Ruptured Globe

All content on Eyewiki is protected by copyright law and the Terms of Service. This content may not be reproduced, copied, or put into any artificial intelligence program, including large language and generative AI models, without permission from the Academy.

Article initiated by:

Alexander A. Foster, Brandon Chau Lam

All contributors:

Anna Murchison, MD, MPH, Zeba A. Syed, MD, Grant A. Justin, MD, Alexander A. Foster, Bharat Gurnani MBBS,DNB,FCRS,FICO(UK), FAICO (Cornea, AIIMS, AIOS), FAICO (Refractive Surgery, AIIMS, AIOS), MRCS (Ed), MNAMS, Boonkit Purt, MD, Grayson W Armstrong MD MPH, Henry Bair, MD

Assigned editor:

Grayson W Armstrong MD MPH

Review:

Assigned status Update Pending

 by Grayson W Armstrong MD MPH on January 29, 2026.

add
Contributing Editors:	add

Disease Entity

Definition and Mechanism

An open globe injury is a full-thickness wound of the cornea or sclera. Under the Birmingham Eye Trauma Terminology system, rupture describes an open globe injury caused by blunt trauma. Transient deformation and increased intraocular pressure cause the eyewall to fail at a weak point, which may be remote from the impact. Laceration describes an outside-in injury and includes penetrating injury, perforating injury, and injury with a retained intraocular foreign body.

This article focuses on blunt rupture. The initial precautions apply to every suspected open globe: avoid pressure and manipulation, protect the eye with a rigid shield, control pain and nausea, and obtain urgent ophthalmic care. For a stepwise approach by first responders, emergency department clinicians, and community clinicians, see Pre-Ophthalmologist Management of Eye Trauma.

Birmingham Eye Trauma Terminology (BETT) which classified ruptured globe injuries as a sub-category of open globe injury

Risk Factors

Rupture may follow a direct blow, fall, collision, assault, or blast. Previous penetrating keratoplasty, large-incision cataract surgery, radial keratotomy, or other structurally weakening surgery can leave a site susceptible to traumatic wound dehiscence years later. A corneal graft wound remains vulnerable throughout life. Older adults are particularly susceptible to fall-related open globe injury and are more likely to have previous intraocular surgery.

Blunt trauma over a previous incision, unexplained visual loss, an abnormal pupil, or altered anterior-chamber depth should prompt open-globe precautions even when an external wound is not visible.

Diagnosis

History

Establish the mechanism, energy, setting, and time of injury. Ask about preinjury vision and previous ocular trauma or surgery. A high-velocity projectile or mixed blunt and penetrating mechanism raises concern for an intraocular foreign body. Obtain tetanus immunization history, possible soil or organic contamination, medications and allergies, anticoagulant or antiplatelet use, relevant medical conditions, and the time of last food or drink.

Assess associated injuries concurrently. Airway, breathing, circulation, and other life-threatening problems take precedence. For an isolated chemical exposure, begin irrigation immediately; when a globe is known or strongly suspected to be open, use the special precautions below. Clinically evident orbital compartment syndrome also requires immediate treatment, with the approach modified if an open globe may coexist.

Physical Examination

Obtain useful diagnostic information without pressing on the eye or forcing the eyelids open. When this can be done safely, document visual acuity in each eye, pupil shape and reactivity, and a relative afferent pupillary defect. Inspect the face, orbital rim, lids, and visible anterior segment. Findings concerning for rupture include marked visual loss, a peaked or irregular pupil, abnormal anterior-chamber depth, distorted globe contour, dense or circumferential subconjunctival hemorrhage, and displaced or extruded intraocular tissue. An intact-looking anterior segment does not exclude a posterior rupture.

If an open globe is obvious or strongly suspected, limit further examination, place a rigid shield, and obtain urgent ophthalmology consultation. Do not perform tonometry, digital palpation, retropulsion, forced eyelid retraction, gonioscopy, or scleral depression. A normal or elevated intraocular pressure, if measured before the injury was recognized, does not exclude an open globe. Do not remove an embedded object or manipulate, excise, or replace prolapsed tissue.

When the diagnosis remains uncertain and there is no obvious wound or tissue prolapse, a trained clinician may use a gentle slit-lamp examination and fluorescein Seidel testing without pressure. Seidel testing is unnecessary and contraindicated in an obvious open globe. A negative test cannot exclude a self-sealed or posterior wound. Persistent clinical concern warrants ophthalmologist assessment and, when indicated, surgical exploration.

