CLINICAL PEARLS AND PITFALLS In order to avoid extrusion of intraocular contents, open-globe injury requires rapid recognition and emergent evaluation by an ophthalmologist Clinical findings include teardrop pupil, 360 degrees of bullous subconjunctival hemorrhage, or enophthalmos ( Fig 114.3 ) If any of the above is present, immediately place an eye shield and minimize disturbing the child Current Evidence The visual prognosis in pediatric open-globe injury may be poor The following factors seem to be most predictive of poor visual outcome: blunt injury, injury resulting from a gun, age 5 mm), wounds involving the sclera and associated injuries such as hyphema, vitreous hemorrhage, or retinal detachment Prompt recognition and immediate referral to an ophthalmologist, ideally one with pediatric expertise, is the accepted standard of care Goals of Treatment Open-globe injury is an ominous trauma that warrants emergent ophthalmology consultation The goal of treatment in the emergency department (ED) is to avoid causing extrusion of contents from the eye, while awaiting definitive surgical repair Further ocular examination should be stopped immediately when an openglobe injury is suspected and pain control and antiemetics should be initiated Clinical Considerations Clinical Recognition An open-globe injury is defined by the presence of a full-thickness break in the cornea or sclera ( Fig 114.4 ) This condition can occur following trauma by sharp implements, projectiles, or blunt trauma Sharp objects can directly penetrate the globe In the case of blunt trauma, significant force causes compression of the globe, raising intraocular pressure and leading to rupture Although severe intraocular disruption may occur, the globe has a remarkable ability to maintain its integrity Upon injury, the iris or choroid may move and plug the wound Blue, brown, or black material on the surface of the sclera may be visible as the iris or choroid forms a plug ( Fig 114.5 ) With small lacerations that are plugged by iris or choroid, the globe may maintain a remarkably normal external appearance Alternatively, with the movement of the iris or choroid in