An 88 y.o f arrives to the ED for an eye injury. She reports that she had a fall at home hitting her left eye directly on the bed post. She now complains of severe pain and swelling in her left eye. On physical examination, she has severe periorbital swelling and has a laceration likely involving the lacrimal punctum and duct. Direct visualization of the eye reveals:

Globe Injury

Open globe injuries can either be open globe ruptures, or open globe lacerations. Globe ruptures typically occur from blunt injury mechanisms as in the case presented. Open globe lacerations typically occur from penetrating injuries with sharp objects or even projectiles.

Injury can be classified by zone of injury:

Eye Anatomy Review:

History

When concerned about possible globe injury important questions to ask include:

• Mechanism of injury
• Time of injury 
• If possibility of foreign body or projectile, ask composition of foreign body
• History of eye surgeries
• Tetanus status

Physical exam

            If you have high suspicion of possible globe rupture avoid any procedure or examination that puts pressure on the eye. This is the most important take away for globe rupture. This includes eyelid retraction or intraocular pressure measurements. In likely globe rupture also avoid placing any medication or diagnostic drops into the eye (i.e. tetracaine, fluorescein). Leave any protruding foreign bodies in place. If on initial examination the anterior chamber is flat, then the patient has certain globe rupture and discontinue exam and protect the eye from any manipulation.

Physical exam findings in globe rupture or laceration:

• Afferent pupillary defect (swinging flashlight test)

• Abnormally shaped or teardrop pupil:

• Obvious change on anterior chamber depth (increase or decrease)
• Leaking vitreous fluid
• Positive sidel test (waterfall or teardrop appearance on fluorescein exam):

• Prolapse of iris, ciliary body, or choroid

• Sudden marked decrease in visual acuity
  • Should be checked in each eye. If pt is unable to read eye chart, you can use the ability to count fingers or detect hand motions. 

Management

• Emergent Ophthalmology consultation 
• Evaluate for other life-threatening trauma. 
• Avoid high dose ketamine (6mg/kg) or succinylcholine as these can increase intraocular pressures (controversial if clinically significant)
•  Eye shield, bed rest, NPO
• Pain medication with Antiemetic, as vomiting increases intraocular pressure
• Do not put anything in the eye, including fluorescein, tetracaine, or eye pressure measurements, as any eye pressure or manipulation can increase loss of vitreous fluid. 
• Many of these occur via blunt force and can be associated with blowout fractures, ocular muscle entrapment, orbital hemorrhage, or retrobulbular hematoma. CT of the eye without contrast is the imaging modality of choice and can also further characterize signs of globe rupture (intraocular FB, intraocular air, eye wall globe deformity, and volume loss). CT should not delay ophthalmology consultation
• Tetanus prophylaxis. 
• Empiric antibiotic therapy to prevent posttraumatic endophthalmitis as patients who develop this have poor outcomes. UptoDate recommends giving Vancomycin (15 mg/kg, maximum dose: 1.5 g) and ceftazidime (50 mg/kg: maximum dose 2 g)

Prognosis

• Depends upon:
  • Mechanism (blunt mechanism is worse)
  • time between injury and closure (goal <24 hrs)
  • Degree of initial injuries
  • Presence of FB
  • Development of endophthalmitis 
  • Initial visual acuity (better visual acuity has better outcome)

Take Home Points:

• Careful eye examination and clinical suspicion are needed to diagnose globe rupture. Many times this is a clinical rather than radiological diagnosis.
• If not obvious on exam, a Seidel sign can help diagnose open globe on fluorescein staining. 
• Avoid any manipulation of the globe once diagnosed – no IOP checks, do not manipulate eyelids, no eye drops, etc. 
• Emergently consult ophthalmology
• Place eye shield, elevate head of bed, prevent vomiting
• Update tetanus, give abx. 

Author:
Kara Finnegan, DO
Peer Reviewed and Edited By:
Timothy Stokes, MD