eMedicine Specialties > Emergency Medicine > Ophthalmology

Globe Rupture: Follow-up

Author: Joe Robson, MD, Consulting Staff, Emergency Service Partners, Department of Emergency Medicine, Palestine Regional Medical Center, Guadalupe Regional Medical Center, St Joseph Medical Center, Cedar Park Regional Medical Center
Coauthor(s): Amy J Behrman, MD, Associate Professor, Department of Emergency Medicine, Director, Division of Occupational Medicine, University of Pennsylvania School of Medicine; Stephanie Abbuhl, MD, Vice Chair, Associate Professor, Department of Emergency Medicine, University of Pennsylvania School of Medicine; Attending Physician in Emergency Services, Hospital of the University of Pennsylvania
Contributor Information and Disclosures

Updated: Jul 16, 2009

Follow-up

Further Inpatient Care

  • Further care is at the discretion of the consulting ophthalmologist.

Transfer

  • Transfer may be necessary if the patient presents to an institution without ophthalmology consultation services or without the ability to provide the definitive surgical repair.

Deterrence/Prevention

  • Proper protective eyewear is the mainstay of prevention of ocular injury.
  • Industrial sites are mandated to provide at-risk employees with protective eyewear.
  • Physicians should encourage their patients to use eye shields when using lawn-care, woodworking, or metalworking equipment.

Complications

  • After globe rupture, delayed postoperative or exogenous endophthalmitis, and infection involving the deep structures of the eye, are always potential complications.
  • Depending on the organism involved, endophthalmitis may present within hours of the globe rupture or, as with fungal organisms, the infection may not appear until weeks later.
  • Sympathetic ophthalmia is an inflammation that can develop in the uninjured eye weeks to months after the initial injury. Thought to be an autoimmune response to normally isolated tissues of the uvea that are exposed with injury, the condition and its symptoms of pain, decreased visual acuity, and photophobia, may improve after enucleation of the injured eye. Treatment may also include immunosuppressive agents, including steroids.

Prognosis

  • The prognosis depends largely on the extent of injury and the time from injury until appropriate surgical treatment.
    • In a study by Lee et al, the charts of 62 patients aged 16 years and younger who had been treated for open globe injuries were reviewed.3 In addition to location and extent of injury, unfavorable outcomes were also related to the initial presentation of hyphema, vitreous hemorrhage, retina detachment, cornea wound across the pupil, and endophthalmitis.
    • In a retrospective review, Unver et al sought to determine the value of calculating an ocular trauma score (OTS) in patients with open-globe injuries. OTS variables included visual acuity, rupture, endophthalmitis, perforating injury, retinal detachment, and afferent pupillary defect, and OTS was calculated in 114 eyes of 114 patients at time of initial presentation. In this study, presenting and final visual acuity were grouped into categories, assigned numerical values, and OTS variables were converted into OTS category. No statistically significant difference was found in final visual acuity between the results of this study and the OTS study group. Unver et al concluded that an ocular trauma score can provide reliable prognostic information for open-globe injuries.4  
  • The prognosis should be guarded until after surgery.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to diagnose and operate urgently worsens an already grim prognosis for preservation of visual acuity.
  • Endophthalmitis is a frequently devastating complication. Systemic antibiotics are indicated prophylactically.
  • Exploration and repair of more obvious, but less serious, injuries may cause further damage to the globe and worsen outcome.
  • An obvious globe rupture may present with other life-threatening injuries that could be overlooked.
  • Use of succinylcholine
    • The patient with globe rupture may present with other major injuries that necessitate endotracheal intubation.
    • Classic teaching warns that the use of succinylcholine as a paralytic agent in the setting of an open globe injury carries a theoretical risk of extrusion of the ocular contents through a rise in intraocular pressure and spasm of the rectus muscles. Some current anesthesia and ophthalmology texts continue to classify succinylcholine as "contraindicated" in the presence of an open globe injury for this reason, despite a lack of evidence in the literature.
    • The phenomenon of extrusion of ocular contents after administration of succinylcholine in the setting of open globe injury is not well documented in the literature and seems to be limited to anecdotal evidence. Anesthesia induction using succinylcholine has been performed routinely at some eye centers without evidence of ocular extrusion.
    • Some studies suggest that pretreatment with a nondepolarizing agent prior to the administration of succinylcholine eliminates this theoretical risk. In one study with 100 patients with penetrating eye injuries, no adverse events were reported.
    • Although the use of succinylcholine in the setting of open globe injury remains controversial, the need for this agent as a valuable adjunct to airway management should be weighed against the theoretical risk of ocular extrusion. Refer to local practice guidelines at one's institution.
 


