Globe rupture occurs when the integrity of the outer membranes of the eye is disrupted by blunt or penetrating trauma. Any full-thickness injury to the cornea, sclera, or both is considered an open globe injury and is approached in the same manner in the acute setting. Globe rupture is an ophthalmologic emergency and requires definitive management by an ophthalmologist. Although the globe's position within the orbit protects it from injury in many situations, damage to the posterior segment of the eye is associated with a very high frequency of permanent visual loss. Prompt recognition and ophthalmologic intervention are essential to maximizing functional outcome.
Globe rupture secondary to trauma is shown in the image below.
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Operating microscope view of a globe rupture secondary to blunt trauma by a fist. Notice the dark arc in the bottom of the photo representing the cili....
Globe rupture may occur when a blunt object impacts the orbit, compressing the globe along the anterior-posterior axis causing an elevation in intraocular pressure to a point that the sclera tears. The rupture site is most commonly near the globe’s equator posterior to the insertion of the rectus muscles, which is where the sclera is weakest and thinnest.[1] Sharp objects or those traveling at high velocity may perforate the globe directly. Small foreign bodies may penetrate the eye and remain within the globe. The possibility of globe rupture should be considered and ruled out during the evaluation of all blunt and penetrating orbital traumas as well as in all cases involving high-speed projectiles with potential for ocular penetration.
More than 2 million eye injuries occur in the United States annually, with more than 40,000 resulting in some degree of permanent visual impairment. Trauma to the eye represents approximately 3% of all ED visits in the United States.[2] Approximately 34% of ophthalmic presentations in the emergency department are related to trauma, while the remaining 66% are unrelated to injury.[3] One third of all cases of childhood blindness result from ocular trauma.
Mortality/Morbidity
Globe rupture and posterior segment injury have always been associated with a high frequency of visual loss. Approximately 30%-40% of monocular blindness cases result from ocular trauma.[4] With modern diagnostic techniques, surgical approaches, and rehabilitation, many eyes can be salvaged with retention of vision.[5]
Patients should not be given a hopeful prognosis until full, usually operative, evaluation is complete. Achieving or maintaining useful vision depends on several prognostic factors, such as the severity of the initial trauma, involvement of ocular structures, preoperative visual acuity, and timely diagnosis and treatment.[6]
Race
No racial predilection exists for globe rupture.
Sex
Because of occupational and recreational preferences, most globe rupture injuries are found in men (78.6%).[7] Men are more likely to experience penetrating injuries (69.9%), whereas women present more often with blunt globe rupture (68.1%).[7]
Age
Globe rupture typically occurs at a younger age in men (median age, 36 y) than in women (median age, 73 y).[7]
A high percentage of globe rupture occurrences are in adolescent boys.
The prognosis depends largely on the extent of injury and the time from injury until appropriate surgical treatment.
In a study by Lee et al, the charts of 62 patients aged 16 years and younger who had been treated for open globe injuries were reviewed.[8] In addition to location and extent of injury, unfavorable outcomes were also related to the initial presentation of hyphema, vitreous hemorrhage, retinal detachment, cornea wound across the pupil, and endophthalmitis.
In a retrospective review, Esmaeli et al studied 176 cases of ruptured globe to identify clinical and histopathologic factors that may predict ocular survival and final visual acuity after penetrating ocular trauma. Predictors of excellent final visual acuity (20/60 or better) were initial visual acuity of 20/200 or better, wound location anterior to the plane of insertion of the 4 rectus muscles, wound length 10 mm or less, and sharp mechanism of injury. Poor visual acuity at first visit, rupture globe, zone III injuries, history of penetrating keratoplasty, retinal detachment, vitreous hemorrhage, and dislocation of crystalline lens were found to be poor prognostic factors.[6]
The prognosis should be guarded until after surgical evaluation.
The clinical history is important, and details regarding the circumstance and mechanism of injury should be obtained with the following in mind:
Before focusing on the eye injury, is there an associated extraocular injury (eg, subdural hemorrhage secondary to fall)?
What was the patient doing at the time of injury (eg, hammering metal)?
