Diagnosis: Traumatic Globe Rupture
Mechanical eye injuries can cause significant morbidity and visual impairment and therefore should be addressed promptly. Figure 1 (image credit) is a schematic diagram of how mechanical eye injuries are classified. Mechanical eye injury tends to occur more often in young males. These injuries tend to occur from accidents in the home but can also arise from workplace injuries, motor vehicle accidents, or assaults. Globe rupture can be caused by blunt trauma (i.e. mechanical fall, motor vehicle accidents) or a penetrating object (i.e. glass, bb pellets, wood shavings). When globe rupture is caused by a blunt trauma, it can lead to increased intraocular pressure and rupture at the weakest site. For patients with no history of ocular surgery, the weakest site is usually the posterior to the extraocular muscles, near the equatorial sclera, whereas for patients with prior ocular surgery, the weakest site is the incision site, such a corneal wound from prior cataract extraction. Ruptures can also occur at the limbus.
Evaluation and Management
Patients tend to present with severe eye pain and decreased vision. For history, it is important to elicit the cause of the injury, any progression of symptoms (due to concern for endophthalmitis), vaccination history (as a tetanus shot may be required), and the last time the patient had anything to eat or drink (in case surgery is needed). It is important to evaluate their visual acuity, pupil for any irregularities (i.e. peaking which can suggest the site of full thickness laceration) and examine the eye under slit lamp to look for any foreign bodies, corneal or scleral lacerations, breaks or tears in the iris, and quality and position of the lens. The eye should also be examined posteriorly. Orbital imaging should be obtained to rule out intraocular foreign body and other orbital injuries such as orbital fracture and retrobulbar hematoma.
Importantly, any treatment or management considerations should avoid any increases in intraocular pressure (i.e. avoid use of succinylcholine during surgery). Furthermore, any eye manipulation or attempt to remove the foreign body should be avoided until surgery. Assessment of intraocular pressure should be deferred. The eye should be protected using a rigid eye shield or cup.
If there is concern for open globe rupture, the Seidel test can be used which helps determine the site of injury through fluorescein staining.
The patient should immediately undergo surgical globe exploration and repair as soon as safely possible. Following surgery, the patient should be treated with topical and systemic antibiotics to decrease risk of endophthalmitis and other infections.
For visual prognosis, this often depends on the patient’s visual acuity at presentation and thus all patients should be educated about proper eye protection and safety. Ocular Trauma Score (OTS) and Classification and Regression Tree (CART) are prognostic scores that have been shown to have high accuracy in helping predict a patient’s visual prognosis following ocular trauma or globe injury. Patients should be urgently treated as globe ruptures can lead to permanent blindness and severe infection (i.e. endophthalmitis, sympathetic ophthalmia).
References and Additional Resources:
- Blair K, Alhadi SA, Czyz CN. Globe Rupture. [Updated 2022 Jan 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551637/
- Wang D, Deobhakta A. Open Globe Injury: Assessment and Preoperative Management. Jeng BH (Eds). American Academy of Ophthalmology EyeNet. August 2020. Available from https://www.aao.org/eyenet/article/open-globe-injur
- Stelton CR, Patel MR. Seidel Test. Syed ZA (Eds).American Academy of Ophthalmology: EyeWiki. January 2022. Available from https://eyewiki.aao.org/Seidel_Test
Case 6 Index