Difference between revisions of "Globe rupture"

(→‎Background)
(→‎ManagementLayer 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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==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>==
 
==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
 
*Consult ophtho immediately
−
*Do not manipulate the eye  
+
**Keep NPO
−
*Eye covering with metal shield or paper cup
+
*Prevent further injury
−
*Elevate head of bed
+
**Do not manipulate the eye  
−
*Treat [[nausea/vomiting]]
+
**Eye covering with metal shield (Fox shield) or paper cup (do not place a patch that touches globe)
−
*Broad spectrum IV [[antibiotics]]
+
*Minimize elevations in intraocular pressure
−
**[[Ceftazidime]] 1gm + [[vanco]] 1 gm
+
**Elevate head of bed
−
**[[penicillin allergy]]: [[Cipro]] + [[vanco]]
+
**bed rest; no bending/lifting/Valsalva
−
*[[Tetanus]], if indicated
+
**Consider anti-emetic (e.g. [[ondansterone]] 4mg IV)
−
*Keep patient NPO
+
*IV pain medications PRN
−
*[[Intubation]], if necessary
+
*[[Tetanus prophylaxis]] (if indicated)
−
**[[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>
 +
 
 +
===[[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, '''OR'''
 +
*Second choice: [[Vancomycin]] IV and [[cetazidime]]
 +
 
 +
====Intra-ocular foreign body PRESENT====
 +
*[[Ceftazidime]] 1gm + [[vancomycin]] 1 gm
 +
*[[penicillin allergy]]: [[Cipro]] + [[vanco]]
  
 
==Disposition==
 
==Disposition==

Revision as of 20:28, 17 December 2017

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
    • 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. ondansterone 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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