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Emergency And Acute Medicine - Globe Rupture
Basics Description
A globe rupture is a full-thickness injury of the cornea or sclera caused by trauma. Blunt trauma results in a sudden diffuse rise in intraocular pressure, leading to rupture at the weakest points of the eye such as the extraocular muscle insertions, corneoscleral junction, or limbus where the sclera is thinnest. Penetrating injuries occur when sharp objects or projectiles directly lacerate the sclera or anterior eye and are most commonly anterior due to protection from the bony orbit. Posterior injuries may occur with orbital fractures or penetrating trauma through the eyelid or eyebrow. Prognosis is worse with large lacerations, injuries posterior to rectus muscle insertions, blunt mechanisms, intraocular foreign bodies (especially organic), vitreous extrusion, lens damage, hyphema, retinal detachment, poor initial visual acuity, afferent pupillary defect, and delays to operative repair.
Etiology
Common causes include falls, blunt impact injuries, sports-related trauma, indirect concussive injuries such as explosions, sharp or stabbing injuries (accidental or intentional), and projectile injuries from industrial accidents, firearms, BB pellets, or blast-related shrapnel such as glass.
Diagnosis Signs And Symptoms
Patients may present with eye pain, localized swelling and ecchymosis, scleral or corneal laceration, extrusion of intraocular contents, markedly decreased visual acuity, restricted extraocular movements, hyphema, severe circumferential subconjunctival hemorrhage with bloody chemosis, abnormally deep or shallow anterior chamber, irregular pupil pointing toward the lesion, lens subluxation, commotio retinae, and low intraocular pressure. Tonometry should not be performed if globe rupture is suspected.
History
Assessment should include the mechanism of injury, concern for retained intraocular foreign body, prior eye surgery, preinjury visual acuity, tetanus status, and time of last oral intake.
Physical Exam
A careful penlight or slit-lamp examination should be performed to look for signs of rupture. Once a globe rupture is suspected or identified, further ocular examination should be deferred until surgical repair to avoid pressure on the eye and extrusion of contents. If rupture is excluded, a full ophthalmologic exam including visual acuity, slit-lamp evaluation, fundus exam, Seidel test, and intraocular pressure measurement may be performed. Ultrasound should only be used if rupture is not suspected.
Essential Workup
If globe rupture is suspected or confirmed, minimize examination and manipulation of the eye until operative repair.
Diagnosis Tests And Interpretation
Preoperative laboratory studies include CBC, electrolytes, and coagulation tests. Imaging may include orbital radiographs to identify metallic foreign bodies and CT of the orbits with axial and coronal views. MRI is contraindicated until metallic foreign bodies are excluded. B-scan ultrasound may be used only when rupture is not suspected.
Differential Diagnosis
Intraocular foreign body, hyphema, severe subconjunctival hemorrhage with chemosis, partial corneal laceration, and partial scleral laceration.
Treatment Pre Hospital
Place a rigid eye shield without applying pressure to the globe. If no shield is available, a protective cup may be used.
Initial Stabilization Therapy
Avoid manipulation of the eye and prevent activities that increase intraocular pressure such as coughing, vomiting, or straining.
Ed Treatment Procedures
Immediate ophthalmologic consultation is required for surgical management. Maintain NPO status, elevate the head of the bed, provide antiemetics, and apply a protective eye shield without pressure. Update tetanus immunization. Administer broad-spectrum IV antibiotics targeting skin flora and injury-specific contaminants, commonly vancomycin with ceftazidime or ciprofloxacin. Identify and manage associated injuries. Succinylcholine is relatively contraindicated but may be used with appropriate precautions if necessary for airway control.
In pediatric patients, consider nonaccidental trauma and minimize crying or agitation to prevent extrusion of ocular contents.
Medication
Commonly used agents include vancomycin, ceftazidime, ciprofloxacin, clindamycin, tobramycin, and antiemetics such as ondansetron or prochlorperazine.
Follow-Up Disposition
All patients with globe rupture or penetrating eye injury require admission. Discharge is appropriate only if globe penetration has been definitively excluded.
Issues For Referral
Emergent ophthalmologic consultation is essential, as delays increase the risk of infection and poor visual outcomes. Patients should be counseled on protective eyewear to prevent recurrence when appropriate.
Follow-Up Recommendations
Postoperative follow-up with ophthalmology is mandatory.
Key Clinical Insights And Avoidable Errors
Do not manipulate the eye when globe rupture is suspected or confirmed. Always place a protective eye shield without pressure. Treat nausea and vomiting aggressively to prevent increases in intraocular pressure. Ensure tetanus prophylaxis and initiate empiric antibiotics tailored to the injury mechanism promptly.
