Difference between revisions of "Globe rupture"

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(AntibioticsLayer 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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==Background==
 
==Background==
 
*Vision threatening emergency
 
*Vision threatening emergency
*Rupture of the sclera of the eye
+
*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]]
+
*[[Blunt Eye Trauma]]
##Caused by suddenly elevated IOP
+
**Caused by suddenly elevated IOP
#Penetrating trauma
+
*Penetrating trauma
##Suspect globe penetration w/ any puncture or laceration of eyelid or periorbital area
+
**Suspect globe penetration with any puncture or laceration of eyelid or periorbital area
##More commonly assoc w/ objects from metal on metal, lawn mower, drills, grinders
+
**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
+
*[[Eye pain]]
#+/- decreased visual acuity
+
*+/- [[vision loss|decreased visual acuity]]
#Tear-shaped pupil
+
*Teardrop-shaped pupil
#Extrusion of intraocular content  
+
*Flat anterior chamber
#Subconjunctival hemorrhage involving entire sclera
+
*Extrusion of intraocular content  
#Hemorrhagic chemosis
+
*[[Subconjunctival hemorrhage]] involving entire (360 degree) sclera
#Slit-lamp
+
*[[red eye|Hemorrhagic chemosis]]
##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
 
  
==Diagnosis==
+
===[[Slit-lamp]]===
 +
*Once the diagnosis of a ruptured globe is made, further examination should be DEFERRED until the time of surgical repair in the operating room.  Consider diagnosis via penlight exam. Slit lamp findings described below, but crucial to avoid any pressure on eye, which risks extrusion of intraocular contents.
 +
*Deep or shallow anterior chamber compared to fellow eye, full thickness scleral or corneal laceration, severe subconjunctival hemorrhage (especially involving 360 degrees of bulbar conjunctiva, often bulbous), peaked or irregular pupil, iris transillumination defect, lens material or vitreous in the AC, foreign body tract or new cataract in the lens, limitation of extraocular motility (greatest in the direction of rupture), intraocular contents may be outside of the globe
 +
*[[Hyphema]], periorbital ecchymosis, [[Lens dislocation]], traumatic optic neuropathy, choroidal rupture, dislocated/subluxed lens
 +
*Seidel's sign - do not perform this test if suspect open globe
 +
**May be falsely negative if scleral rupture is small
 +
 
 +
==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 Acuity
+
*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%
  
==DDx==
+
==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>==
*[[Orbital Blowout Fracture]]
+
*Consult ophtho immediately for emergent surgical repair
*[[Retrobulbar Hematoma]]
+
**Keep NPO
*[[Traumatic Hyphema]]
+
*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]]
  
==Treatment==
+
====Children====
*Consult ophtho immediately
+
*For children < 12 years, cefazolin 25-50 mg/kg/day in three divided doses, and gentamicin 2 mg/kg iv q8h. Gentamicin peak and trough levels are obtained one-half hour before and after the fifth dose, and BUN/Cr levels are evaluated every other day.
*Do not manipulate the eye
 
**No eye drops
 
*Eye covering with metal shield or paper cup
 
*Elevate head of bed
 
*Treat nausea/vomiting
 
*Broad spectrum IV ABX
 
**Ceftazidime 1gm + vanco 1 gm
 
**PCN allergy: Cipro + vanco
 
*Tetanus, if indicated
 
*Keep patient NPO
 
*If intubation necessary, recent studies show succinylcholine and ketamine <3 mg/kg are ok.
 
  
 
==Disposition==
 
==Disposition==
Line 61: Line 73:
  
 
==See Also==
 
==See Also==
[[Orbital Blowout Fracture]]
+
*[[Orbital Blowout Fracture]]
 +
*[[Ocular foreign body]]
  
==Source==
+
==References==
*Tintinalli
+
<references/>
*UpToDate
 
*Rosen's
 
  
[[Category:Ophtho]]
+
[[Category:Ophthalmology]]

Latest revision as of 03:51, 4 March 2020

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

Slit-lamp

  • Once the diagnosis of a ruptured globe is made, further examination should be DEFERRED until the time of surgical repair in the operating room. Consider diagnosis via penlight exam. Slit lamp findings described below, but crucial to avoid any pressure on eye, which risks extrusion of intraocular contents.
  • Deep or shallow anterior chamber compared to fellow eye, full thickness scleral or corneal laceration, severe subconjunctival hemorrhage (especially involving 360 degrees of bulbar conjunctiva, often bulbous), peaked or irregular pupil, iris transillumination defect, lens material or vitreous in the AC, foreign body tract or new cataract in the lens, limitation of extraocular motility (greatest in the direction of rupture), intraocular contents may be outside of the globe
  • Hyphema, periorbital ecchymosis, Lens dislocation, traumatic optic neuropathy, choroidal rupture, dislocated/subluxed lens
  • Seidel's sign - do not perform this test if suspect open globe
    • May be falsely negative if scleral rupture is small

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
  • 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

Children

  • For children < 12 years, cefazolin 25-50 mg/kg/day in three divided doses, and gentamicin 2 mg/kg iv q8h. Gentamicin peak and trough levels are obtained one-half hour before and after the fifth dose, and BUN/Cr levels are evaluated every other day.

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