Globe rupture – including penetrating eye injury and intraocular foreign body

Theory

Globe rupture occurs when the integrity of the outer coat of the eye (cornea and/or sclera) is disrupted by blunt or penetrating trauma. The globe is vulnerable to blunt injury by objects smaller than the protective orbital rim e.g. golf ball, squash ball. Blunt trauma causes anterior-posterior compression of the globe, raised intra-ocular pressure and rupture of the globe at sites of relative scleral thinning (limbus, sites of extra-ocular muscle insertion, insertion of the optic nerve). A posterior globe rupture may be difficult to diagnose in the emergency department and a high degree of suspicion is needed. Sharp objects or those travelling at high velocity may perforate the globe directly. Small foreign bodies may penetrate the eye and remain within the globe.

Early recognition and surgical repair is critical to maximising visual outcome. Poor prognostic factors include blunt injuries, poor initial visual acuity, presence of a relative afferent pupil defect or retinal detachment, absence of a red reflex, associated lid trauma and posterior wound location.

Post-traumatic endophthalmitis is a rare complication, but has poor visual prognosis. The most common organisms are Streptococcus species, coagulase-negative Straphylococcus, and Bacillus cereus.

Appropriate ophthalmic surgical treatment is thought to minimise the risk of sympathetic ophthalmia, although evidence for this is weak.

Principles of intern management are to prevent vomiting, pain, infection and further injury prior to transfer to ophthalmic care.

Globe rupture is an emergency and needs repair before attending to other non-life threatening injuries e.g. associated facial lacerations.

Immediate intern management prior to ophthalmic care

Suspect the diagnosis in all cases of blunt and penetrating orbital trauma and all cases involving high-speed projectiles with potential for ocular penetration. The majority of cases are in young men. You do not need to be certain the globe is ruptured – refer all patients in whom the diagnosis is suspected. Signs can be subtle: small lid lacerations may conceal vision-threatening globe perforations. Good visual acuity and absence of pain does not rule out globe rupture.

Avoid all pressure on or around the injured eye to prevent extrusion of intraocular contents. Protect the eye with a shield. Do not apply eye drops, ointment or patches.
Leave impaled foreign bodies in situ.
Administer antiemetics e.g. metoclopramide hydrochloride 10 mg or prochlorperazine 12.5 mg to prevent Valsalva manoeuvres.
Administer analgesics as indicated.
Administer antibiotics to prevent endophthalmitis if significant delay is expected
- ciprofloxacin 750 mg (child 20 mg/kg up to 750 mg) orally as a single dose
- PLUS
- vancomycin 25 mg/kg up to 1.5 g (child <12 years 30 mg/kg up to 1.5 g). Give IV as a single dose. Slow infusion required, maximum 5 mg/min
- Alternate prophylaxis
- gentamicin 5 mg/kg IV as a single dose
- PLUS
- cephazolin 2 g (child 50 mg/kg up to 2 g) IV as a single dose
Document tetanus immune status and update as indicated.
Ascertain what time was the last meal. The patient should be kept NPO.
Refer for ophthalmic care. If transfer is needed, transfer by road ambulance or air ambulance with the cabin altitude at sea level or as low as safe.

Clinical features

History

Decreased vision
Pain
History of trauma e.g. golf ball, squash ball
History of high velocity injury e.g. grinding, hammering metal on metal

Other (obtain later)

Time of injury
Tetanus status
Allergies

Examination

When globe rupture is suspected, minimise examination to avoid loss of ocular contents. Pressure on eyelids in attempted examination is dangerous
Measure visual acuity if possible
Ruptured globe: severe subconjunctival haemorrhage or swelling (chemosis), deep or shallow anterior chamber compared with the other eye, blood in the anterior chamber (hyphaema), pupil abnormalities (dilated, distorted, or unreactive), lids sunken (enophthalmos), limitation of extra-ocular motility, intra-ocular contents outside globe
Penetrating injury: full-thickness scleral or corneal laceration accompanying signs of ruptured globe
Consider other injuries. An obvious globe rupture may present with other life-threatening injuries that can be overlooked e.g. frontal lobe injury in patient with a penetrating eye injury through the upper eyelid.

Investigations

Imaging

Perform orbital CT scan only if available and does not cause a delay in transfer.

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