More on Globe Rupture

Overview: Globe Rupture
Differential Diagnoses & Workup: Globe Rupture
Treatment & Medication: Globe Rupture
Follow-up: Globe Rupture
Multimedia: Globe Rupture
References

References

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

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

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

  4. [Best Evidence] Unver YB, Kapran Z, Acar N, Altan T. Ocular trauma score in open-globe injuries. J Trauma. Apr 2009;66(4):1030-2. [Medline].

  5. Brunette DD. Ophthalmology. In: Rosen's Emergency Medicine. Vol 2. 2002:908-927.

  6. Catalano R. Ocular Emergencies. Philadelphia: WB Saunders;1992.

  7. Friedberg MA, Rapuano CJ. Office and Emergency Room Diagnosis and Treatment of Eye Disease. Philadelphia, Pa: JB Lippincott; 1990.

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

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

  10. Kunimoto DY, Kanitar KD, Maker MS. The Wills Eye Manual. 4th ed. 2004.

  11. Linden JA, Renner GS, Scott. Trauma to the Globe. In: Emergency Medical Clinics of North America: Emergency Treatment of the Eye. Philadelphia: WB Saunders;1995.

  12. Mader TH, Carroll RD, Slade CS, George RK, Ritchey JP, Neville SP. Ocular war injuries of the Iraqi Insurgency,January-September 2004. Ophthalmology. Jan 2006;113(1):97-104. [Medline].

  13. Nelson LB. Injuries to the eye. In: Nelson Textbook of Pediatrics. Philadelphia, Pa: WB Saunders; 1996.

  14. Poon A, McCluskey PJ, Hill DA. Eye injuries in patients with major trauma. J Trauma. Mar 1999;46(3):494-9. [Medline].

  15. Sanford JP, Eliopoulos GM, Moellering RC. The Sanford Guide to Antimicrobial Therapy. Antimicrobial Therapy Inc; 2005.

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

Further Reading

Keywords

globe rupture, ocular trauma, vision loss, scleral rupture, open-globe injuries, open globe injuries, penetrating orbital traumas, blunt orbital traumas, eye injuries, penetrating eye injury, perforating eye injuries, foreign body in the eye

Contributor Information and Disclosures

Author

Joe Robson, MD, Consulting Staff, Emergency Service Partners, Department of Emergency Medicine, Palestine Regional Medical Center, Guadalupe Regional Medical Center, St Joseph Medical Center, Cedar Park Regional Medical Center
Joe Robson, MD is a member of the following medical societies: American Medical Association, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Amy J Behrman, MD, Associate Professor, Department of Emergency Medicine, Director, Division of Occupational Medicine, University of Pennsylvania School of Medicine
Amy J Behrman, MD is a member of the following medical societies: American College of Occupational and Environmental Medicine
Disclosure: Nothing to disclose.

Stephanie Abbuhl, MD, Vice Chair, Associate Professor, Department of Emergency Medicine, University of Pennsylvania School of Medicine; Attending Physician in Emergency Services, Hospital of the University of Pennsylvania
Stephanie Abbuhl, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Edward A Michelson, MD, Program Director, Associate Professor, Department of Emergency Medicine, University Hospital Health Systems in Cleveland
Edward A Michelson, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier Medical Center
Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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