Eyeball trauma: causes, symptoms, diagnosis, treatment

An eye injury is a mechanical damage to the wall of the eye (cornea and sclera) and the internal "optics" with the risk of rapid vision loss. The basic dichotomy is categorized as closed injury (the wall of the eye is intact) and open injury (a full-thickness wound). This terminology is standardized by the BETT system and is critical for diagnosis, management, and prognosis. With an open injury, every hour counts: timely, hermetic closure of the wound within the first 24 hours reduces the risk of intraocular infection and improves outcomes. [1]

In real practice, combined injuries are not uncommon: tissue falls out of the wound, foreign bodies get inside, the retina and optic nerve are damaged; sometimes orbital fractures and a dangerous “compartment syndrome” of the orbit occur, requiring immediate decompression (lateral canthotomy with cantholysis). [2]

One sentence reminder: if you suspect an open injury, do not press on the eye, do not measure pressure, apply a hard protective shield, antiemetics for nausea, and urgently transport to an ophthalmology hospital. [3]

Terms and classification: "what we're talking about"

The BETT system classifies eyeball injuries as closed (contusion, lamellar lesion of the wall) and open (rupture - due to blunt impact; lesional wound - due to a sharp object). Lesional wounds are classified as penetrating (single entry), perforating (entry and exit), and with an intraocular foreign body. For prognosis, the wound zone is indicated: 1 - cornea and limbus, 2 - sclera up to 5 mm posteriorly, 3 - more than 5 mm posteriorly. [4]

The Ocular Trauma Score and its modern modifications are used for preliminary prognosis. The outcome is typically most strongly determined by baseline visual acuity; a "revised" version for open injuries was proposed in 2025, but it still requires external validation. [5]

Table 1. BETT Classification - a quick cheat sheet for the patient chart

Block	What to record
Integrity	Closed/Open trauma. [6]
Subtype open	Rupture (blunt force) / Lesion wound (sharp object).
Laser: clarification	Penetrating / Perforating / With intraocular foreign body.
Zone	1 - cornea/limbus; 2 - sclera ≤ 5 mm posterior; 3 - sclera > 5 mm posterior.

ICD-10 and ICD-11 codes

In ICD-10, block S05 "Damage to the eye and orbit" covers: S05.0 - damage to the conjunctiva and abrasion of the cornea without a foreign body; S05.1 - contusion of the eyeball and orbital tissues; S05.2-S05.3 - lacerating injury/laceration of the eye; S05.5-S05.6 - penetrating wound of the eyeball; S05.7 - avulsion of the eye; S05.8-S05.9 - other and unspecified. In clinical modifications, codes are detailed by the side and stage of care. [7]

In ICD-11, the NA06 section "Injury to the eye or orbit" includes, in particular, NA06.4 (injury to the conjunctiva or corneal abrasion), NA06.1 (penetrating wound of the orbit), NA06.8 (traumatic injury to the eyeball). ICD-11 uses post-coordination - the mechanism, anatomy, and side specifiers are added to the main code. [8]

Table 2. Frequently used codes (guideline)

Classifier	Code	Description
ICD-10	S05.0	Conjunctival injury and corneal abrasion without foreign body. [9]
ICD-10	S05.2 / S05.3	Laser injury/rupture of the eyeball. [10]
ICD-10	S05.5 / S05.6	Penetrating wound of the eyeball (with/without foreign body). [11]
ICD-11	NA06.4	Conjunctival injury or corneal abrasion.[12]
ICD-11	NA06.8	Traumatic injury to the eyeball. [13]

Epidemiology

Open eye trauma is a globally significant cause of monocular blindness. Current reviews estimate its global incidence at approximately 3.5–4.5 cases per 100,000 population per year; the range is wider in individual countries due to differences in working conditions and safety. While relative rates have been declining in recent decades, the absolute burden remains high. [14]

