4.2 Penetrating Injury, Sclera/Episclera

eyes.nhs.scot/
Eyecare Guidelines/
Section 4 - Sclera/Episclera/
4.2 Penetrating Injury, Sclera/Episclera

Date of revision:

21/09/2026

Date of next review:

21/09/2026

Date of publication:

26/10/2026

Differential Diagnosis ⁽¹⁾

Non‑penetrating (blunt) ocular or periocular trauma
Chemical injury

Possible management by optometrist

Immediate Advice and Assessment

Suspected Penetrating Injury ⁽¹⁾

Do not apply pressure to the eye if there is any evidence or suspicion of globe penetration.

Look carefully for:

- Extra‑ocular foreign bodies
- Intra‑ocular foreign bodies (IOFBs)

History ⁽¹⁾

Obtain a detailed history, including:

Mechanism of injury

Nature, size and speed of any foreign body

Circumstances surrounding the injury

Particular suspicion of an IOFB should be raised where:

Metal has struck metal

Protective eyewear was not worn

Where penetration is uncertain or an IOFB is suspected, perform a dilated fundus examination if clinically appropriate.

Additional Assessment ⁽¹⁾

Check and record visual acuity

Establish tetanus status where possible

If a full‑thickness globe laceration is suspected:

Do not force the eyelids open

Do not exert pressure on the eye
Advise the patient to avoid coughing, straining or Valsalva manoeuvres

Immediate Protective Measures ⁽¹⁾

Protect the eye with a rigid plastic eye shield (e.g. cartella shield)

Do not pad the eye

If a penetrating object remains in situ:

Do not attempt removal

If uveal tissue is prolapsing:

Do not attempt repositioning

Advise the patient to remain nil by mouth, except for a small amount of water if required to take medication.

Treatment

Topical anaesthetic (to aid examination only) ⁽¹⁾

systemic pain relief and antiemetic as required ⁽¹⁾(if available, with advice from local pharmacy/GP) ⁽⁷⁾
- To assist swallowing of tablets, a small amount of water is permissible ⁽¹⁾

N.B. Without delaying referral, consider systemic antiemetic medication where active vomiting is present, as retching and vomiting may exacerbate ocular injury. Choice of antiemetic should be guided by local HES consultation, contraindications and patient factors ⁽⁷⁾

Typical dosage/duration

(Blue text = IP, black text = non-IP)

Not Applicable for this condition ⁽⁷⁾

Further management options

First aid followed by emergency referral; no intervention ⁽¹⁾

Clearly communicate the urgency of the condition ⁽¹⁾

Instruct the patient they are required to attend the hospital eye department (or A&E if no ophthalmology support available) immediately ⁽¹⁾

Follow local protocols for same-day referral ⁽⁷⁾, ensuring a clinician (in the receiving department) is informed the patient is attending ⁽¹⁾

Possible management in secondary care or local/community pathways where available

See Further management options ^(1,7)

Orbital CT scan, ultrasound, X-ray other investigations ⁽¹⁾

Surgical management of penetrating injury ⁽¹⁾

Tetanus prophylaxis considerations ⁽¹⁾

Endophthalmitis prophylaxis ⁽¹⁾

Follow-up includes examination for possible sympathetic ophthalmia affecting fellow eye (occurs in 0.19% of cases of penetrating trauma in adults and 0.39% in children) ⁽¹⁾

College of Optometrists Clinical Management Guideline⁽¹⁾

Trauma (penetrating) - College of Optometrists *

*With special thanks to The College of Optometrists for providing the evidence framework for diagnosis and management from the Clinical Management Guidelines (CMGs) for this condition. All references to the College/CMGs are included where appropriate and form the basis of the Community Eyecare Guidelines.

Guidance is informed by the following sources

College of Optometrists Clinical Management Guidelines Clinical Management Guidelines - College of Optometrists
Advisory alignment with the College of Optometrists Formulary Optometrists' Formulary - College of Optometrists
Advisory alignment with the BNF BNF (British National Formulary) | NICE
Advisory alignment with the Summary Product Characteristics taken from the EMC Home - electronic medicines compendium (emc)
Advisory alignment with Scottish Health Board formularies (where a clear majority is present) *
Advisory alignment with expert consensus (CEGG), informed by sources 2-5 above
Advisory alignment with expert consensus (CEGG)
“Annex C of the Statement” https://www.eyes.nhs.scot/for-professionals/legislation/

* Scottish formularies should be available within the Prescribing section of your Health Board pages on the eyes.nhs.scot website. If unavailable, contact your local Health Board for further information; Health Boards landing page

If you have a query relating to this page, please email NSS.ComEyecareGuidelineGroup@nhs.scot

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CEG disclaimer for guidelines awaiting update:

The Eyecare Guidelines area of the eyes.nhs.scot website (“Website”) is intended as a reference source for education and clinical decision support and is intended for use by ophthalmic healthcare professionals working in Scotland.

As such, the Eyecare Guidelines are not intended for use by the general public and do not replace the advice of a healthcare professional. Members of the public should seek advice directly from their optometrist.

Before reading the Eyecare Guidelines or making any management decisions based upon them, all users should read the ‘supporting information’ page which gives more detail around the content of the Guidelines and useful website links [link to Supporting Information page].

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Users should note that that the Eyecare Guidelines guidance is not mandatory. The guidelines will not be suitable for every situation and they are not intended to be a substitute for specialist expertise and clinical judgement. Users assume all responsibility for using/interpreting the information within the Eyecare Guidelines section of the website. Users should also note that the Eyecare Guidelines should not be adhered to in isolation and should be considered in conjunction with other national and locally available guidance/pathways. 

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