Associated and Alternative Injuries

• Other open globe mechanisms: penetrating injury, perforating injury, and injury with a retained intraocular foreign body.
• Closed-globe contusion, traumatic hyphema, or lens injury.
• Orbital fracture, orbital hemorrhage, or orbital compartment syndrome.
• Traumatic optic neuropathy or retinal injury.

Open globe injury and orbital compartment syndrome can coexist. Suspected rupture is a relative contraindication to lateral canthotomy and cantholysis because decompression can worsen ocular damage. Avoid globe palpation and tonometry, and obtain immediate ophthalmic and trauma input for an urgent case-specific decision. If specialist assistance cannot arrive promptly, the most experienced available clinician must balance ongoing orbital ischemia against the risk of worsening the globe injury. Imaging and routine transfer logistics must not create avoidable delay. See Orbital Compartment Syndrome.

Imaging

Rupture is principally a clinical diagnosis. Noncontrast thin-section CT of the orbits is the preferred initial imaging study when the examination is limited, the diagnosis is uncertain, a foreign body is possible, or associated orbital and facial injuries require assessment. CT should support surgical planning without delaying ophthalmology consultation, transfer, or treatment of a clinically apparent injury.

Suggestive CT findings include altered globe contour, abnormal anterior-chamber depth, lens displacement or disruption, vitreous hemorrhage, and intraocular air. A 2026 systematic review found CT sensitivity of 74% and specificity of 93% for open globe injury, and sensitivity of 69% for intraocular foreign bodies. A negative CT therefore cannot exclude either condition.

Non-ophthalmologists should not perform ocular ultrasonography before closure when an open globe is suspected or confirmed. Probe pressure may extrude intraocular contents. An ophthalmologist may occasionally consider a carefully performed examination when its diagnostic benefit outweighs that risk; the imaging review did not establish the safety of preoperative ultrasound. B-scan is more commonly used after primary closure when hemorrhage or other opacity prevents a fundus view.

MRI is not a first-line acute-trauma study and must not be performed while a potentially ferromagnetic intraocular or orbital foreign body remains possible. Any subsequent use for suspected nonmetallic material should be determined with ophthalmology and radiology.

Injury Classification

After examination or surgical exploration establishes the extent of injury, record the wound mechanism, location, presenting vision, and associated findings. In the conventional zone classification, zone I involves the cornea and limbus, zone II extends into sclera up to 5 mm posterior to the limbus, and zone III extends farther posteriorly. The most posterior extent determines the zone. Classification helps communicate severity and prognosis but should not prolong the initial examination or delay treatment.

Management

Initial Care and Transfer

Suspected or confirmed rupture is an ophthalmic emergency. After stabilization, obtain immediate ophthalmology consultation and transfer to a facility with ophthalmic surgical capability. Handoff should include the mechanism, time of injury, vision and pupil findings obtained safely, previous surgery, possible contamination or foreign body, imaging already performed, medications given, and last oral intake.

Primary closure should occur as soon as clinically feasible and generally within 24 hours of injury. A systematic review associated repair within 24 hours with less endophthalmitis than longer delay, but all included studies were retrospective and the evidence predominantly concerned penetrating and foreign-body injuries. This supports prompt repair without establishing a universal requirement for immediate overnight surgery or a safe waiting period for an individual patient.

Care Before Ophthalmologist Evaluation or Repair

• Place a rigid eye shield that rests on the surrounding orbital bones without touching the globe. Do not use a pressure patch, circumferential wrap, or gauze beneath the shield.
• Do not remove, shorten, or manipulate a protruding object. If it extends beyond a standard shield, use a rigid cover that clears the object and protects it from accidental contact.
• Keep the patient nil per os in anticipation of anesthesia. Establish intravenous access and record the time of last intake.
• Give systemic analgesia and antiemetic therapy promptly. Minimize agitation, coughing, retching, straining, and unnecessary exertion. Elevate the head approximately 30 degrees when compatible with systemic injuries and hemodynamic status.
• Begin systemic broad-spectrum antimicrobial prophylaxis promptly according to the local open-globe protocol and ophthalmologist guidance. Do not delay transfer or repair to obtain a particular regimen. Adjust the choice and dose for age, allergies, renal function, contamination, delayed presentation, and possible intraocular foreign body.
• Assess tetanus prophylaxis. Penetrating, puncture, crush, devitalized, and contaminated wounds are dirty or major wounds under CDC guidance. Give an age-appropriate tetanus-containing vaccine for an unknown, absent, or incomplete primary series. With a complete primary series, give a booster for a dirty or major wound if at least 5 years have elapsed since the last dose. Tetanus immune globulin is indicated for dirty or major wounds with an unknown, absent, or incomplete primary series, or with HIV or severe immunodeficiency. Antibiotics do not replace tetanus prophylaxis.
• Do not irrigate a suspected mechanical open globe, explore or debride the wound, or attempt bedside closure. Avoid topical ointments before repair. Use topical medications only when specifically directed by the ophthalmologist.

