03 / Ophthalmic Surgery · open
Primary repair of an open globe
The ruptured eye is closed watertight as the first, not the final, operation: anatomy tonight, vision's verdict later.
Indication: Full-thickness injury of cornea or sclera; protected with a shield, no pressure on the eye, repair without delay.
On the tray for this operation
Test yourself on the tray
Stage
1 / 4
Protection and assessment
From suspicion onward: rigid shield, nothing that presses the globe, antiemetics, nil by mouth, imaging for a foreign body without MRI if metal is possible.
Watch for: Extrusion of intraocular contents from external pressure · Missed intraocular foreign body
The surgeon asks
Why are antiemetics part of the emergency management of an open globe?
Why are we operating?
Primary repair of the open globe restores the eye's integrity as a pressurised chamber: every wound is closed watertight, anatomy is returned to its compartments, and the eye is stabilised for whatever staged reconstruction follows. The operation's first principle governs everything before it too: nothing must press on an open eye, because the globe's contents are held in only by what remains of its wall.
Pulls toward surgery
Gives the team pause
Shared foundations
What the surgeon is thinking
Protection and assessment
Why is the best pre-operative examination a limited one?
Because pressure expresses contents: lids are not forced, no drops instilled, no pads applied, a rigid shield protects, and the definitive examination happens under anaesthesia where the eye cannot squeeze against itself. Antiemetics are part of eye surgery here: vomiting is an intraocular pressure spike with a name.
Examination and exploration under anaesthesia
What is the exploration mapping before any suture?
The wound's full extent: corneal lacerations are traced to the limbus and beyond, conjunctiva is opened to follow scleral wounds posteriorly, because the visible wound is often the iceberg's tip. Prolapsed tissue is repositioned or minimally excised by doctrine (uvea repositioned where viable), and the repair is planned on the whole map, not the visible fragment.
Watertight closure
Why does the closure start at the limbus?
The limbus is the eye's fixed geographic landmark: restoring it first re-establishes the globe's architecture, and the corneal and scleral closures then proceed from known anatomy. Corneal sutures are placed for a watertight, astigmatism-conscious seal; the endpoint is an eye that holds pressure, tested, not presumed.
Antibiosis and the next operations
Why is the primary repair deliberately not the definitive operation?
The injured eye declares its lens, retina and vitreous status over days: primary repair restores the closed chamber, and cataract, foreign-body and retinal surgery are staged when imaging and inflammation allow. Endophthalmitis prophylaxis, a shield, and honest counselling (including, later and rarely, the sympathetic ophthalmia conversation) close the first act.
Decision points
CT shows a metallic intraocular foreign body. Remove it at primary repair?
Close primarily, stage the removal with vitreoretinal surgery
The common pathway: a watertight globe tonight, definitive vitrectomy and extraction by the retinal team on a planned list.
Primary removal
For accessible foreign bodies with the right team present, or high-risk material: doctrine and logistics decide, not bravado.
The foreign body sets clocks (infection risk, and toxicity for some metals) but rarely demands midnight heroics: the sequencing question is answered by the injury's anatomy and the available expertise, with antibiotics covering the interval either way. MRI stays forbidden throughout until metal is excluded.
The globe is devastated: no light perception, contents disorganised. Repair or enucleate?
Primary repair, always attempt
The rule: primary enucleation is almost never done. Eyes recover unexpected function, the patient participates in later decisions, and nothing is foreclosed at the worst possible hour.
Primary enucleation
Reserved for the truly unreconstructable globe, decided by senior surgeons, ideally with the patient's informed involvement: a rarity by design.
The doctrine exists because the stakes are irreversible and the emergency assessment unreliable: repair first, reassess in daylight with imaging and counsel. The sympathetic ophthalmia risk that once argued for early enucleation is rare and managed, not a midnight trigger.
Leaving the OR
The handoff
- Procedure
- Primary repair: corneoscleral laceration closed watertight, limbus first
- Findings
- Wound mapped limbus to 4 mm posterior; uveal prolapse repositioned; no IOFB on CT
- Prophylaxis
- Systemic and topical antibiotics running; tetanus covered; MRI flagged as forbidden pending metal exclusion
- Watch for
- Shield on at all times, antiemetics charted, pain with vision change as the endophthalmitis sentence
A fictional educational patient, handed over the way real ones are.
The postoperative course
- Day 0-1Shield, antiemetics and analgesia: the closed globe is protected from every pressure, including the patient's own rubbing and retching.
- Days 1-7Inflammation managed, infection watched for by name, and the staged plan drawn: imaging, lens and retina assessments as the eye quietens.
- WeeksSecondary procedures as staged: cataract surgery, vitrectomy, foreign-body work: the reconstruction the primary repair made possible.
- MonthsVisual outcome declared honestly (it tracks the injury more than the repair), refraction and rehabilitation completed, and the fellow eye's protection (eyewear counselling) made permanent.
Watch it done
Open globe repair from a retina surgeon
A Mayo lecture on ocular trauma and the primary repair.
Source: Mayo Clinic · Watch on YouTube