Globe Rupture, Emergency Medicine

Basics

Description

A full-thickness corneal or scleral injury owing totrauma
Blunt trauma/globe rupture:
- Causes an abrupt rise in intraocular pressure diffusely
- Subsequent rupture of the eye either opposite the point of impact or at the weakest points:
  - Extraocular muscle insertion
  - Corneoscleral junction
  - Limbus, where the sclera is thinnest
Penetrating injury/globe laceration:
- Occurs with sharp objects or projectiles injuring the sclera or anterior eye directly
- Most commonly anterior-the bony orbit protects the globe laterally and posteriorly
- Posterior injury can occur with fracture of the bony orbit or with penetrating injuries of the eyelid or eyebrow.
Prognosis worse with:
- Larger lacerations
- Injury posterior to the rectus insertion
- Blunt injury
- Intraocular foreign body, especially if made of organic material
- Vitreous extrusion
- Lens damage
- Hyphema
- Retinal detachment
- Poor visual acuity at presentation
- Afferent pupillary defect
- Increased time to OR

Etiology

Falls, impact injuries
Sport-related injuries (e.g., elbow, ball impacts, arrows, game controllers, etc.)
Indirect concussive injuries (explosions)
Sharp instrument/stabbing injuries, accidental or intentional
Projectile injuries (industrial, firearms, BB pellets, blast explosion shrapnel-glass, etc.)

Diagnosis

Signs and Symptoms

Pain
Localized ecchymosis and swelling
Scleral or corneal laceration
Extrusion of intraocular contents
Markedly decreased visual acuity
Limited extraocular motion
Hyphema
Severe subconjunctival hemorrhage and edema, especially if circumferential bloody chemosis
Abnormally deep or shallow anterior chamber
Low intraocular pressure:
- Note: Do not perform tonometry if there is suspected rupture.
Irregular pupil (points toward lesion)
Subluxed lens
Commotio retinae-gray-white discoloration of the retina

History

Mechanism of injury:
- Assess for possibility of retained intraocular foreign body
History of previous eye surgery
Preinjury visual acuity
Assess tetanus status
Ascertain time of last PO intake

Physical Exam

Penlight or slit-lamp exam observing for signs of globe rupture
If the diagnosis of ruptured globe is made, defer further ocular exam until the time of surgical repair:
- Prevents placing any undue pressure on the eye and risking extrusion of the intraocular contents
If no evidence of globe rupture on initial survey, proceed with thorough ophthalmologic exam:
- Visual acuity
- Slit-lamp exam
- Cornea
- Anterior chamber
- Iris
- Sclera
- Fundus
- Retina
Seidel test: Observe if fluorescein moves away as contents (which appear yellow-green) leak out at site of rupture:
Measure intraocular pressure
- Perform only if globe rupture is definitely not present.
Ultrasound (only if rupture not suspected)

Essential Workup

Perform thorough ocular exam as outlined above:

Once diagnosis of globe rupture is suspected or made, defer further exam until time of repair.

Diagnosis Tests & Interpretation

Lab
Preoperative labs:

CBC
Electrolytes
Coagulation studies

Imaging

Orbital radiograph (anteroposterior/lateral) for metallic intraocular foreign body
CT scan of the orbits (axial and coronal views)
MRI scan of the orbits after retained metallic foreign body is ruled out
B-scan US of the eye

Diagnostic Procedures/Surgery

Slit-lamp
Fluorescein

Differential Diagnosis

Intraocular foreign body
Hyphema
Severe subconjunctival hemorrhage and chemosis
Partial corneal laceration
Partial scleral laceration

Treatment

Pre-Hospital

Place a shield (not patch) over eye with no pressure on the globe.
Use a Styrofoam cup if no shield available.

Initial Stabilization/Therapy

Keep manipulation of the eye to a minimum if ruptured globe is suspected.
Try to prevent any activity that will cause an increase in intraocular pressure such as straining, coughing, or vomiting.

Ed Treatment/Procedures

Prepare for definitive surgical management:
- Emergent ophthalmologic consultation
- Thorough physical exam to identify concurrent injuries
- Preoperative labs and ECG as indicated
- No food or drink (NPO)
Minimize intraocular pressure to reduce further injury
- Administer antiemetic for nausea/vomiting
- Elevate the head of the bed
- Protective eye shield (NO pressure on the globe itself)
Update tetanus status.
Administer prophylactic antibiotics IV:
- Skin organisms (staph, strep) most common
- Consider injury-specific contaminants in cases of animal bites, organic foreign body, etc.
- Vancomycin + ceftazidime OR vancomycin + ciprofloxacin if allergic to penicillin
Succinylcholine is relatively contraindicated:
- However, with a defasciculating dose of a nondepolarizing agent and sufficient anesthesia, it may be used.

Consider nonaccidental trauma
Because of risk of extrusion of intraocular contents, straining/crying should be avoided. Try to keep them happy!

Medication

Ceftazidime: 1-2 g (peds: 30-50 mg/kg) IV q8h
Ciprofloxacin: 400 mg (peds: 10 mg/kg) IV q12h
Clindamycin: 450 mg (peds: 8-12 mg/kg) IV q8h
Ondansetron (Zofran): 4 mg IV
Prochlorperazine (Compazine): 5-10 mg IV/IM
Tobramycin: 2 mg/kg (peds: 2 mg/kg) IV q8h
Vancomycin: 15 mg/kg IV q8-12h (peds: 10 mg/kg IV q6h)

Follow-Up

Disposition

Admission Criteria

All patients with globe rupture/penetrating eye injuries
Early enucleation for severe injury

Discharge Criteria
Globe penetration excluded
Issues for Referral

Emergent ophthalmologic consultation in the ED may be needed to definitively rule out globe rupture owing to difficulty with exam and the desire to minimize manipulation of the eye.
Speed is of the essence since the risk of infection increases with prolonged time to operative repair.
If appropriate, patient should be counseled on use of protective eyewear to prevent recurrence.

Followup Recommendations

Postoperative ophthalmology follow-up

Pearls and Pitfalls

Do not manipulate the eye if you suspect or confirm a ruptured globe:
- Place eye shield over affected eye.
Administer antiemetic for patients with nausea and vomiting to prevent elevation of intraocular pressure and extrusion of globe contents.
Update tetanus
Empiric antibiotics tailored to clinical scenario

Additional Reading

Linden JA, Renner GS.Trauma to the globe. Emerg Med Clin North Am. 1995;13(3):581-605.
Marx JA, Hockberger RS, Walls RM, et al. Rosens Emergency Medicine. 7th ed. Philadelphia, PA: Saunders; 2009;863-864.
Navon SE. Management of the ruptured globe. Int Ophthalmol Clin. 1995;35:71-91.
Sabaci G, Bayer A, Mutlu FM, et al. Endophthalmitis after deadly-weapon-related open-globe injuries: Risk factors, value ofprophylactic antibiotics, and visual outcomes. Am J Ophthalmol. 2002;133:62-69.
Skarbek-Borowska SE, Campbell KT. Globe rupture and nonaccidental trauma: Two case reports. Pediatr Emerg Care. 2011;27(6):544-546.

Codes

ICD9

871.0 Ocular laceration without prolapse of intraocular tissue
871.2 Rupture of eye with partial loss of intraocular tissue

ICD10

S05.20XA Oclr lac/rupt w prolaps/loss of intraoc tiss, unsp eye, init
S05.30XA Oclr lac w/o prolaps/loss of intraoc tissue, unsp eye, init

SNOMED

231791008 Rupture of globe
23293006 Rupture of eye with partial loss of intraocular tissue (disorder)

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