Large databases show that men are more frequently injured; in children and adolescents, the "male" risk is approximately 1.8 times higher, with the leading causes being sports, games, and fireworks. In older age, the contribution of falls increases. [15]

According to multicenter reviews, timely primary closure of an open wound within 24 hours statistically reduces the risk of endophthalmitis, one of the key complications that worsens the visual prognosis. [16]

Table 3. Epidemiological landmarks

Indicator	Rating/trend
Global incidence of open trauma	3.5-4.5 per 100,000 per year. [17]
Children and teenagers	The risk in boys is approximately 1.8 times higher. [18]
The contribution of falls in the elderly	Increases with age; important target for prevention. [19]
Early wound closure	< 24 hours - less endophthalmitis and better outcomes. [20]

Causes and risk factors

Four dominant mechanisms are: blunt force (ball, impact, fall), sharp object (glass, knife, metal), high-speed particles (grinding, drilling - often with a foreign body), and chemical burns. In addition to domestic scenarios, industrial ones are also common, especially where eye protection is poorly observed. [21]

The main modifiable risks are working with metal/wood/glass without protective eyewear and contact sports without a mask. For young children, this includes access to pyrotechnics and sharp objects; for the elderly, this includes falls due to balance and vision problems. [22]

Pathogenesis

In a closed injury, the shock wave and acceleration displace the ocular structures: blood enters the anterior chamber (hyphema), damaging the iris and lens, and hemorrhages, retinal tears, and retinal detachment are possible in the posterior segment. In an open injury, a full-thickness wound leads to loss of intraocular fluid, a drop in pressure, and a gateway for microflora. Intraocular foreign bodies increase the risk of infection and proliferative complications. [23]

Orbital compression (compartment syndrome) rapidly deprives the eye of perfusion—the time reserve is measured in hours; delay in decompression threatens irreversible vision loss. [24]

Symptoms and red flags

Pain, burning, photophobia, blurred vision, double vision, pupil deformity, blood in the anterior chamber, profuse subconjunctival bleeding, and a sharp decline in visual acuity are all reasons for immediate evaluation. Rapidly increasing exophthalmos with deteriorating vision is a suspicion of orbital compartment syndrome and an indication for emergency decompression. [25]

Table 4. What to do/what not to do in the first minutes

Situation	Do it	It is forbidden
Suspected open injury	Hard protective shield, pain relief, antiemetics, urgent delivery	Pressure bandage, palpation, pressure measurement, ultrasound until sealing. [26]
Suspected high velocity foreign body	Computed tomography of the orbits	Magnetic resonance imaging to exclude metal. [27]
Chemical burn	Immediate copious rinsing to pH 7.0-7.4 with repeated checks	"Wait for the doctor" without irrigation. [28]

Diagnostics: step-by-step algorithm

Step 1: Triage and protection. First, treat life-threatening injuries, then the eye. If there's any doubt about an open injury, apply a shield; do not attempt anything that increases pressure in the eye. [29]

Step 2: Inspection. History of mechanism, identification of entry wound, visual acuity testing if possible, slit lamp and fluorescein - only if full-thickness wound is excluded. [30]

Step 3. Visualization. Thin-section computed tomography of the orbits is the method of choice for suspected open trauma and foreign bodies: the integrated assessment shows a specificity of approximately 0.94 and a sensitivity of approximately 0.77 (917 eyes). The most informative signs are: deformation of the ocular contour, a “flattened” eye, intraocular gas or blood. [31]

Step 4. Chemical burns. Before a “fine” examination – irrigation to normal pH, then repeat pH checks for about an hour, removal of particles, then a more extensive examination. [32]

Table 5. Computed tomography in open trauma: what to look for

Sign	Diagnostic value
Eyeball contour/asymmetry (flattened eye)	One of the most common and specific symptoms. [33]
Intraocular gas and blood	Confirm full-thickness wound/penetration. [34]
Change in the depth of the anterior chamber, lens dislocation	"Indirect" signs of serious injury. [35]
Foreign body	Requires surgical removal. [36]

