Globe rupture: Difference between revisions

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==Background==
==Background==
Be careful not to apply pressure to eye
[[File:Schematic diagram of the human eye en.png|thumb|Eye anatomy.]]
*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==
*Eye covering
[[File:PMC4219229 MEAJO-21-347-g002.png|thumb|Globe rupture with protruding uveal tissue.]]
*Elevate head of bed
[[File:PMC5000536 JOVR-11-313-g006.png|thumb|Globe rupture with deep penetrating orbital wounds and extensive globe laceration.]]
*Prevent nausea/vomiting
*[[Eye pain]]
*Prophy abx
*+/- [[vision loss|decreased visual acuity]]
**Ceftaz 1gm + Vanco 1 gm
*Teardrop-shaped pupil
**PCN allergy: Cipro + vanc
*Flat anterior chamber
*Surgical emergency
*Extrusion of intraocular content
*[[Subconjunctival hemorrhage]] involving entire (360 degree) sclera
*[[red eye|Hemorrhagic chemosis]]
 
===[[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==
[[File:PMC3038515 IJO-59-131-g007.png|thumb|positive Seidel’s test.]]
*Inspect lids, lashes, cornea, sclera, and pupils.
*Evaluate for a relative afferent pupillary defect
*Visual acuity
*Do NOT perform tonometry for [[IOP]]
*Positive Seidel’s test is indicative of globe rupture
 
===Work-Up===
*Non-contrast CT orbit
**Consider if concern for intraocular foreign body '''OR''' diagnosis is unclear
**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]]
 
====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==
==See Also==
[[Orbital Blowout Fracture]]
*[[Orbital Blowout Fracture]]
*[[Ocular foreign body]]


==Source==
==References==
Donaldson 5/08 (trauma reports)
<references/>


[[Category:Ophtho]]
[[Category:Ophthalmology]]

Latest revision as of 23:38, 16 December 2020

Background

Eye anatomy.
  • 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

Globe rupture with protruding uveal tissue.
Globe rupture with deep penetrating orbital wounds and extensive globe laceration.

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

positive Seidel’s test.
  • Inspect lids, lashes, cornea, sclera, and pupils.
  • Evaluate for a relative afferent pupillary defect
  • Visual acuity
  • Do NOT perform tonometry for IOP
  • Positive Seidel’s test is indicative of globe rupture

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
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