Is this activity more likely to cause a blunt, penetrating, and perforating injury? In men, projectile injuries are the most frequent cause of globe injuries and are often work-related or occur during home improvement projects.[7] Women are more likely to suffer blunt globe injury from falls or motor vehicle accidents.
What type of object is likely to have struck the globe?
Is it possible that there is an intraocular foreign body? Assume this to be true if a high-speed projectile was involved.
When did the injury occur?
Where did the injury occur (eg, home, construction site)?
What is the patient's baseline visual acuity? Severe myopia increases the risk of injury from anterior-posterior compression.
Does the patient use corrective lenses or contacts? If so, have contacts been removed?
If caused by a motor vehicle accident, was a seatbelt used and did airbags deploy?
Medical history may include the following:
Prior history of ocular surgery (prior cataract extraction increases the risk of an occult cataract wound rupture)
Preexisting medical conditions
Medications (including eye drops)
Medication allergies
Tetanus status
Time of last meal
Symptoms may include the following:
Pain
Pain may be difficult to assess in patients with obtundation or distracting injuries.
Patients with penetrating injuries may not experience severe pain initially, even if there is an intraocular foreign body.
Loss of vision or blurred vision
Diplopia
If present, diplopia is usually due to entrapment and dysfunction of extraocular muscles with associated orbital floor blowout fractures.
Diplopia may be due to traumatic cranial nerve palsy from associated head injury.
Monocular diplopia may be due to associated lens dislocation or subluxation.
The diagnosis of globe rupture may be obvious, although this is not the most common presentation. The eye can be misshapen with uveal tissue prolapsing out of an anterior scleral or corneal wound. Sometimes, an identifiable foreign body is still in the eye when the patient arrives to the ED.
More often, the diagnosis of globe rupture is not immediately apparent. The most frequent sites of rupture are not easily visualized, and more superficial injuries may block examination of the posterior segment. In cases of blunt trauma, swelling of the face and lids may complicate visualization of the eye. Penetrating injuries from very small sharp objects may create tiny wounds that are difficult to visualize.
Examination of the injured eye should proceed systematically with the goal of identifying and protecting a ruptured globe.
It is critical to avoid putting pressure on a ruptured globe to prevent extrusion of intraocular contents and further ocular injury.
In young children where the extent of intraocular injury cannot be assessed because of poor cooperation, sedation and support from an ophthalmologist may be necessary to ensure a complete and accurate examination.
Visual acuity and eye movement
Visual acuity should be assessed in both the injured and uninjured eye. It may be limited to "counts fingers at 18 inches" or "light perception only”.
Extraocular movement should be evaluated to rule out entrapment from an associated orbital floor fracture.
Orbits
Orbits should be examined for bony deformity, foreign body, and globe displacement.
Orbital rim fractures may be palpable and raise suspicion for entrapment and possible associated globe rupture.
Orbital crepitus indicates subcutaneous emphysema from an associated sinus fracture.
Orbital foreign bodies that may have impaled or perforated the globe should be left undisturbed until surgery.
A ruptured globe may present with enophthalmos (recession of the globe within the orbit).
An associated retrobulbar hemorrhage may cause exophthalmos, even with an occult scleral rupture.
Eyelid
Eyelid and lacrimal injuries should be evaluated with the major goal of identifying and protecting possible deep injuries to the globe.
Even small lid lacerations may conceal vision-threatening globe perforations.
Lid repairs should not proceed until globe injury is ruled out.
Conjunctiva
Conjunctival lacerations may overlie more serious scleral injuries.
Severe conjunctival hemorrhage (often covering 360 degrees of bulbar conjunctiva) may indicate globe rupture.
Cornea and sclera
A full-thickness laceration to the cornea or sclera constitutes an open globe perforation, and it should be repaired in the operating room.
Prolapse of the iris through a full-thickness corneal laceration may be visible as a dark discoloration at the site of injury.
Scleral buckling is indicative of rupture with extrusion of ocular contents.
Intraocular pressure will likely be low, but measurement is contraindicated to avoid pressure on the globe.
