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Globe Rupture Clinical Presentation

  • Author: John R Acerra, MD; Chief Editor: Steven C Dronen, MD, FAAEM  more...
 
Updated: Oct 26, 2015
 

History

The clinical history is important, and details regarding the circumstance and mechanism of injury should be obtained with the following in mind:

  • What was the patient doing (ie, hammering metal) at the onset of injury?
  • Assess likelihood of other associated extraocular injury (ie, subdural hemorrhage secondary to fall)?
  • Consider the possibility of blunt, penetrating, and perforating injury.
  • Type of object to strike globe; consider the possibility of intraocular foreign body.
  • Time of the injury
  • Location where injury occurred (ie, home or construction site)
  • Use of corrective or protective lenses
  • Severely myopic eyes may be more vulnerable to injury from anterior-posterior compression.
  • Use of a seat belt or airbag deployment in motor vehicle crash
  • Projectile injuries in men are the most frequent causes of globe injuries with common causes being work related or home improvement projects. [6]

Medical history may include the following:

  • Prior history of ocular surgery (ie, prior cataract extraction should prompt search for an occult cataract wound rupture)
  • Preexisting medical conditions
  • Medications (including eye drops)
  • Medication allergies
  • Tetanus status
  • Time of last meal

Symptoms may include the following:

  • Pain
    • Pain may be difficult to assess in patients with obtundation or distracting injuries.
    • Pain may not be severe initially in sharp injuries, with or without intraocular foreign body.
  • Both preinjury and postinjury vision
  • Diplopia
    • If present, diplopia is usually due to entrapment and dysfunction of extraocular muscles with associated orbital floor blowout fractures.
    • Diplopia may be due to traumatic cranial nerve palsy from associated head injury.
    • Monocular diplopia may be due to associated lens dislocation or subluxation.
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Physical

Physical examination

The diagnosis of globe rupture is sometimes obvious. The eye can be misshapen with uveal tissue prolapsing out of an anterior scleral or corneal wound. Sometimes, an identifiable foreign body is still in the eye when the patient arrives to the ED.

Globe rupture is more often occult on presentation. The most frequent sites of rupture are not easily visualized, and more superficial injuries may block examination of the posterior segment. Very small sharp foreign bodies can enter the eye through small wounds that are difficult to visualize.

Examination of the injured eye should proceed systematically with the goal of identifying and protecting a ruptured globe.

It is critical to avoid putting pressure on a ruptured globe to prevent any potential extrusion of intraocular contents and to avoid further damage.

In young children where the extent of intraocular injury cannot be assessed because of poor cooperation, the examination can be performed under conscious sedation with support from an ophthalmologist.

Visual acuity and eye movement

Visual acuity should be assessed in both the injured and uninjured eye. It may be limited to "counts fingers at 18 inches" or "light perception only”.

Extraocular movement should be evaluated to rule out entrapment from an associated orbital floor fracture.

Orbits

Orbits should be examined for bony deformity, foreign body, and globe displacement.

Orbital rim fractures may be palpable and raise suspicion for entrapment and possible associated globe rupture.

Orbital crepitus indicates subcutaneous emphysema from an associated sinus fracture.

Orbital foreign bodies that may have impaled or perforated the globe should be left undisturbed until surgery.

A ruptured globe may present with enophthalmos (recession of the globe within the orbit).

An associated retrobulbar hemorrhage may cause exophthalmos, even with an occult scleral rupture.

Eyelid

Eyelid and lacrimal injuries should be evaluated with the major goal of identifying and protecting possible deep injuries to the globe.

Even small lid lacerations may conceal vision-threatening globe perforations.

Lid repairs should not proceed until globe injury is ruled out.

Conjunctiva

Conjunctival lacerations may overlie more serious scleral injuries.

Severe conjunctival hemorrhage (often covering 360 degrees of bulbar conjunctiva) may indicate globe rupture.

Cornea and sclera

A full-thickness laceration to the cornea or sclera constitutes an open globe perforation, and it should be repaired in the operating room.

Prolapse of the iris through a full-thickness corneal laceration may be visible as a dark discoloration at the site of injury.

Scleral buckling is indicative of rupture with extrusion of ocular contents.

Intraocular pressure will likely be low, but measurement is contraindicated to avoid pressure on the globe.

More subtle or partially self-sealing corneal wounds may require use of fluorescein dye, typically completed by a consulting ophthalmologist. In a full-thickness laceration with aqueous flowing from the anterior chamber, a clear stream of fluid parting the yellow fluorescein dye is noted on illumination with a Wood's lamp (positive Seidel test).[1]

Pupils

Pupils should be examined for shape, size, light reflex, and afferent pupillary defect (APD).

A peaked, teardrop-shaped, or otherwise irregular pupil may indicate globe rupture.

Anterior chamber

Slit lamp examination in the cooperative patient may show associated injuries such as iris transillumination defect (red reflex obscured by vitreous hemorrhage); corneal lacerations; iris prolapse; hyphema from ciliary body disruption; and lens injuries, including dislocation or subluxation.

A shallow anterior chamber may be the only sign of occult globe rupture and is associated with a worse prognosis. A posterior rupture may present with a deeper anterior chamber due to extrusion of vitreous from the posterior segment.

Other findings

Vitreous hemorrhage after trauma suggests retinal or choroidal tear, optic nerve avulsion, or foreign body.

Retinal tears, edema, detachments, and hemorrhage may accompany globe rupture.

