Difference between revisions of "Globe rupture"

(NO intra-ocular foreign body)
Line 13: Line 13:
  
 
==Clinical Features==
 
==Clinical Features==
*Eye pain
+
*[[Eye pain]]
*+/- decreased visual acuity
+
*+/- [[vision loss|decreased visual acuity]]
 
*Tear-shaped pupil
 
*Tear-shaped pupil
 
*Extrusion of intraocular content  
 
*Extrusion of intraocular content  
*Subconjunctival hemorrhage involving entire sclera
+
*[[Subconjunctival hemorrhage]] involving entire sclera
 
*Hemorrhagic chemosis
 
*Hemorrhagic chemosis
  
 
===Slit-lamp===
 
===Slit-lamp===
 
*Shallow anterior chamber
 
*Shallow anterior chamber
*Hyphema
+
*[[Hyphema]]
 
*Seidel's sign - do not perform this test if suspect open globe
 
*Seidel's sign - do not perform this test if suspect open globe
 
**May be falsely negative if scleral rupture is small
 
**May be falsely negative if scleral rupture is small
*Lens dislocation
+
*[[Lens dislocation]]
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
Line 33: Line 33:
 
*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
  
Line 50: Line 50:
 
**Elevate head of bed
 
**Elevate head of bed
 
**Bed rest; no bending/lifting/Valsalva
 
**Bed rest; no bending/lifting/Valsalva
**Consider anti-emetic (e.g. [[ondansteron]] 4mg IV)
+
**Consider [[antiemetics|antiemetic]] (e.g. [[ondansteron]] 4mg IV)
*IV pain medications PRN
+
*IV [[analgesia|pain medications]] PRN
 
*[[Tetanus prophylaxis]] (if indicated)
 
*[[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>
 
*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>

Revision as of 17:57, 28 September 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

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
  • 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