More subtle or partially self-sealing corneal wounds may require use of fluorescein dye. In a full-thickness laceration with aqueous flowing from the anterior chamber, a clear stream of fluid parting the yellow fluorescein dye is noted on illumination with a Wood's lamp (positive Seidel test).[1]
Pupils
Pupils should be examined for shape, size, light reflex, and afferent pupillary defect (APD).
A peaked, teardrop-shaped, or otherwise irregular pupil suggests globe rupture.
Anterior chamber
Slit lamp examination in the cooperative patient may show associated injuries such as iris transillumination defect (red reflex obscured by vitreous hemorrhage); corneal lacerations; iris prolapse; hyphema from ciliary body disruption; and lens injuries, including dislocation or subluxation.
A shallow anterior chamber may be the only sign of occult globe rupture and is associated with a worse prognosis. A posterior rupture may present with a deeper anterior chamber due to extrusion of vitreous from the posterior segment.
Other findings
Vitreous hemorrhage after trauma suggests retinal or choroidal tear, optic nerve avulsion, or foreign body.
Retinal tears, edema, detachments, and hemorrhage may accompany globe rupture.
Globe rupture in adults may occur after blunt injury during motor vehicle accidents, sports activity, assault, or other trauma.
Globe penetration or perforation may occur with gunshot and stab wounds, workplace accidents, and any accident involving sharp objects or projectiles.
Be particularly suspicious of eye injuries caused by metal striking metal (eg, hammer and chisel), as well as high-speed grinding or cutting involving metal or stone.
One third of eye injuries occurring in children and adolescents (< 16 y) are sports related.[9] Basketball, water sports, baseball, racquet sports, martial arts, wrestling, and archery are frequently implicated.
Eye injures associated with the sudden release of a tense bungee cord are increasingly in frequency.
BB and pellet guns present an extreme hazard to all age groups.
Eye injuries from paintball weapons are becoming increasingly reported, with globe rupture occurring in 5% of injuries.[10]
After globe rupture, delayed postoperative or exogenous endophthalmitis, and infection involving the deep structures of the eye, are always potential complications.
Depending on the organism involved, endophthalmitis may present within hours of the globe rupture, or, as with fungal organisms, the infection may not appear until weeks later.
The recommended approach in the evaluation of potential globe rupture or penetration is to maintain a high index of suspicion for what is often an occult injury. A careful and detailed ocular examination should be followed by appropriate diagnostic studies. Computed tomography of the orbits and adjacent structures is often the diagnostic procedure of choice.
CT scanning of the eye is the preferred modality for further assessment of occult open globe injuries.[11] CT is the most sensitive readily available imaging study to detect occult rupture, associated optic nerve injury, and small foreign bodies, as well as to visualize the anatomy of the globe and orbit.
Axial and coronal views of the brain and orbits without contrast utilizing 1-2 mm cuts should be obtained.
Some nonmetallic foreign bodies, such as wood, glass, or plastic, may be difficult to visualize acutely on CT.
The sensitivity and specificity of ocular CT in determining occult open globe injury varies. Sensitivities ranging from 56-68% and 70%, and specificities of 70-100% and 98% have been reported in recent studies,[12, 13] illustrating the need for surgical exploration for definitive diagnosis and management.
Radiography
Orbital plain films of the orbits and sinuses are rarely used for diagnosis in orbital trauma.
A 3-view plain film series is most useful in evaluating the bony orbits and the sinuses and in identifying radiopaque foreign bodies.
Waters projection provides the best view of the orbital floor and detects air-fluid levels in the maxillary sinuses.
Caldwell or anteroposterior view visualizes the medial orbital wall, the lateral and superior orbital rims, as well as the ethmoid and frontal sinuses.
The third projection, or lateral view, is most useful in visualizing the orbital roof, maxillary and frontal sinuses, zygoma, and sella turcica.
MRI
MRI is of limited usefulness in the acute stages of ocular trauma and is contraindicated if any concern exists for metallic intraocular foreign body.
MRI is excellent in identifying injuries of the soft tissues of the globe and orbit and can be particularly helpful in localizing an organic foreign body, such as wood, that appears similar to soft tissue or air on CT scan.
