Ocular trauma accounts for a major cause of worldwide visual morbidity that especially affects the young population. Ocular trauma comprises a wide field with varied mode and settings of injury. The Birmingham Eye Trauma Terminology (BETT) system has described specific terminology and assessment describing different eye injuries [1] (Table 3.1). This system has been endorsed by the International Society of Ocular Trauma, United States Eye Injury Registry, the Hungarian Eye Injury Registry, the Vitreous Society, the Retina Society, and the American Society of Ophthalmology.

While laceration and rupture are both open-globe injuries; a laceration generally implies full-thickness wound of the eye wall caused by a sharp object, and rupture is described as full-thickness wound of the eye wall caused by blunt trauma. The eye wall gives way at its weakest point which may or may not be at the site of impact. Some exceptions are like pellet and blast injuries, which have significant blunt force, still considered lacerations. The sole purpose of this section is to discuss details of presentation and management of globe rupture.

Globe rupture may occur when a blunt object hits the globe, which compresses it anteroposteriorly along the horizontal axis, causing sudden rise of intraocular pressure to a point that the sclera tears. Ruptures from blunt trauma are most common at the anatomically thinner parts of the sclera, such as at the site of insertions of the extraocular muscles, at the limbus, or at the site of previous ocular surgery [2, 3].

The global pattern of eye injuries and their consequences emerging from a review of data compiled from the ophthalmic literature and WHO’s Blindness Data Bank by Négrel AD et al. suggest that globally approximately 55 million people are exposed to ocular trauma each year, restricting activities more than one day; 750,000 cases require hospitalization each year, including some 200,000 open-globe injuries; and approximately 1.6 million people become blind from injuries, wherein bilateral low vision is found in 2.3 million people and unilateral low vision in almost 19 million [4].

Most of the epidemiological data of ocular trauma are based on information from more developed countries. The incidence rates of ocular trauma requiring hospitalization for those with definite ocular trauma (principal diagnosis) were 13.2 per 100,000 population and for total ocular trauma (principal or secondary diagnoses) 27.3 per 100,000 population per year in the United States [5, 6], 8.1 per 100,000 persons per year in Scotland [7], 12.6 per 100,000 persons per year in Singapore [8], and 15.2 per 100,000 persons per year in Australia [9]. In the United States alone, eye injuries cost >$300 million per year due to loss of productivity, medical expenses, and workers’ compensation [10]. Developing countries, where the actual incidence may be much more, suffer the worst brunt of the problem.

The major risk factors for ocular trauma include age, gender, socioeconomic status, and lifestyle.

Open-globe injuries occur at a relatively younger age in men (median age 36 year) than in women (median age 73 year). Approximately one third of patients with eye trauma are children. Because of occupational and recreational predilection, open-globe injuries are common in men (78.6 %). However, men are more likely to have lacerations (69.9 %), whereas women present more frequently with globe rupture (68.1 %). Projectile-related injuries are more common in men (54.9 %). Compared to men, falls accounted for majority of globe injuries in women (8.1 % versus 55.3 %) [11].

As ocular injuries causing globe rupture are more frequent in the workplace or during recreational activities; co-workers, co-players, or bystanders can play an important role in the management of such cases by giving initial support and bringing the victim to emergency care service at the earliest. Appropriate and timely management plays a significant role in the final outcome of these cases.

Usually an emergency department physician is the first skilled person to receive such cases. Approach to such a patient depends to a large extent on the age as well as mental and physical condition of the patient. While children are more prone for trauma, they usually are less cooperative for clinical examination. Often subtle injuries are missed in such cases. So these cases need more careful monitoring and evaluation whenever there is doubt of eye trauma. If necessary, examination under sedation or general anesthesia may be appropriate. A gentle and organized approach is essential.

Essential steps to be followed in the emergency department are:

Once the patient reaches the ophthalmologist’s care, a quick review of the primary physician’s note and the test reports should be done. A brief systemic evaluation to detect any change in vital systemic status should be done. Thereafter a systematic examination to the patient’s injuries should be done to develop a logical treatment plan. Examination should be carried out promptly and comprehensively, as the details of internal structures of the eye may be obscured soon by edema or media opacity. The uninjured eye should also be thoroughly examined. Photographic documentation is invaluable not only for comparison of treatment outcome but also for medicolegal purpose. If photographic documentation is not possible, detailed drawing of all the injuries should be done. It should be assumed that any periocular or ocular trauma could include a ruptured globe.