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
A Fox eye shield or other rigid device (bottom of a polystyrene foam cup) should be placed over the affected eye. Avoid any eye manipulation that may increase intraocular pressure with potential extrusion of intraocular contents.
Administer antiemetics (eg, ondansetron) to prevent Valsalva maneuvers.
Administer sedation and analgesics as needed.
Avoid any topical eye solutions (eg, fluorescein, tetracaine, cycloplegics) in cases of known globe perforation or rupture.
Administer prophylactic antibiotics. Although the goal is to prevent endophthalmitis or an internal eye infection, parenterally administered antibiotics penetrate the globe poorly. The frequency of endophthalmitis after open globe injury has been estimated to be about 6.8%. [15] Skin organisms, such as Streptococcus species, Staphylococcus aureus, and Staphylococcus epidermidis are most frequently involved. Consequently, intravenous third-generation cephalosporins and vancomycin have been recommended in high-risk cases. 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. An open globe laceration is considered a tetanus prone wound.
Ensure the patient is kept nothing by mouth (NPO).
Ensure definitive management by an ophthalmologist.
Surgical repair should be expedited.
The use of intraocular steroids is controversial. Ocular steroids should probably not be used if fungal infection is suspected. [6]
Consultations
Ophthalmologist: Suspected globe rupture mandates urgent ophthalmology consultation.
Prevention
Proper protective eyewear is the mainstay of prevention of ocular injury.
Industrial sites are mandated to provide at-risk employees with protective eyewear.
Physicians should encourage their patients to wear protective glasses or face shields when using lawn-care, woodworking, or metalworking equipment.
Further Inpatient Care
Further care of patients with globe rupture is at the discretion of the consulting ophthalmologist.
Transfer
Transfer is required if the patient presents to an institution without ophthalmology consultation services or without the ability to provide the definitive surgical repair.
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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.
