Globe rupture: Difference between revisions
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==Background== | ==Background== | ||
*Vision threatening emergency | *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 | *Be careful not to apply pressure to eye | ||
**Evert lids with paperclips or eyelid retractors | **Evert lids with paperclips or eyelid retractors | ||
==Causes== | ===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<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> | |||
==Clinical Features== | ==Clinical Features== | ||
*[[Eye pain]] | |||
*+/- [[vision loss|decreased visual acuity]] | |||
*Tear-shaped pupil | |||
*Extrusion of intraocular content | |||
*[[Subconjunctival hemorrhage]] involving entire sclera | |||
*[[red eye|Hemorrhagic chemosis]] | |||
==Diagnosis== | ===[[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 DDX}} | |||
==Evaluation== | |||
*Inspect lids, lashes, cornea, sclera, and pupils. | *Inspect lids, lashes, cornea, sclera, and pupils. | ||
*Evaluate for a relative afferent pupillary defect | *Evaluate for a relative afferent pupillary defect | ||
*Visual | *Visual acuity | ||
*Do NOT perform tonometry for IOP | *Do NOT perform tonometry for [[IOP]] | ||
==Work-Up== | ===Work-Up=== | ||
*Non-contrast CT orbit | *Non-contrast CT orbit | ||
**Consider if concern for intraocular foreign body OR diagnosis is unclear | **Consider if concern for intraocular foreign body '''OR''' diagnosis is unclear | ||
**Sensitivity ~60% | **Sensitivity ~60% | ||
== | ==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 [[antiemetics|antiemetic]] (e.g. [[ondansteron]] 4mg IV) | |||
*IV [[analgesia|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> | |||
===[[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>=== | |||
====NO intra-[[ocular foreign body]]==== | |||
*First choice: [[Fluoroquinolone]] IV, such as Levofloxacin '''OR''' | |||
*Second choice: [[Vancomycin]] IV and [[ceftazidime]] | |||
== | ====Intra-[[ocular foreign body]] PRESENT==== | ||
* | *[[Ceftazidime]] 1gm + [[vancomycin]] 1 gm | ||
*Penicillin allergy: [[Ciprofloxacin]] + [[vancomycin]] | |||
* | |||
==Disposition== | ==Disposition== | ||
| Line 61: | Line 69: | ||
==See Also== | ==See Also== | ||
[[Orbital Blowout Fracture]] | *[[Orbital Blowout Fracture]] | ||
*[[Ocular foreign body]] | |||
== | ==References== | ||
<references/> | |||
[[Category: | [[Category:Ophthalmology]] | ||
Revision as of 16:47, 5 October 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
- Ears
- Nose
- Oral
- Other face
- Zygomatic arch fracture
- Zygomaticomaxillary (tripod) fracture
- Related
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 antiemetic (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
- First choice: Fluoroquinolone IV, such as Levofloxacin OR
- Second choice: Vancomycin IV and ceftazidime
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
References
- ↑ 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
- ↑ 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
- ↑ 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
- ↑ Libonati MM, Leahy JJ, Ellison N: The use of succinylcholine in open eye surgery. Anesthesiology 1985; 62:637-640
- ↑ 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