Basics Description
A globe rupture is a full-thickness injury of the cornea or sclera caused by trauma. Blunt trauma results in a sudden diffuse rise in intraocular pressure, leading to rupture at the weakest points of the eye such as the extraocular muscle insertions, corneoscleral junction, or limbus where the sclera is thinnest. Penetrating injuries occur when sharp objects or projectiles directly lacerate the sclera or anterior eye and are most commonly anterior due to protection from the bony orbit. Posterior injuries may occur with orbital fractures or penetrating trauma through the eyelid or eyebrow. Prognosis is worse with large lacerations, injuries posterior to rectus muscle insertions, blunt mechanisms, intraocular foreign bodies (especially organic), vitreous extrusion, lens damage, hyphema, retinal detachment, poor initial visual acuity, afferent pupillary defect, and delays to operative repair.
Etiology
Common causes include falls, blunt impact injuries, sports-related trauma, indirect concussive injuries such as explosions, sharp or stabbing injuries (accidental or intentional), and projectile injuries from industrial accidents, firearms, BB pellets, or blast-related shrapnel such as glass.
Diagnosis Signs And Symptoms
Patients may present with eye pain, localized swelling and ecchymosis, scleral or corneal laceration, extrusion of intraocular contents, markedly decreased visual acuity, restricted extraocular movements, hyphema, severe circumferential subconjunctival hemorrhage with bloody chemosis, abnormally deep or shallow anterior chamber, irregular pupil pointing toward the lesion, lens subluxation, commotio retinae, and low intraocular pressure. Tonometry should not be performed if globe rupture is suspected.
History
Assessment should include the mechanism of injury, concern for retained intraocular foreign body, prior eye surgery, preinjury visual acuity, tetanus status, and time of last oral intake.
Physical Exam
A careful penlight or slit-lamp examination should be performed to look for signs of rupture. Once a globe rupture is suspected or identified, further ocular examination should be deferred until surgical repair to avoid pressure on the eye and extrusion of contents. If rupture is excluded, a full ophthalmologic exam including visual acuity, slit-lamp evaluation, fundus exam, Seidel test, and intraocular pressure measurement may be performed. Ultrasound should only be used if rupture is not suspected.
Essential Workup
If globe rupture is suspected or confirmed, minimize examination and manipulation of the eye until operative repair.
Diagnosis Tests And Interpretation
Preoperative laboratory studies include CBC, electrolytes, and coagulation tests. Imaging may include orbital radiographs to identify metallic foreign bodies and CT of the orbits with axial and coronal views. MRI is contraindicated until metallic foreign bodies are excluded. B-scan ultrasound may be used only when rupture is not suspected.
Differential Diagnosis
Intraocular foreign body, hyphema, severe subconjunctival hemorrhage with chemosis, partial corneal laceration, and partial scleral laceration.
Treatment Pre Hospital
Place a rigid eye shield without applying pressure to the globe. If no shield is available, a protective cup may be used.
Initial Stabilization Therapy
Avoid manipulation of the eye and prevent activities that increase intraocular pressure such as coughing, vomiting, or straining.
Ed Treatment Procedures
Immediate ophthalmologic consultation is required for surgical management. Maintain NPO status, elevate the head of the bed, provide antiemetics, and apply a protective eye shield without pressure. Update tetanus immunization. Administer broad-spectrum IV antibiotics targeting skin flora and injury-specific contaminants, commonly vancomycin with ceftazidime or ciprofloxacin. Identify and manage associated injuries. Succinylcholine is relatively contraindicated but may be used with appropriate precautions if necessary for airway control.
In pediatric patients, consider nonaccidental trauma and minimize crying or agitation to prevent extrusion of ocular contents.
Medication
Commonly used agents include vancomycin, ceftazidime, ciprofloxacin, clindamycin, tobramycin, and antiemetics such as ondansetron or prochlorperazine.
Follow-Up Disposition
All patients with globe rupture or penetrating eye injury require admission. Discharge is appropriate only if globe penetration has been definitively excluded.
Issues For Referral
Emergent ophthalmologic consultation is essential, as delays increase the risk of infection and poor visual outcomes. Patients should be counseled on protective eyewear to prevent recurrence when appropriate.
Follow-Up Recommendations
Postoperative follow-up with ophthalmology is mandatory.
Key Clinical Insights And Avoidable Errors
Do not manipulate the eye when globe rupture is suspected or confirmed. Always place a protective eye shield without pressure. Treat nausea and vomiting aggressively to prevent increases in intraocular pressure. Ensure tetanus prophylaxis and initiate empiric antibiotics tailored to the injury mechanism promptly.
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