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Causes

Globe rupture in adults may occur after blunt injury during motor vehicle accidents, sports activity, assault, or other trauma.

Globe penetration or perforation may occur with gunshot and stab wounds, workplace accidents, and other accidents involving sharps or projectiles.

Be particularly suspicious of eye injuries caused by metal striking metal (eg, hammer and chisel).

One third of eye injuries occurring in children and adolescents (< 16 y) are sports related.[7] Basketball, water sports, baseball, racquet sports, martial arts, wrestling, and archery are frequently implicated.

BB and pellet guns present an extreme hazard to all age groups.

Eye injuries from paintball weapons are becoming increasingly reported, with globe rupture occurring in 5% of injuries.[8]

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Contributor Information and Disclosures
Author

John R Acerra, MD Assistant Professor, Department of Emergency Medicine, Hofstra North Shore-LIJ School of Medicine; Director, International Emergency Medicine Fellowship, North Shore-LIJ Health System

John R Acerra, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Derek J Golden, MD Attending Physician, Department of Emergency Medicine, West Hills Hospital and Medical Center

Derek J Golden, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Douglas Lavenburg, MD Clinical Professor, Department of Emergency Medicine, Christiana Care Health Systems

Douglas Lavenburg, MD is a member of the following medical societies: American Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Edward A Michelson, MD Associate Professor, Program Director, Department of Emergency Medicine, University Hospital Health Systems of Cleveland

Edward A Michelson, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Joe Robson, MD, Amy J Behrman, MD, and Stephanie Abbuhl, MD, to the development and writing of this article.

References
  1. Sharma R, Brunette DD. Ophthalmology. Marx, ed. Rosen's Emergency Medicine. 7th ed. 2009. Vol 2: Chap 69.

  2. Olitsky S, Hug D, Smith L. Injuries to the eye. Kliegman R, ed. Nelson Textbook of Pediatrics. 18th ed. 2007. Chap 634.

  3. Bord SP, Linden J. Trauma to the globe and orbit. Emerg Med Clin North Am. 2008 Feb. 26(1):97-123, vi-vii. [Medline].

  4. Rubasmen PE. Posterior segment ocular trauma. Yanoff M, Duker J, eds. Ophthalmology. 3rd ed. 2008. 6.42.

  5. Esmaeli B, Elner SG, Schork MA, Elner VM. Visual outcome and ocular survival after penetrating trauma. A clinicopathologic study. Ophthalmology. 1995 Mar. 102(3):393-400. [Medline].

  6. Koo L, Kapadia MK, Singh RP, Sheridan R, Hatton MP. Gender differences in etiology and outcome of open globe injuries. J Trauma. 2005 Jul. 59(1):175-8. [Medline].

  7. Rodriguez JO, Lavina AM, Agarwal A. Prevention and treatment of common eye injuries in sports. Am Fam Physician. 2003 Apr 1. 67(7):1481-8. [Medline].

  8. Listman DA. Paintball injuries in children: more than meets the eye. Pediatrics. 2004 Jan. 113(1 Pt 1):e15-8. [Medline].

  9. Harlan JB Jr, Pieramici DJ. Evaluation of patients with ocular trauma. Ophthalmol Clin North Am. 2002 Jun. 15(2):153-61. [Medline].

  10. Arey ML, Mootha VV, Whittemore AR, Chason DP, Blomquist PH. Computed tomography in the diagnosis of occult open-globe injuries. Ophthalmology. 2007 Aug. 114(8):1448-52. [Medline].

  11. Hoffstetter P, Schreyer AG, Schreyer CI, et al. Multidetector CT (MD-CT) in the Diagnosis of Uncertain Open Globe Injuries. Rofo. 2009 Oct 26. [Medline].

  12. Essex RW, Yi Q, Charles PG, Allen PJ. Post-traumatic endophthalmitis. Ophthalmology. 2004 Nov. 111(11):2015-22. [Medline].

  13. Lee CH, Lee L, Kao LY, Lin KK, Yang ML. Prognostic indicators of open globe injuries in children. Am J Emerg Med. 2009 Jun. 27(5):530-5. [Medline].

  14. Vachon CA, Warner DO, Bacon DR. Succinylcholine and the open globe. Tracing the teaching. Anesthesiology. 2003 Jul. 99(1):220-3. [Medline].

  15. Libonati MM, Leahy JJ, Ellison N. The use of succinylcholine in open eye surgery. Anesthesiology. May 1985. 62:637-639. [Medline].

  16. Augsburger J, Asbury T. Ocular & orbital trauma. Rioodan-Eva P, Whitcher JP, eds. Vaughan & Asbury's General Ophthalmology. 17th ed. 2007. Chap 19.

  17. Khaw PT, Shah P, Elkington AR. Injury to the eye. BMJ. 2004 Jan 3. 328(7430):36-8. [Medline]. [Full Text].

  18. Yuan WH, Hsu HC, Cheng HC, Guo WY, Teng MM, Chen SJ, et al. CT of globe rupture: analysis and frequency of findings. AJR Am J Roentgenol. 2014 May. 202 (5):1100-7. [Medline].

 
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Operating microscope view of a globe rupture secondary to blunt trauma by a fist. Notice the dark arc in the bottom of the photo representing the ciliary body visible through the scleral breach. Subconjunctival hemorrhage of this severity should raise suspicion of occult globe rupture. Photo courtesy of Brian C Mulrooney, MD.
 
 
 
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