Eye (Globe) Rupture
An eye rupture is also known as a globe rupture. It happens when there is a disruption of the outer membranes of the eye because of a penetrating trauma or blunt trauma to the eye. Any injury that goes through the sclera or the cornea of the eye is considered to be an open glob injury and is treated as such in the emergency room or hospital. A globe rupture is a medical emergency needing management by a trained ophthalmologist. Damage to the posterior aspect of the eye means an injury to the retina, which can result in permanent loss of vision.
A globe rupture can happen when the eye is impacted by a blunt object, compressing the eye from front to back, increasing the intraocular pressure, rupturing the globe. The rupture usually happens in the whit part of the eye (the sclera) where the tissue is inserted into the extraocular muscles. Sharp or high velocity objects can directly perforate the globe and small foreign bodies can penetrate the eye tissues and can be stuck inside the eye.
There are about 2 million eye injuries in the US each year with about 40,000 injuries causing some kind of permanent vision loss. Trauma to the eye makes up about three percent of all visits to the emergency department. Eye injuries cause about a third of all instances of blindness in childhood.
Ruptures to the globe and injuries to the back of the eye have been linked to a high incidence of loss of vision. Modern techniques, including better surgeries and adequate rehabilitation, can restore vision in some cases of eye ruptures. A hopeful prognosis cannot be given until the eye has been fully evaluated and treated with surgery. Things that predict a poor outcome include being only able to see light, wounds that affect the back of the eye, wounds greater than 10 mm in length, and missile injuries to the eye. Most injuries occur in younger men with a median age of about 36 years. Many globe ruptures occur during sports injuries in teenage boys.
Taking a History
It is important to take a clinical history of any suspected globe injury in order to understand the mechanism of injury. Things that should be asked include the following:
- Was there any other injury besides the eye, such as a head injury?
- What was the patient doing at the time of injury?
- Was the injury blunt, perforating, or penetrating?
- When did the injury happen?
- Where did the injury take place?
- Was the patient wearing protective or corrective lenses?
- Is the patient nearsighted (as there is a greater chance of globe injury)?
- Was a seatbelt used in a motor vehicle accident?
- Was there a projectile involved?
- Does the patient have previous eye injury?
- Are there other medical injuries?
- Is the patient taking an eye drop or other medication?
- Does the patient have a medication allergy?
- What is the tetanus status?
- When was the last meal?
Symptoms that must be asked about include the following?
- Is the eye painful?
- What is the vision like before and after the injury?
- Is double vision present?
Sometimes the diagnosis of an eye rupture is very obvious. There can be an obviously misshapen eye with tissue coming out of a wound. A foreign body may be visible or may be lodged and floating inside the eye. Very small foreign bodies may have entered the eye without any obvious external injury. During the examination, no pressure should be put on the eye so that more of the intraocular contents won’t spill out and further injure the eye. Conscious sedation may be required in order to examine the eye of a child.
Visual acuity should be checked in both eyes and may be limited to the ability to count fingers at a certain distance or to the perception of light only. External ocular muscles should be evaluated to make sure there hasn’t been entrapment of a muscle from a fracture of the orbital floor.
The orbit itself should be evaluated for displacement of the globe, a foreign body, or a deformity of the affected bones. Fractures of the orbital rim may be able to be felt as a step off injury where the fracture is located. Crepitus (air in the tissues) can be seen if a sinus has been fractured. Foreign bodies may be examined but shouldn’t be removed until the patient goes to surgery. The eye may be recessed into the orbital cavity.
The eyelid and tear ducts should be looked at with the goal of identifying deeper injuries to the globe. Small lid lacerations can conceal perforations of the eye itself. The eyelid should not be repaired until there is no evidence of a globe perforation. Conjunctival lacerations should be looked for as they are more serious than scleral lacerations. If there is a lot of bleeding in the conjunctiva, this may mean that there is a globe injury.
