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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

  • A full-thickness corneal or scleral injury owing totrauma
  • Blunt trauma/globe rupture:Causes an abrupt rise in intraocular pressure diffuselySubsequent rupture of the eye either opposite the point of impact or at the weakest points:Extraocular muscle insertionCorneoscleral junctionLimbus, where the sclera is thinnest
  • Penetrating injury/globe laceration:Occurs with sharp objects or projectiles injuring the sclera or anterior eye directlyMost commonly anterior-the bony orbit protects the globe laterally and posteriorlyPosterior injury can occur with fracture of the bony orbit or with penetrating injuries of the eyelid or eyebrow.
  • Prognosis worse with:Larger lacerationsInjury posterior to the rectus insertionBlunt injuryIntraocular foreign body, especially if made of organic materialVitreous extrusionLens damageHyphemaRetinal detachmentPoor visual acuity at presentationAfferent pupillary defectIncreased 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 acuitySlit-lamp examCorneaAnterior chamberIrisScleraFundusRetina
  • Seidel test: Observe if fluorescein moves away as contents (which appear yellow-green) leak out at site of rupture:
  • Measure intraocular pressurePerform 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

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 consultationThorough physical exam to identify concurrent injuriesPreoperative labs and ECG as indicatedNo food or drink (NPO)
  • Minimize intraocular pressure to reduce further injuryAdminister antiemetic for nausea/vomitingElevate the head of the bedProtective eye shield (NO pressure on the globe itself)
  • Update tetanus status.
  • Administer prophylactic antibiotics IV:Skin organisms (staph, strep) most commonConsider 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.

See Also (Topic, Algorithm, Electronic Media Element)

  • Blowout Fracture
  • Corneal Abrasion
  • Corneal Foreign Body
  • Hyphema
  • Retinal Detachment
  • Visual Loss

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)