Author:
Alexand er T.Limkakeng , Jr.
Brand on T.Ruderman
Description
- A full-thickness corneal or scleral injury owing to trauma
- Blunt trauma/globe rupture:
- Causes an abrupt rise in intraocular pressure diffusely
- Subsequent rupture of the eye either opposite the point of impact or at the weakest points:
- Extraocular muscle insertion
- Corneoscleral junction
- Limbus, where the sclera is thinnest
- Penetrating injury/globe laceration:
- Occurs with sharp objects or projectiles injuring the sclera or anterior eye directly
- Most commonly anterior and involving the cornea - the bony orbit protects the globe laterally and posteriorly
- Posterior injury can occur with fracture of the bony orbit or with penetrating eyelid/eyebrow injuries
- Prognosis worse with:
- Larger lacerations
- Posterior injuries
- Blunt injury
- Intraocular foreign body, especially if made of organic material
- Vitreous extrusion
- Lens damage
- Hyphema
- Retinal detachment
- Poor visual acuity at presentation
- Afferent pupillary defect
- Increased time to OR
Etiology
- Falls, impact injuries
- Sport-related injuries (e.g., elbow, ball impacts, arrows, game controllers, etc.)
- Indirect concussive injuries (explosions)
- Sharp instrument/stabbing injuries, accidental or intentional
- High-velocity projectile injuries (industrial, firearms, BB pellets, blast explosion shrapnel)
Signs and Symptoms
- Pain, redness, tearing following trauma
- 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
- Timing and mechanism of injury:
- Assess for possibility of retained intraocular foreign body - do not remove protruding foreign bodies
- History of previous eye surgeries
- Preinjury visual status
- Assess tetanus status
- 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 surgery:
- Prevents 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 (aids in prognosis)
- Ocular motility
- Slit-lamp exam: Cornea, anterior chamber, iris, sclera, fundus, retina
- Afferent pupillary defect indicates posterior injury
- 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 not definitely present
- US (only if rupture not definitely present)
- Identify any concomitant injuries
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
Diagnostic Tests & Interpretation
Lab
Preoperative labs:
- CBC
- Electrolytes
- Coagulation studies
Imaging
- Orbital x-ray (anteroposterior/lateral) for metallic intraocular foreign body
- B-scan US of the eye
- CT scan of the orbits preferred over MRI for identifying fractures and foreign bodies (only 56-75% sensitive). Consider if brain or cervical spine imaging is necessary
Diagnostic Procedures/Surgery
Differential Diagnosis
- Intraocular foreign body
- Hyphema
- Severe subconjunctival hemorrhage and chemosis
- Partial corneal/scleral laceration
- Facial/orbital fractures
- Retrobulbar hemorrhage
Prehospital
- 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 and try to prevent activities that increase intraocular pressure such as straining, coughing, or vomiting. Elevate head
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 antiemetics for nausea/vomiting
- Pain control
- Antitussives as needed
- Elevate the head of the bed
- Protective eye shield (NO pressure on the globe)
- Update tetanus status
- Administer prophylactic IV antibiotics:
- Skin organisms (staph, strep) most common. Risk of endophthalmitis is 2.6-30%
- Vancomycin and a fluoroquinolone (moxifloxacin or levofloxacin) OR ceftazidime. Fluoroquinolone preferred due to vitreous penetration
- 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
- Clindamycin: 450 mg (peds: 8-12 mg/kg) IV q8h
- Levofloxacin: 750 mg (peds: 10 mg/kg) IV q24h
- Moxifloxacin: 400 mg (peds: 10 mg/kg) IV q24h
- 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)
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
- GelstonCD. Common eye emergencies . Am Fam Phys. 2013;88(8):515-519.
- RomaniukVM. Ocular trauma and other catastrophes . Emerg Med Clin N Am. 2013;31:399-411.
- SabaciG, BayerA, MutluFM, 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-BorowskaSE, CampbellKT. Globe rupture and nonaccidental trauma: Two case reports . Pediatr Emerg Care. 2011;27(6):544-546.
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