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Globe Rupture: Treatment & Medication

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

Treatment

Prehospital Care

• A suspected or obvious ruptured globe should be protected from any pressure or inadvertent contact with a rigid shield during transport.
• Impaled foreign bodies should be left undisturbed.
• Eye patches are contraindicated.

Emergency Department Care

• Avoid all pressure on or around the injured eye to prevent extrusion of intraocular contents. Continue to protect the eye with a rigid shield. If a shield is not available, the bottom of a Styrofoam cup works well.
• Administer antiemetics (eg, promethazine [Phenergan], prochlorperazine [Compazine]) to prevent Valsalva maneuvers.
• Administer analgesics as indicated.
• Administer prophylactic antibiotics, ideally within 6 hours of the injury, to prevent endophthalmitis. This potentially devastating complication occurs in about 5% of penetrating trauma cases and in as many as 10% of trauma cases from a foreign body. Skin organisms, such as Streptococcus species, Staphylococcus aureus, and Staphylococcus epidermidis are most frequently involved. Attention should be given to species-specific pathogens if injury is due to bites (ie, dysgonic fermenter type 2 [DF2] and Eikenella for dog bites; Pasteurella multocida for cat bites) or if organic material is likely to have been introduced (ie, gram-negative organisms or fungi in a farming injury).
• Document tetanus immune status and update as indicated.
• Ascertain what time was the last meal. The patient should be kept NPO.
• Consult an ophthalmologist, and admit the patient to the hospital on bedrest with bathroom privileges.
• Surgical repair should be expedited. If repair is impossible, enucleation usually is necessary, either initially or within the first 7-14 days after the trauma.
• Ocular steroids have no role in the acute setting of a ruptured globe.

Consultations

• Ophthalmologist
  • Consult an ophthalmologist immediately.
  • Avoid any further manipulation of the injured eye while protection with a rigid shield is maintained, pending evaluation by an ophthalmologist.

Medication

The goal of pharmacotherapy is to prevent infections and pathophysiologic complications.

Antibiotics

Prophylactic systemic antibiotics are indicated in all cases of globe rupture. The risk of posttraumatic endophthalmitis is greatest when a penetrating injury exists, particularly with a retained intraorbital foreign body. Skin flora are the most common organisms, but contamination with soil, farm or animal flora, human saliva, or nonsterile water may introduce gram-negative organisms, anaerobes, and fungi. A complete list of antibiotics and their spectrum of activity is beyond the scope of this article. An example regimen is listed:

For adults, give cefazolin 1 g IV q8h plus ciprofloxacin 400 mg IV q12h. Newer fluoroquinolones, gatifloxacin and moxifloxacin, may have better vitreous penetration and anaerobic activity.

For children <12 years, give cefazolin 25-50 mg/kg/d IV divided tid plus gentamicin 2 mg/kg IV q8h.

If surgery must be delayed for any reason or if foreign body and/or organic contamination are considered likely, antibiotics with better penetration of the vitreous should be used prophylactically.

The list below provides examples of potential antibiotic choices and is not an exhaustive discussion. The ultimate choice of antibiotics is based on the individual characteristics of the injury and the patient, the determination of the degree of risk for infection and the likely organisms involved, and a specific drug's intraocular penetration characteristics.

Cefazolin (Ancef, Kefzol, Zolicef)

First-generation semisynthetic cephalosporin that by binding to 1 or more penicillin-binding proteins arrests bacterial cell wall synthesis and inhibits bacterial replication. Poor capacity to cross blood-brain barrier. Primarily active against skin flora, including S aureus. Typically used alone for skin and skin-structure coverage. Regimens for IV and IM dosing are similar.

Ciprofloxacin (Cipro)

Provides excellent coverage against staphylococcal organisms and Pseudomonas, but it is not a good antibiotic for streptococci or anaerobes. Has excellent penetration of the eye in IV form. Anaerobic coverage can be achieved with addition of clindamycin, which also covers streptococci, except for enterococci.

Tobramycin (Nebcin)

Aminoglycoside used as an alternative for children allergic to penicillin or for breastfeeding or pregnant women. Add clindamycin if anaerobic contamination is likely.

Clindamycin (Cleocin)

Often added to ciprofloxacin or tobramycin for coverage of anaerobes and streptococci.

Imipenem-cilastatin (Primaxin)

A penicillin-type antibiotic with broad coverage of gram-positive, gram-negative (including Pseudomonas), and anaerobic infections. Imipenem penetrates the aqueous and vitreous humor in high concentrations even without the presence of active inflammation.

Gentamicin (Garamycin, Jenamicin)

Aminoglycoside antibiotic for gram-negative coverage bacteria including Pseudomonas species. Synergistic with beta-lactamase against enterococci. Interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits.
Dosing regimens are numerous and are adjusted based on CrCl and changes in volume of distribution, as well as body space into which agent needs to distribute. Dose of gentamicin may be given IV/IM. Each regimen must be followed by at least trough level drawn on third or fourth dose, 0.5 h before dosing; may draw peak level 0.5 h after 30-min infusion.

Vancomycin

May be used as an alternative to cefazolin for adults allergic to penicillin. Provides excellent gram-positive coverage, including Bacillus. To avoid toxicity, current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dose. Use creatinine clearance to adjust dose in patients with renal impairment.

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