Ultrasonography
Ocular ultrasonography by an emergency physician is contraindicated if there is a high suspicion for globe rupture.
Ultrasonography can be used to evaluate noninvasively for lens dislocation, retrobulbar hemorrhage, retinal detachment, and intraocular foreign body. Visualization of periorbital gas may also prompt an ED physician to search for orbital fracture.
The Seidel test is intended to detect the leak of aqueous fluid following globe penetration. It should not be performed if globe rupture or penetration has already been confirmed, as any unnecessary manipulation of the globe is contraindicated. However, the Seidel test may prove useful in the diagnosis of more occult injuries. If an aqueous leak is present, it may be detected on slit-lamp examination following the instillation of fluorescein dye by a clear band in the stain extending downward from the suspected site of injury. The clear band is caused by dilution of the fluorescein by leaking aqueous fluid. If the Seidel test result is positive, any further manipulation of the eye is contraindicated.
Additional diagnostic tests
Further testing is based upon the mechanism of injury and the potential for nonocular injuries.
Life- or limb-threatening injuries should be addressed initially.
Consider injuries to head, spinal cord, and facial bones.
A Fox eye shield or other rigid device (bottom of a polystyrene foam cup) should be placed over the affected eye. Avoid any eye manipulation that may increase intraocular pressure with potential extrusion of intraocular contents.
Administer antiemetics (eg, ondansetron) to prevent Valsalva maneuvers.
Administer sedation and analgesics as needed.
Avoid any topical eye solutions (eg, fluorescein, tetracaine, cycloplegics) in cases of known globe perforation or rupture.
Administer prophylactic antibiotics. Although the goal is to prevent endophthalmitis or an internal eye infection, parenterally administered antibiotics penetrate the globe poorly. The frequency of endophthalmitis after open globe injury has been estimated to be about 6.8%.[14] Skin organisms, such as Streptococcus species, Staphylococcus aureus, and Staphylococcus epidermidis are most frequently involved. Consequently, intravenous third-generation cephalosporins and vancomycin have been recommended in high-risk cases. Attention should be given to species-specific pathogens if injury is due to bites (ie, dysgonic fermenter type 2 [DF2] and Eikenella for dog bites; Pasteurella multocida for cat bites) or if organic material is likely to have been introduced (ie, gram-negative organisms or fungi in a farming injury).
Document tetanus immune status and update as indicated. An open globe laceration is considered a tetanus prone wound.
Ensure the patient is kept nothing by mouth (NPO).
Ensure definitive management by an ophthalmologist.
Surgical repair should be expedited.
The use of intraocular steroids is controversial. Ocular steroids should probably not be used if fungal infection is suspected.[5]
Transfer is required if the patient presents to an institution without ophthalmology consultation services or without the ability to provide the definitive surgical repair.
Clinical Context:
Third-generation cephalosporin. Treatment of infections of respiratory tract, urinary tract, skin, intra-abdominal and osteomyelitis, sepsis, and meningitis caused by susceptible gram-negative aerobic organisms such as Enterobacteriaceae and Pseudomonas.
Clinical Context:
Provides excellent coverage against staphylococcal organisms and Pseudomonas, but it is not a good antibiotic for streptococci or anaerobes. Has excellent penetration of the eye in IV form. Anaerobic coverage can be achieved with addition of clindamycin, which also covers streptococci, except for enterococci.
Clinical Context:
Aminoglycoside antibiotic for gram-negative coverage bacteria including Pseudomonas species. Synergistic with beta-lactamase against enterococci. Interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits.
Dosing regimens are numerous and are adjusted based on CrCl and changes in volume of distribution, as well as body space into which agent needs to distribute. Dose of gentamicin may be given IV/IM. Each regimen must be followed by at least trough level drawn on third or fourth dose, 0.5 h before dosing; may draw peak level 0.5 h after 30-min infusion.
Clinical Context:
May be used as an alternative to cefazolin for adults allergic to penicillin. Provides excellent gram-positive coverage, including Bacillus. To avoid toxicity, current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dose. Use creatinine clearance to adjust dose in patients with renal impairment.