Comparative evidence does not establish one universally superior systemic antibiotic regimen, route, or duration. The 2023 meta-analysis found no significant difference between oral and intravenous regimens in the studied populations, but high-risk cases were excluded. These findings should not be used to omit prophylaxis or substitute oral treatment routinely in contaminated, delayed, or otherwise high-risk injuries. Intraocular antibiotics at repair are a separate surgeon-directed decision.

Chemical Contamination with an Open Globe

For an ordinary chemical splash, begin copious irrigation immediately with clean water or an available suitable solution. Do not withhold irrigation because of a hypothetical concern for rupture. If an open globe is known or strongly suspected, do not apply pressure, remove a protruding object, insert an irrigation lens, or irrigate the open globe. Decontaminate surrounding skin without directing fluid into the wound, apply a noncontact rigid shield, and obtain immediate ophthalmology, trauma, and toxicology guidance. See Chemical (Alkali and Acid) Injury of the Conjunctiva and Cornea.

Surgery

The initial operation aims to restore globe integrity and prevent further loss of intraocular contents. Exploration identifies the full wound extent, followed by repair to achieve closure and restore anatomy as safely as possible. The surgeon determines whether prolapsed tissue can be preserved, how to manage vitreous and lens injury, and whether tissue loss requires a graft. General anesthesia is commonly used, with the anesthetic plan coordinated to limit pressure on the eye and avoid coughing or straining.

Lens surgery, foreign-body removal, or vitreoretinal surgery may be performed during primary repair or staged according to the injury, contamination, posterior-segment findings, available expertise, and systemic condition. Retinal detachment, endophthalmitis, or an infectious or toxic foreign body can require urgent additional intervention. Primary closure does not complete treatment of every injury; the ophthalmic team should establish a plan for subsequent assessment and surgery.

Postoperative Care

Review soon after surgery, usually the following day, to assess closure, inflammation, infection, and the need for further treatment. Topical antibiotics, corticosteroids, and cycloplegics are commonly prescribed under ophthalmologist supervision. Continue systemic prophylaxis according to the treating protocol and injury risk. Maintain eye protection and restrict activities that could place pressure on the healing globe.

Follow-up must include posterior-segment assessment. If the fundus remains obscured after closure, gentle B-scan can evaluate for retinal detachment or other pathology. Retinal detachment may become apparent days to weeks after injury, and risk is higher with vitreous hemorrhage, poor presenting vision, and posterior wounds. Repeated assessment may be required even when the initial postoperative evaluation is reassuring.

Complications

Important complications include endophthalmitis, retinal detachment, proliferative vitreoretinopathy, cataract or lens displacement, corneal scarring and irregular astigmatism, wound leakage, glaucoma, hypotony, and phthisis. These may require additional medical treatment or reconstructive surgery. Increasing pain, redness, or visual loss after repair warrants urgent reassessment.

Sympathetic ophthalmia is a rare inflammatory complication that can threaten the fellow eye. A meta-analysis did not show evidence that primary enucleation or evisceration reduces this risk compared with primary repair. An eye that is structurally repairable should not be removed solely because presenting vision is no light perception or to follow an assumed fixed window for preventing sympathetic ophthalmia. Decisions about eye removal require individualized assessment and discussion with the patient.

Prognosis

Presenting visual acuity, a relative afferent pupillary defect, wound location and extent, and associated retinal or optic-nerve damage help inform prognosis. Posterior injury and poor initial vision generally predict worse outcomes, but presenting vision alone does not establish the final result. Explain the possibility of multiple operations and revise expectations as the extent of injury and recovery become clearer.

The Ocular Trauma Score combines presenting vision with rupture, endophthalmitis, perforating injury, retinal detachment, and an afferent pupillary defect to estimate outcome categories. It can support counseling, but it predicts groups rather than an individual certainty. A 2026 systematic review found meaningful correlation with final vision but only moderate, heterogeneous agreement between predicted and observed categories. A score should not determine whether an eye is offered repair. See Ocular Trauma Score.

Prevention and Rehabilitation

Counsel patients about appropriate protective eyewear during hazardous work and recreation. Patients with previous penetrating keratoplasty should understand their continuing risk of wound rupture. Address fall risk in older adults. After substantial visual loss, protect the fellow eye and arrange optical correction, low-vision rehabilitation, and support for daily activities as appropriate.