SIGNS AND SYMPTOMS 
- Pain
- Localized ecchymosis and swelling
- Scleral or corneal laceration
- Extrusion of intraocular contents
- Markedly decreased visual acuity
- Limited extraocular motion
- Hyphema
- Severe subconjunctival hemorrhage and edema, especially if circumferential bloody chemosis
- Abnormally deep or shallow anterior chamber
- Low intraocular pressure:
- Note: Do not perform tonometry if there is suspected rupture.
- Irregular pupil (points toward lesion)
- Subluxed lens
- Commotio retinae—gray-white discoloration of the retina
History
- Mechanism of injury:
- Assess for possibility of retained intraocular foreign body
- History of previous eye surgery
- Preinjury visual acuity
- Assess tetanus status
- Ascertain time of last PO intake
Physical Exam
- Penlight or slit-lamp exam observing for signs of globe rupture
- If the diagnosis of ruptured globe is made, defer further ocular exam until the time of surgical repair:
- Prevents placing any undue pressure on the eye and risking extrusion of the intraocular contents
- If no evidence of globe rupture on initial survey, proceed with thorough ophthalmologic exam:
- Visual acuity
- Slit-lamp exam
- Cornea
- Anterior chamber
- Iris
- Sclera
- Fundus
- Retina
- Seidel test: Observe if fluorescein moves away as contents (which appear yellow-green) leak out at site of rupture:
- Measure intraocular pressure
- Perform only if globe rupture is definitely not present.
- Ultrasound (only if rupture not suspected)
ESSENTIAL WORKUP
Perform thorough ocular exam as outlined above:
- Once diagnosis of globe rupture is suspected or made, defer further exam until time of repair.
DIAGNOSIS TESTS & INTERPRETATION
Lab
Preoperative labs:
- CBC
- Electrolytes
- Coagulation studies
Imaging
- Orbital radiograph (anteroposterior/lateral) for metallic intraocular foreign body
- CT scan of the orbits (axial and coronal views)
- MRI scan of the orbits after retained metallic foreign body is ruled out
- B-scan US of the eye
Diagnostic Procedures/Surgery
DIFFERENTIAL DIAGNOSIS
- Intraocular foreign body
- Hyphema
- Severe subconjunctival hemorrhage and chemosis
- Partial corneal laceration
- Partial scleral laceration
[Outline]
PRE-HOSPITAL
- Place a shield (not patch) over eye with no pressure on the globe.
- Use a Styrofoam cup if no shield available.
INITIAL STABILIZATION/THERAPY
- Keep manipulation of the eye to a minimum if ruptured globe is suspected.
- Try to prevent any activity that will cause an increase in intraocular pressure such as straining, coughing, or vomiting.
ED TREATMENT/PROCEDURES
- Prepare for definitive surgical management:
- Emergent ophthalmologic consultation
- Thorough physical exam to identify concurrent injuries
- Preoperative labs and ECG as indicated
- No food or drink (NPO)
- Minimize intraocular pressure to reduce further injury
- Administer antiemetic for nausea/vomiting
- Elevate the head of the bed
- Protective eye shield (NO pressure on the globe itself)
- Update tetanus status.
- Administer prophylactic antibiotics IV:
- Skin organisms (staph, strep) most common
- Consider injury-specific contaminants in cases of animal bites, organic foreign body, etc.
- Vancomycin + ceftazidime OR vancomycin + ciprofloxacin if allergic to penicillin
- Succinylcholine is relatively contraindicated:
- However, with a defasciculating dose of a nondepolarizing agent and sufficient anesthesia, it may be used.
Pediatric Considerations
- Consider nonaccidental trauma
- Because of risk of extrusion of intraocular contents, straining/crying should be avoided. Try to keep them happy!
MEDICATION
- Ceftazidime: 1–2 g (peds: 30–50 mg/kg) IV q8h
- Ciprofloxacin: 400 mg (peds: 10 mg/kg) IV q12h
- Clindamycin: 450 mg (peds: 8–12 mg/kg) IV q8h
- Ondansetron (Zofran): 4 mg IV
- Prochlorperazine (Compazine): 5–10 mg IV/IM
- Tobramycin: 2 mg/kg (peds: 2 mg/kg) IV q8h
- Vancomycin: 15 mg/kg IV q8–12h (peds: 10 mg/kg IV q6h)
[Outline]
DISPOSITION
Admission Criteria
- All patients with globe rupture/penetrating eye injuries
- Early enucleation for severe injury
Discharge Criteria
Globe penetration excluded
Issues for Referral
- Emergent ophthalmologic consultation in the ED may be needed to definitively rule out globe rupture owing to difficulty with exam and the desire to minimize manipulation of the eye.
- Speed is of the essence since the risk of infection increases with prolonged time to operative repair.
- If appropriate, patient should be counseled on use of protective eyewear to prevent recurrence.
FOLLOW-UP RECOMMENDATIONS
Postoperative ophthalmology follow-up
[Outline]
- Linden JA, Renner GS. Trauma to the globe. Emerg Med Clin North Am. 1995;13(3):581–605.
- Marx JA, Hockberger RS, Walls RM, et al. Rosen's Emergency Medicine. 7th ed. Philadelphia, PA: Saunders; 2009;863–864.
- Navon SE. Management of the ruptured globe. Int Ophthalmol Clin. 1995;35:71–91.
- Sabaci G, Bayer A, Mutlu FM, et al. Endophthalmitis after deadly-weapon-related open-globe injuries: Risk factors, value of prophylactic antibiotics, and visual outcomes. Am J Ophthalmol. 2002;133:62–69.
- Skarbek-Borowska SE, Campbell KT. Globe rupture and nonaccidental trauma: Two case reports. Pediatr Emerg Care. 2011;27(6):544–546.
See Also (Topic, Algorithm, Electronic Media Element)
Alexander T. Limkakeng, Jr.
Megan G. Kemnitz