Prophylactic systemic antibiotics should be given to cover organisms commonly associated with posttraumatic endophthalmitis, including Bacillus species, S aureus,Pseudomonas species, gram-negative bacilli, anaerobes, corynebacteria, and streptococci. Topical antibiotics are also commonly given postoperatively.
The list below provides examples of potential antibiotic choices and is not an exhaustive discussion. The ultimate choice of antibiotics is based on the individual characteristics of the injury and the patient, the determination of the degree of risk for infection and the likely organisms involved, and a specific drug's intraocular penetration characteristics.
What is globe rupture?What is the pathophysiology of globe rupture?What is the prevalence of globe rupture in the US?What is the visual prognosis associated with globe rupture?What are the racial predilections of globe rupture?What are the sexual predilections of globe rupture?Which age groups have the highest prevalence of globe rupture?What is the prognosis of globe rupture?What is the focus of the clinical history for globe rupture?What are the signs and symptoms of globe rupture?How is globe rupture diagnosed?How is visual acuity and eye movement assessed in suspected globe rupture?Which orbital findings suggest globe rupture?How are eyelids assessed in the evaluation of globe rupture?Which conjunctiva findings suggest globe rupture?Which cornea and sclera findings suggest globe rupture?Which pupil findings suggest globe rupture?Which slit lamp exam findings are characteristic of globe rupture?What does a finding of vitreous hemorrhage suggest in the evaluation of globe rupture?What causes globe rupture?What are the possible complications of globe rupture?What are the differential diagnoses for Globe Rupture?How is globe rupture diagnosed?Which lab tests are performed in the workup of globe rupture?What is the role of CT scanning in the workup of globe rupture?What is the role of radiography in the workup of globe rupture?What is the role of MRI in the workup of globe rupture?What is the role of ultrasonography in the workup of globe rupture?What is the role of the Seidel test in the workup of globe rupture?Which nonocular tests are performed in the workup of globe rupture?When are eyelid or conjunctival lacerations treated in patients with suspected globe rupture?What is included in prehospital care for globe rupture?How is globe rupture treated in the emergency department (ED)?Which specialist consultations are beneficial to patients with globe rupture?How is globe rupture prevented?When is inpatient care indicated in the treatment of globe rupture?When is patient transfer required for the treatment of globe rupture?What is the role of medications in the treatment of globe rupture?Which medications in the drug class Antibiotics are used in the treatment of Globe Rupture?
John R Acerra, MD, Assistant Professor, Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell; Director, International Emergency Medicine Program, LIJ Medical Center, Northwell Health System
Disclosure: Nothing to disclose.
Coauthor(s)
Derek J Golden, MD, Attending Physician, Department of Emergency Medicine, West Hills Hospital and Medical Center
Disclosure: Nothing to disclose.
Sarah L Gilman, New York College of Osteopathic Medicine
Disclosure: Nothing to disclose.
Specialty Editors
Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Douglas Lavenburg, MD, Clinical Professor, Department of Emergency Medicine, Christiana Care Health Systems
Disclosure: Nothing to disclose.
Chief Editor
Steven C Dronen, MD, FAAEM, Chair, Department of Emergency Medicine, LeConte Medical Center
Disclosure: Nothing to disclose.
Additional Contributors
Edward A Michelson, MD, Associate Professor, Program Director, Department of Emergency Medicine, University Hospital Health Systems of Cleveland
Disclosure: Nothing to disclose.
Acknowledgements
The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Joe Robson, MD, Amy J Behrman, MD, and Stephanie Abbuhl, MD, to the development and writing of this article.
Operating microscope view of a globe rupture secondary to blunt trauma by a fist. Notice the dark arc in the bottom of the photo representing the ciliary body visible through the scleral breach. Subconjunctival hemorrhage of this severity should raise suspicion of occult globe rupture. Photo courtesy of Brian C Mulrooney, MD.
Operating microscope view of a globe rupture secondary to blunt trauma by a fist. Notice the dark arc in the bottom of the photo representing the ciliary body visible through the scleral breach. Subconjunctival hemorrhage of this severity should raise suspicion of occult globe rupture. Photo courtesy of Brian C Mulrooney, MD.
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