eMedicine Specialties > Emergency Medicine > Ophthalmology

Globe Rupture

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: Feb 16, 2007

Introduction

Background

Globe rupture occurs when the integrity of the outer membranes of the eye is disrupted by blunt or penetrating trauma. Any full-thickness injury to the cornea, sclera, or both is considered an open globe injury and is approached in the same fashion in the acute setting. Globe rupture represents a major ophthalmologic emergency and always requires surgical intervention. Although the globe's position within the orbit protects it from injury in many situations, damage to the posterior segment of the eye is associated with a very high frequency of permanent visual loss. Early recognition and ophthalmologic intervention are critical to maximizing functional outcome.

Pathophysiology

Globe rupture may occur when a blunt object impacts the orbit, causing anterior-posterior compression of the globe and raising intraocular pressure to a point that the sclera tears. Ruptures from blunt trauma usually occur at the sites where the sclera is thinnest, at the insertions of the extraocular muscles, at the limbus, and around the optic nerve. Sharp objects or those traveling at high velocity may perforate the globe directly. Small foreign bodies may penetrate the eye and remain within the globe. The possibility of globe rupture should be considered and ruled out during the evaluation of all blunt and penetrating orbital traumas as well as in all cases involving high-speed projectiles with potential for ocular penetration.

Frequency

United States

More than 2 million eye injuries occur in the United States annually, with more than 40,000 resulting in some degree of permanent visual impairment. One third of all cases of childhood blindness result from ocular trauma.

Mortality/Morbidity

• Globe rupture and posterior segment injury have always been associated with a high frequency of visual loss, but recent advances in microsurgical techniques have greatly improved the prognosis for some patients.
• Generally, blunt injuries have a somewhat better visual outcome than penetrating or perforating injuries.
• Patients should not be given a hopeful prognosis until full, usually operative, evaluation is complete. At presentation, reduced or absent vision, anterior chamber deformity, pupillary irregularity, chemosis, hyphema, vitreous hemorrhage, and decreased intraocular pressure worsen the prognosis.

Race

• No racial predilection exists.

Sex

• Because of occupational and recreational preferences, globe rupture is more common in males than in females.

Age

• Globe rupture is more common in younger patients, with most cases occurring in those younger than 40 years.
• A high percentage of occurrences are in adolescent boys.

Clinical

History

• Mechanism of injury
  • Blunt, penetrating, or perforating
  • Nature of object suspected
  • Assess the likelihood of foreign bodies within the globe and/or orbit.
  • Eye injuries occurring at construction or metalworking sites should be assumed to include metallic intraorbital foreign body until ruled out.
  • Organic foreign bodies, such as wood, carry a particularly high infection rate.
  • Bite and scratch wounds carry a high risk for infection with common and species-specific agents.
• Circumstances of injury
  • Exact time of the injury
  • Location where injury occurred
  • Use of corrective or protective lenses
  • Eyewear may protect or contribute to harm in acute injury.
  • Severely myopic eyes may be more vulnerable to injury from anterior-posterior compression.
  • Use of seat belt or airbag deployment in motor vehicle crash
• Medical history
  • Ocular history
    • Previous eye surgery or injury - Tissues may be more susceptible to rupture.
    • Preinjury vision in both eyes
  • Preexisting diseases
  • Medications (including eye drops) and allergies
  • Tetanus status
• Symptoms
  • 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.
  • Vision - Usually greatly decreased
  • 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.

Physical

• Physical examination
  • Globe rupture may be immediately apparent on examination but is frequently occult, as the most frequent sites of rupture are not easily visualized and more superficial injuries may block examination of the posterior segment.
  • Examination of the injured eye should proceed systematically but always with the goal of identifying and protecting a ruptured globe.
  • It is critical to avoid putting pressure on a ruptured globe to minimize potential extrusion of intraocular contents and to avoid further damage.
• Visual acuity and eye movement
  • Visual acuity should be documented as accurately as possible for the injured and uninjured eye, even if it is 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. Often, those with scleral ruptures beneath a rectus muscle avoid gazing in the field of action of that muscle.
• 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 a 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.
• 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.

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 years) are sports related.
• 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.

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