A full thickness laceration of the cornea or sclera is indicative of a globe perforation that needs to be surgically repaired. If the iris has prolapsed through the cornea, there may be a darkened area at the site of the laceration. If the sclera has buckled, this means there has been a globe rupture. Fluorescein dye can be used to identify subtle wounds of the cornea.
The pupils should be examined to see if there is a light reflex, a pupillary defect, or an abnormal shape or size. A pupil that is not completely round can mean that there has been a rupture to the globe.
A slit lamp evaluation should be done if the patient is cooperative to see if there is blood in the anterior chamber between the iris and the cornea. It can also show lens injuries, iris prolapses, corneal lacerations, and hyphema of the eye.
Causes of a Globe Rupture
Rupture of the globe in adult patients can occur during a sports activity, an assault, or from a motor vehicle crash. The globe can be penetrated or perforated by a gunshot wound, a stab wound, a workplace injury, or to any other type of injury involving a projectile or sharp object. Hammer and chisel injuries must be very suspicious for a penetrating globe rupture.
A third of all eye injuries in teens and children are related to sports. This can include water sports, basketball injuries, baseball injuries, martial arts injuries, archery injuries, tennis injuries and wrestling injuries. Injuries from pellet guns or BB guns are problematic for people in all age groups. Paint ball injuries are on the rise with rupture of the globe occurring in five percent of cases.
Treatment of Globe Ruptures
If the globe is obviously ruptured or suspected to be ruptured, it should be protected from sustaining any type of pressure on the eye during transport to the emergency room. Any foreign object that is impaled should be left as is until it is evaluated in the emergency room. No eye patches should be used. A paper or foam cup can be taped over the affected eye as long as it doesn’t touch the eye or any foreign object.
The patient should be given medications for nausea to avoid vomiting, which can increase the eye pressure. Pain medication and sedation should be given as necessary. No topical solutions should be given if a globe rupture is suspected.
Antibiotics should be given prophylactically in order to prevent an infection of the internal part of the eye. Unfortunately, antibiotics that are given by IV tend to penetrate the eye rather poorly. Organisms such as Staphylococcus aureus and Staphylococcal epidermidis are the most common infections involved in these types of injuries. If the injure is due to a bite, antibiotics that protect against cat bites and dog bites should be given. A tetanus shot should be given if the tetanus status is not up to date.
The patient should be given nothing by mouth and should be seen immediately by an ophthalmologist with the idea that surgery be done as soon as possible.
Medications should be given in order to prevent eye infections. There should be antibiotic coverage for Bacillus species, Staph aureus, Pseudomonas, anaerobes, Corynebacterium species, streptococcal species, and gram negative bacilli. Topical antibiotics are usually given after surgery.
The choices of antibiotics for a globe rupture are listed as follows:
- Fortaz (ceftazidime)—this is a third generation cephalosporin that can treat infections due to Pseudomonas and Enterobacter.
- Cipro (ciprofloxacin)—this is a fluoroquinolone used to treat Pseudomonas and Staph infections but it doesn’t cover well for streptococcal or anaerobic infections. It penetrates the eye well when given by IV.
- Garamycin (gentamycin)—this is an aminoglycoside that covers for gram-negative organisms such as pseudomonas.
- Vancocin (vancomycin)—this can be used for people allergic to penicillin. It covers well for gram positive organism, such as Bacillus species.
After a rupture of the globe, there can be complications such as exogenous endophthalmitis or infection of the deeper tissues of the eye. This can occur within hours of rupture of the globe. Fungal infections may not occur until weeks after the injury.
The prognosis of a globe rupture depends on the extent of the eye injury and the time it takes to fix the problem in the operating room. In one study of 62 patients under the age of 16, poor outcomes were associated with having a hyphema, a retinal detachment, a vitreous hemorrhage, endophthalmitis, or a wound occurring across the pupil. Overall, the prognosis of a globe rupture should be considered extremely guarded until after the patient has had surgery.
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