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

• For excellent patient education resources, visit eMedicine's Eye and Vision Center. Also, see eMedicine's patient education article Subconjunctival Hemorrhage (Bleeding in Eye).

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.

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