Globe rupture: Difference between revisions

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==Background==
==Background==
Be careful not to apply pressure to eye
*Vision threatening emergency
*Is a full thickness disruption of sclera or cornea<ref>Layer N, et a. Algorithm for evaluation and management of the ruptured globe in an adult. Department of Ophthamology, University of California, San Francisco. http://www.icoph.org/dynamic/attachments/resources/rupturedglobeico.pdf</ref>
*Be careful not to apply pressure to eye
**Evert lids with paperclips or eyelid retractors


==Diagnosis==
===Causes===
* Tear-shaped pupil
*[[Blunt Eye Trauma]]
* Extrusion of intraocular content
**Caused by suddenly elevated IOP
*Penetrating trauma
**Suspect globe penetration with any puncture or laceration of eyelid or periorbital area
**More commonly associated with objects from metal on metal, lawn mower, drills, grinders<ref>Zhang Y et al. Intraocular foreign bodies in China: clinical characteristics, prognostic factors and visual outcomes in 1421 eyes. Am J Ohthalmol. 2011:152:66-73</ref>


==Treatment==
==Clinical Features==
Ceftaz 1gm
*Eye pain
*+/- decreased visual acuity
*Tear-shaped pupil
*Extrusion of intraocular content
*Subconjunctival hemorrhage involving entire sclera
*Hemorrhagic chemosis


+
===Slit-lamp===
*Shallow anterior chamber
*Hyphema
*Seidel's sign - do not perform this test if suspect open globe
**May be falsely negative if scleral rupture is small
*Lens dislocation


Vanco 1 gm
==Differential Diagnosis==
{{Maxillofacial trauma DDX}}


PCN allergy
==Evaluation==
*Inspect lids, lashes, cornea, sclera, and pupils.
*Evaluate for a relative afferent pupillary defect
*Visual Acuity
*Do NOT perform tonometry for IOP


Cipro + vanc
===Work-Up===
*Non-contrast CT orbit
**Consider if concern for intraocular foreign body '''OR''' diagnosis is unclear
**Sensitivity ~60%


Surgical emergency
==Management<ref>Layer N, et a. Algorithm for evaluation and management of the ruptured globe in an adult. Department of Ophthamology, University of California, San Francisco. http://www.icoph.org/dynamic/attachments/resources/rupturedglobeico.pdf</ref>==
*Consult ophtho immediately for emergent surgical repair
**Keep NPO
*Prevent further injury
**Do not manipulate the eye
**Eye covering with metal shield (Fox shield) or paper cup (do not place a patch that touches globe)
*Minimize elevations in intraocular pressure
**Elevate head of bed
**Bed rest; no bending/lifting/Valsalva
**Consider anti-emetic (e.g. [[ondansteron]] 4mg IV)
*IV pain medications PRN
*[[Tetanus prophylaxis]] (if indicated)
*If [[intubation]] necessary, use [[succinylcholine]] and [[ketamine]] <3mg/kg (do not increase intraocular pressure or cause adverse outcomes)<ref>Libonati MM, Leahy JJ, Ellison N: The use of succinylcholine in open eye surgery. Anesthesiology 1985; 62:637-640</ref>


==Source==
===[[Antibiotics]]<ref>Layer N, et a. Algorithm for evaluation and management of the ruptured globe in an adult. Department of Ophthamology, University of California, San Francisco. http://www.icoph.org/dynamic/attachments/resources/rupturedglobeico.pdf</ref>===
Donaldson 5/08 (trauma reports)
====NO intra-ocular foreign body====
*First choice: [[Fluoroquinolone]] IV, such as Levofloxacin '''OR'''
*Second choice: [[Vancomycin]] IV and [[ceftazidime]]


[[Category:Ophtho]]
====Intra-ocular foreign body PRESENT====
*[[Ceftazidime]] 1gm + [[vancomycin]] 1 gm
*Penicillin allergy: [[Ciprofloxacin]] + [[vancomycin]]
 
==Disposition==
*Admission for surgical repair by ophthalmology
*Transfer to tertiary trauma center if ophthalmologist prefer
 
==See Also==
*[[Orbital Blowout Fracture]]
*[[Ocular foreign body]]
 
==References==
<references/>
 
[[Category:Ophthalmology]]

Revision as of 10:27, 12 April 2019

Background

  • Vision threatening emergency
  • Is a full thickness disruption of sclera or cornea[1]
  • Be careful not to apply pressure to eye
    • Evert lids with paperclips or eyelid retractors

Causes

  • Blunt Eye Trauma
    • Caused by suddenly elevated IOP
  • Penetrating trauma
    • Suspect globe penetration with any puncture or laceration of eyelid or periorbital area
    • More commonly associated with objects from metal on metal, lawn mower, drills, grinders[2]

Clinical Features

  • Eye pain
  • +/- decreased visual acuity
  • Tear-shaped pupil
  • Extrusion of intraocular content
  • Subconjunctival hemorrhage involving entire sclera
  • Hemorrhagic chemosis

Slit-lamp

  • Shallow anterior chamber
  • Hyphema
  • Seidel's sign - do not perform this test if suspect open globe
    • May be falsely negative if scleral rupture is small
  • Lens dislocation

Differential Diagnosis

Maxillofacial Trauma

Evaluation

  • Inspect lids, lashes, cornea, sclera, and pupils.
  • Evaluate for a relative afferent pupillary defect
  • Visual Acuity
  • Do NOT perform tonometry for IOP

Work-Up

  • Non-contrast CT orbit
    • Consider if concern for intraocular foreign body OR diagnosis is unclear
    • Sensitivity ~60%

Management[3]

  • Consult ophtho immediately for emergent surgical repair
    • Keep NPO
  • Prevent further injury
    • Do not manipulate the eye
    • Eye covering with metal shield (Fox shield) or paper cup (do not place a patch that touches globe)
  • Minimize elevations in intraocular pressure
    • Elevate head of bed
    • Bed rest; no bending/lifting/Valsalva
    • Consider anti-emetic (e.g. ondansteron 4mg IV)
  • IV pain medications PRN
  • Tetanus prophylaxis (if indicated)
  • If intubation necessary, use succinylcholine and ketamine <3mg/kg (do not increase intraocular pressure or cause adverse outcomes)[4]

Antibiotics[5]

NO intra-ocular foreign body

Intra-ocular foreign body PRESENT

Disposition

  • Admission for surgical repair by ophthalmology
  • Transfer to tertiary trauma center if ophthalmologist prefer

See Also

References

  1. ↑ Layer N, et a. Algorithm for evaluation and management of the ruptured globe in an adult. Department of Ophthamology, University of California, San Francisco. http://www.icoph.org/dynamic/attachments/resources/rupturedglobeico.pdf
  2. ↑ Zhang Y et al. Intraocular foreign bodies in China: clinical characteristics, prognostic factors and visual outcomes in 1421 eyes. Am J Ohthalmol. 2011:152:66-73
  3. ↑ Layer N, et a. Algorithm for evaluation and management of the ruptured globe in an adult. Department of Ophthamology, University of California, San Francisco. http://www.icoph.org/dynamic/attachments/resources/rupturedglobeico.pdf
  4. ↑ Libonati MM, Leahy JJ, Ellison N: The use of succinylcholine in open eye surgery. Anesthesiology 1985; 62:637-640
  5. ↑ Layer N, et a. Algorithm for evaluation and management of the ruptured globe in an adult. Department of Ophthamology, University of California, San Francisco. http://www.icoph.org/dynamic/attachments/resources/rupturedglobeico.pdf
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