Differential diagnosis

Lamellar incision versus full-thickness wound – everything depends on this: with a lamellar incision, the wall is intact, and the approach is more conservative; with a full-thickness wound, emergency sealing is recommended.
Contusion versus open trauma – there is no entry wound, but severe intraocular damage is possible.
Perforation in a corneal ulcer can mimic trauma – the decision is made based on the anamnesis, microbiology, and examination of the defect edges.
Orbital compartment syndrome is distinguished by a combination of visual impairment, exophthalmos, a tight eyelid, and very high intraocular pressure – immediate decompression is indicated. [37]

Treatment

General first steps: Apply a firm, pressure-free protective shield, provide pain relief, and if nausea occurs, administer antiemetics. Withhold food and drink until seen by an anesthesiologist. Verify tetanus vaccination status and treat any associated wounds. Pressure dressings and eye pressure tests are contraindicated if an open injury is suspected. [38]

Open trauma (full-thickness wound). The goal is early systemic broad-spectrum antibiotic prophylaxis and hermetic wound closure within the first 24 hours. Frequently used combinations include intravenous vancomycin plus ceftazidime (or cefepime), with adjustments based on local protocols. Early suturing statistically reduces the risk of endophthalmitis; in the case of an intraocular foreign body, vitreoretinal therapy is added. [39]

Intraocular foreign bodies. Non-metallic and organic materials increase the risk of infection; timing of removal and indications for prophylactic intraocular antibiotics are determined on an individual basis. Data on the "mandatory" use of prophylactic intraocular antibiotics are controversial, but their use is common when there is a risk of infection. [40]

Closed trauma (contusion). We manage complications: hyphema, uveitis, iris and lens damage, hemophthalmos, retinal tears and detachments. Focus: pain and intraocular pressure control, surface protection, and early detection of retinal detachment and tears. [41]

Traumatic hyphema. Systematic reviews show that antifibrinolytics (eg, tranexamic acid) reduce the risk of rebleeding, but evidence for effects on long-term vision and major outcomes is limited; corticosteroids and bed rest with dressings lack a strong evidence base for key outcomes. Management is individualized, with an emphasis on pressure and inflammation control. [42]

Chemical burns. The main factor in outcome is the speed and volume of irrigation to normal surface pH (target 7.0-7.4) with repeated checks for approximately one hour. Then comes particle removal, anti-inflammatory therapy, stimulation of epithelialization, infection prevention, and intraocular pressure control. [43]

Corneal abrasions and superficial injuries. When wearing contact lenses, topical antibiotics active against Pseudomonas aeruginosa are mandatory; patch dressings for uncomplicated abrasions have been abandoned. The issue of home administration of short-course local anesthetics remains controversial: emergency departments report the safety of strictly limited use for up to 24 hours in small volumes, while ophthalmological reviews emphasize the lack of evidence and the risk of delayed epithelialization with overuse. The decision should be made only by a physician, under strict selection and monitoring. [44]

Orbital fractures and compartment syndrome. In cases of visual impairment, severe exophthalmos, severe ophthalmoplegia, and very high intraocular pressure, immediate decompression (lateral canthotomy with inferior cantholysis) is necessary. Medications are not a substitute for surgical unloading. [45]

Vitrectomy after open trauma. There is no specific "ideal window" time, but the general principle is primary closure as early as possible, and vitreoretinal interventions are planned based on indications (contamination, ruptures, detachment) and the overall condition. [46]

Tetanus prevention and general trauma management. For soft tissue injuries of the face and eyelids, review vaccinations and administer passive immunization as indicated, and perform thorough surgical debridement of the wound; antibiotics do not prevent tetanus and are not a substitute for vaccination. [47]

