Sir,

Long-term sequelae of open globe injuries include cataract, glaucoma, phthisis bulbi, and sympathetic ophthalmia. We present a case of a severe open globe injury in childhood resulting in macrophthalmos as an adult.

Case report

A 39-year-old man presented with gradual increased prominence of his left eye, which had suffered a corneal penetrating eye injury from a wooden stick at age 7 years and had undergone primary repair.

On examination, best-corrected visual acuities were 6/7.5 OD and perception of light OS. The appearance of the left eye is shown in Figure 1. Intraocular pressures were 16 mmHg OD and 28 mmHg OS. The left eye was aphakic.

Figure 1
figure 1

(a) Left pseudoproptosis especially prominent on downgaze. (b) Scleral thinning with choroid visible under superotemporal bulbar conjunctiva. (c) Nasal corneal neovascularisation and scarring with central climatic droplet keratopathy. The anterior chamber was markedly disrupted.

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Thyroid function tests were normal. An orbital CT scan revealed an elongated left axial length of 33 mm, compared to 26 mm in the right eye (Figure 2a and b). There was no evidence of an intraorbital mass or extraocular muscle enlargement.

Figure 2
figure 2

(a) Axial view of orbital CT scan showing left macrophthalmos measuring 33 mm in the anteroposterior axis, compared to the normal right eye measuring 26 mm. (b) Sagittal view of orbital CT scan of left eye showing pseudoproptosis secondary to an enlarged, deformed left globe.

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Comment

Ocular trauma is the leading cause of monocular blindness in children.1, 2, 3 In a series of 50 eyes that had suffered severe globe rupture and were not removed within 2 weeks of injury,4 the majority (70%) became phthisical. No eyes developed macrophthalmos.

In normal eyes, after the rapid growth in axial length in the first 5 years of life, a slow juvenile phase lasting until age 13 years results in an increase of only 1.3–1.4 mm.5 In a series of 13 adult patients with unilateral childhood traumatic cataract, all injured eyes had greater axial lengths than their normal fellow eyes (range 0.1–11.5 mm, mean 2.48 mm).6 Interestingly, the patient with an injured eye 11.5 mm longer than the normal fellow eye had suffered the injury at age 3 years.

The authors believe that the reported case appears to be the first reported case of severe macrophthalmos following trauma in a juvenile. This could be due to gradual stretching of a biomechanically weakened sclera from previous trauma in response to raised intraocular pressure and extraocular muscle tension. This case suggests that since the dynamic process of emmetropisation continues after the age of 7 years, the axial length might remain malleable, if this process is interrupted by trauma and visual impairment.