Globe rupture

Background

• Vision threatening emergency
• Rupture of the sclera of the eye
• Be careful not to apply pressure to eye
  • Evert lids with paperclips or eyelid retractors

Causes

• Blunt Eye Trauma
  • Caused by suddenly elevated IOP
• Penetrating trauma
  • Suspect globe penetration with any puncture or laceration of eyelid or periorbital area
  • More commonly associated with objects from metal on metal, lawn mower, drills, grinders

Clinical Features

• Eye pain
• +/- decreased visual acuity
• Tear-shaped pupil
• Extrusion of intraocular content
• Subconjunctival hemorrhage involving entire sclera
• Hemorrhagic chemosis
• Slit-lamp
  • Shallow anterior chamber
  • Hyphema
  • Seidel's sign - do not perform this test if suspect open globe
    • May be falsely negative if scleral rupture is small
  • Lens dislocation

Differential Diagnosis

Maxillofacial Trauma

• Le Fort fractures
• Skull fracture (peds)
• Auricular hematoma
• Nasal fracture
  • Nasal septal hematoma
• Zygomatic arch fracture
• Zygomaticomaxillary (tripod) fracture
• Dental trauma
• Mandible fracture

Orbital trauma

Acute

• Ruptured Globe^
• Corneal Abrasion
• Ocular foreign body
• Conjunctival laceration
• Caustic Keratoconjunctivitis^^
• Subconjunctival hemorrhage
• Traumatic iritis
• Traumatic hyphema
• Retinal detachment
• Retrobulbar hemorrhage/hematoma
• Traumatic mydriasis
• Orbital fracture
  • Frontal sinus fracture
  • Naso-ethmoid fracture
  • Inferior orbial wall fracture
  • Medial orbital wall fracture

Subacute/Delayed

• Endophthalmitis^
• Corneal Ulcer^

Evaluation

• Inspect lids, lashes, cornea, sclera, and pupils.
• Evaluate for a relative afferent pupillary defect
• Visual Acuity
• Do NOT perform tonometry for IOP

Work-Up

• Non-contrast CT orbit
  • Consider if concern for intraocular foreign body OR diagnosis is unclear
  • Sensitivity ~60%

Management

• Consult ophtho immediately
• Do not manipulate the eye
• Eye covering with metal shield or paper cup
• Elevate head of bed
• Treat nausea/vomiting
• Broad spectrum IV antibiotics
  • Ceftazidime 1gm + vanco 1 gm
  • penicillin allergy: Cipro + vanco
• Tetanus, if indicated
• Keep patient NPO
• Intubation, if necessary
  • Succinylcholine and ketamine <3mg/kg do not increase intraocular pressure or cause adverse outcomes

Disposition

• Admission for surgical repair by ophthalmology
• Transfer to tertiary trauma center if ophthalmologist prefer

See Also

• Orbital Blowout Fracture
• Ocular foreign body

References

Authors

Jordan Swartz, Lauren Westafer, Daniel Ostermayer, Ross Donaldson, Neil Young