Globe Rupture Clinical Presentation

The clinical history is important, and details regarding the circumstance and mechanism of injury should be obtained with the following in mind:

• Before focusing on the eye injury, is there an associated extraocular injury (eg, subdural hemorrhage secondary to fall)?
• What was the patient doing at the time of injury (eg, hammering metal)?
• Is this activity more likely to cause a blunt, penetrating, and perforating injury? In men, projectile injuries are the most frequent cause of globe injuries and are often work-related or occur during home improvement projects. ^[8] Women are more likely to suffer blunt globe injury from falls or motor vehicle accidents.
• What type of object is likely to have struck the globe?
• Is it possible that there is an intraocular foreign body? Assume this to be true if a high-speed projectile was involved.
• When did the injury occur?
• Where did the injury occur (eg, home, construction site)?
• What is the patient's baseline visual acuity? Severe myopia increases the risk of injury from anterior-posterior compression.
• Does the patient use corrective lenses or contacts? If so, have contacts been removed?
• If caused by a motor vehicle accident, was a seatbelt used and did airbags deploy?

Medical history may include the following:

• Prior history of ocular surgery (prior cataract extraction increases the risk of an occult cataract wound rupture)

• Preexisting medical conditions

• Medications (including eye drops)

• Medication allergies

• Tetanus status

• Time of last meal

Symptoms may include the following:

• Pain

  • Pain may be difficult to assess in patients with obtundation or distracting injuries.

  • Patients with penetrating injuries may not experience severe pain initially, even if there is an intraocular foreign body.

• Loss of vision or blurred 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 examination

The diagnosis of globe rupture may be obvious, although this is not the most common presentation. 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.

More often, the diagnosis of globe rupture is not immediately apparent. The most frequent sites of rupture are not easily visualized, and more superficial injuries may block examination of the posterior segment. In cases of blunt trauma, swelling of the face and lids may complicate visualization of the eye. Penetrating injuries from very small sharp objects may create tiny 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 extrusion of intraocular contents and further ocular injury.

In young children where the extent of intraocular injury cannot be assessed because of poor cooperation, sedation and support from an ophthalmologist may be necessary to ensure a complete and accurate examination.

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. 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). ^[2]

Pupils

Pupils should be examined for shape, size, light reflex, and afferent pupillary defect (APD).

A peaked, teardrop-shaped, or otherwise irregular pupil suggests 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.

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 any accident involving sharp objects or projectiles.

Be particularly suspicious of eye injuries caused by metal striking metal (eg, hammer and chisel), as well as high-speed grinding or cutting involving metal or stone.

One third of eye injuries occurring in children and adolescents (< 16 y) are sports related. ^[10] Basketball, water sports, baseball, racquet sports, martial arts, wrestling, and archery are frequently implicated.

Eye injures associated with the sudden release of a tense bungee cord are increasingly in frequency.

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. ^[11]

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.