eMedicine Specialties > Emergency Medicine > Ophthalmology

Globe Rupture

Author: Derek J Golden, MD, Resident Physician, Department of Emergency Medicine, North Shore University Hospital
Coauthor(s): John R Acerra, MD, Assistant Professor, Department of Emergency Medicine, Albert Einstein College of Medicine; Associate Director, International Emergency Medicine Fellowship, North Shore - LIJ Health System
Contributor Information and Disclosures

Updated: Feb 18, 2010

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 manner in the acute setting. Globe rupture is an ophthalmologic emergency and requires definitive management by an ophthalmologist. 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. Prompt recognition and ophthalmologic intervention are essential to maximizing functional outcome.

Globe rupture secondary to trauma is shown in the image below.

Pathophysiology

Globe rupture may occur when a blunt object impacts the orbit, compressing the globe along the anterior-posterior axis causing an elevation in intraocular pressure to a point that the sclera tears. Ruptures from blunt trauma are most common at the sites where the sclera is thinnest, at the insertions of the extraocular muscles, at the limbus, and at the site of previous intraocular surgery.^1,2 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. Trauma to the eye represents approximately 3% of all ED visits in the United States.³ 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. With modern diagnostic techniques, surgical approaches, and rehabilitation, many eyes can be salvaged with retention of vision.⁴
• Patients should not be given a hopeful prognosis until full, usually operative, evaluation is complete. Predictors of poor final visual acuity after penetrating ocular trauma are initial visual acuity of only light perception or no light perception, wounds extending posterior to rectus muscle insertion plane, wound length greater than 10 mm, and blunt or missile injury.⁵

Race

• No racial predilection exists for globe rupture.

Sex

• Because of occupational and recreational preferences, most globe rupture injuries are found in men (78.6%).⁶ Men are more likely to experience penetrating injuries (69.9%), whereas women present more often with blunt globe rupture (68.1%).⁶

Age

• Globe rupture typically occurs at a younger age in men (median age, 36 y) than in women (median age, 73 y).⁶
• A high percentage of globe rupture occurrences are in adolescent boys.

Clinical

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 
  • 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 
  • 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.

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.

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

• Search for CME/CE on This Topic »

• Bedside Ultrasonography, Ocular Evaluation (Clinical Procedures)

• Subconjunctival Hemorrhage Overview
• Subconjunctival Hemorrhage Causes
• Subconjunctival Hemorrhage Treatment
• Eye and Vision Center
• Subconjunctival Hemorrhage Symptoms