Table 6. Fast algorithm by scenarios

Situation	First	Next
Open wound	Shield, wide intravenous antibiotics, CT scan	Hermetic closure < 24 hours; in case of foreign body - vitreoretinal tactics. [48]
Contusion + hyphema	Protection, peace, pressure control	Antifibrinolytics reduce the risk of rebleeding; effects on final vision have not been proven.[49]
Chemical burn	Immediate irrigation to pH 7.0-7.4, repeat pH checks	Particle removal, anti-inflammatory therapy, infection prevention. [50]
Orbital compartment syndrome	Immediate decompression	Do not expect visualization in a typical picture. [51]

Complications and consequences

Early complications include endophthalmitis, hemorrhage, secondary glaucoma, intraocular tissue prolapse, and damage to the lens and vitreous body. Late complications include scarring, astigmatism, retinal detachment, proliferative vitreoretinal processes, and sympathetic ophthalmia (rare). The risk of infection is higher with delayed surgery and with organic foreign bodies. [52]

Table 7. What worsens the prognosis

Factor	Comment
Zone 3, posterior segment	Higher risk of low end vision.[53]
Intraocular foreign body (non-metal, dirty wound)	More infectious complications. [54]
Long delay in closing	Increased risk of endophthalmitis. [55]

When to see a doctor

Immediately if you've hit or cut your eye, if something has shot into your eye, if you see blood in the eye, a "veil," double vision, sharp pain, or if your eye is "bulging." In case of chemical contact, rinse first, achieve a neutral pH, and only then do anything else. Children and the elderly who have fallen on their eye require an examination, even if "everything seems to have cleared up." [56]

Prevention

At work and at home, wear polycarbonate safety glasses, use protective shields when grinding/drilling, and train in safe techniques. For sports, use certified masks. At home, keep alkalis and acids out of reach of children; if there are fall hazards for the elderly, remove traps and improve lighting. [57]

Table 8. Simple rules that really reduce injuries

Risk	What to do
Working with metal/wood/glass	Always wear safety glasses/mask, especially when grinding and drilling. [58]
Contact sports	Protective masks/shields.
Fireworks and sharp objects in families with children	Prohibition of independent use, keep out of reach.
Falls in the elderly	Remove thresholds and carpets, lighting, vision correction. [59]

Forecast

Outcome is determined by the type of injury, the area of injury, baseline visual acuity, the presence of a foreign body, and the time to sealing. Recent meta-analyses and reviews confirm that primary closure in less than 24 hours is associated with a lower risk of endophthalmitis and better functional outcomes. Computed tomography is useful for planning the procedure but does not replace clinical judgment when in doubt. [60]

Table 9. The role of computed tomography in patient routing

Question	Answer
Is it possible to rule out open trauma based on a picture?	No: even with high specificity, sensitivity is limited; decision is made on the basis of the totality of the data. [61]
What is most characteristic in the pictures?	Deviation of the eyeball contour, intraocular gas/blood, change in the depth of the anterior chamber. [62]
When to do an MRI?	After exclusion of metallic foreign body. [63]

Frequently asked questions

How long does it take to operate on an open wound?
The guideline is the first 24 hours after the injury; the sooner the seal is sealed, the lower the risk of intraocular infection. [64]

Are antibiotics necessary for open trauma?
In practice, intravenous vancomycin is often prescribed immediately in combination with an antipseudomonal cephalosporin (eg, ceftazidime/cefepime) and adjusted according to local protocols; the evidence base for systemic prophylaxis is limited, but the benefit of early closure is compelling. [65]

Can "pain-relieving drops" be administered at home for a corneal abrasion?
Only by doctor's discretion and for a very short period: emergency departments report safe use for 24 hours with strict volume restrictions, but ophthalmology reviews highlight the lack of evidence and the risk of abuse. [66]

What should you do if you have a chemical burn before seeing a doctor?
Immediately and thoroughly rinse with whatever is available (water, saline solutions), check the pH to ensure a stable neutral level, then remove the particles and examine. Don't wait and don't try to "neutralize" the acid with an alkali, or vice versa. [67]