Globe Rupture Workup

  • Author: Derek J Golden, MD; Chief Editor: Steven C Dronen, MD, FAAEM   more...
 
Updated: Feb 18, 2010
 

Laboratory Studies

  • Coagulation studies and complete blood count are appropriate in patients who are likely to have underlying bleeding diatheses.
  • Otherwise, laboratory studies are indicated as appropriate for coexisting trauma and other active medical problems.
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Imaging Studies

  • Computerized tomography
    • CT scanning of the eye is the preferred modality for further assessment of occult open globe injuries.[9] CT is the most sensitive readily available imaging study to detect occult rupture, associated optic nerve injury, and small foreign bodies, as well as to visualize the anatomy of the globe and orbit.
    • Axial and coronal views of the brain and orbits without contrast utilizing 1-2 mm cuts should be obtained.
    • Some nonmetallic foreign bodies, such as wood, glass, or plastic, may be difficult to visualize acutely on CT.
    • The sensitivity and specificity of ocular CT in determining occult open globe injury varies. Sensitivities ranging from 56-68% and 70%, and specificities of 70-100% and 98% have been reported in recent studies,[10, 11] illustrating the need for surgical exploration for definitive diagnosis and management.
  • Radiography
    • Orbital plain films of the orbits and sinuses are rarely used for diagnosis in orbital trauma.
    • A 3-view plain film series is most useful in evaluating the bony orbits and the sinuses and in identifying radiopaque foreign bodies.
    • Waters projection provides the best view of the orbital floor and detects air-fluid levels in the maxillary sinuses.
    • Caldwell or anteroposterior view visualizes the medial orbital wall, the lateral and superior orbital rims, as well as the ethmoid and frontal sinuses.
    • The third projection, or lateral view, is most useful in visualizing the orbital roof, maxillary and frontal sinuses, zygoma, and sella turcica.
  • MRI
    • MRI is of limited usefulness in the acute stages of ocular trauma and is contraindicated if any concern exists for metallic intraocular foreign body.
    • MRI is excellent in identifying injuries of the soft tissues of the globe and orbit and can be particularly helpful in localizing an organic foreign body, such as wood, that appears similar to soft tissue or air on CT scan.
  • Ultrasonography
    • Ocular ultrasonography by an emergency physician is contraindicated if there is a high suspicion for globe rupture.
    • Ultrasonography can be used to evaluate noninvasively for lens dislocation, retrobulbar hemorrhage, retinal detachment, and intraocular foreign body. Visualization of periorbital gas may also prompt an ED physician to search for orbital fracture.
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Other Tests

  • Life- or limb-threatening injuries should be addressed initially.
  • Consider injuries to head, spinal cord, and facial bones.
  • Complete the standard trauma evaluation.
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Procedures

  • Procedures such as repair of eyelid or conjunctival laceration are deferred until globe rupture is ruled out.
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Contributor Information and Disclosures
Author

Derek J Golden, MD  Resident Physician, Department of Emergency Medicine, North Shore University Hospital

Derek J Golden, MD is a member of the following medical societies: American College of Emergency Physicians and American Medical Association

Disclosure: Nothing to disclose.

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

John R Acerra, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

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.

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.

References

  1. Sharma R, Brunette DD. Ophthalmology. In: Marx, ed. Rosen's Emergency Medicine. Vol 2. 7th ed. 2009:Chap 69.

  2. Olitsky S, Hug D, Smith L. Injuries to the eye. In: Kliegman R, ed. Nelson Textbook of Pediatrics. 18th ed. 2007:Chap 634.

  3. Bord SP, Linden J. Trauma to the globe and orbit. Emerg Med Clin North Am. Feb 2008;26(1):97-123, vi-vii. [Medline].

  4. Rubasmen PE. Posterior segment ocular trauma. In: Yanoff M, Duker J, eds. Ophthalmology. 3rd ed. 2008:6.42.

  5. Esmaeli B, Elner SG, Schork MA, Elner VM. Visual outcome and ocular survival after penetrating trauma. A clinicopathologic study. Ophthalmology. Mar 1995;102(3):393-400. [Medline].

  6. Koo L, Kapadia MK, Singh RP, Sheridan R, Hatton MP. Gender differences in etiology and outcome of open globe injuries. J Trauma. Jul 2005;59(1):175-8. [Medline].

  7. 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].

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

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

  10. Arey ML, Mootha VV, Whittemore AR, Chason DP, Blomquist PH. Computed tomography in the diagnosis of occult open-globe injuries. Ophthalmology. Aug 2007;114(8):1448-52. [Medline].

  11. Hoffstetter P, Schreyer AG, Schreyer CI, et al. Multidetector CT (MD-CT) in the Diagnosis of Uncertain Open Globe Injuries. Rofo. Oct 26 2009;[Medline].

  12. Essex RW, Yi Q, Charles PG, Allen PJ. Post-traumatic endophthalmitis. Ophthalmology. Nov 2004;111(11):2015-22. [Medline].

  13. 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].

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

  15. Libonati MM, Leahy JJ, Ellison N. The use of succinylcholine in open eye surgery. Anesthesiology. May 1985;62:637-639. [Medline].

  16. Augsburger J, Asbury T. Ocular & orbital trauma. In: Rioodan-Eva P, Whitcher JP, eds. Vaughan & Asbury's General Ophthalmology. 17th ed. 2007:Chap 19.

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

 
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Operating microscope view of a globe rupture secondary to blunt trauma by a fist. Notice the dark arc in the bottom of the photo representing the ciliary body visible through the scleral breach. Subconjunctival hemorrhage of this severity should raise suspicion of occult globe rupture. Photo courtesy of Brian C Mulrooney, MD.
 
 
 
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