. Clin Exp Ophthalmol. 2015 Aug;43(6):508-13.
  28. ↑ Zhang Y, Zhang MN, Jiang CH, Yao Y, Zhang K. Endophthalmitis following open globe injury. Br J Ophthalmol. 2010 Jan;94(1):111-4.
  29. ↑ Agrawal R, Rao G, Naigaonkar R, Ou X, Desai S. Prognostic factors for vision outcome after surgical repair of open globe injuries. Indian J Ophthalmol. 2011 Nov-Dec;59(6):465-70.
  30. ↑ Fujikawa A, Mohamed YH, Kinoshita H, Matsumoto M, Uematsu M, Tsuiki E, Suzuma K, Kitaoka T. Visual outcomes and prognostic factors in open-globe injuries. BMC Ophthalmol. 2018 Jun 8;18(1):138.
  31. ↑ Zhang Y, Zhang MN, Jiang CH, Yao Y. Development of sympathetic ophthalmia following globe injury. Chin Med J (Engl). 2009 Dec 20;122(24):2961-6.
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