Continuing Education Activity

Globe rupture is a vision-threatening emergency. It is essential that clinicians have a high index of suspicion for globe rupture when treating patients with ocular trauma. This activity outlines the evaluation and management of patients presenting with a globe rupture and reviews the role of the healthcare team in evaluating and treating patients with this condition.

Objectives:

• Summarize the epidemiology of globe rupture.
• Explain the common physical exam findings associated with globe rupture.
• Outline the treatment and management options available for globe rupture.
• Describe interprofessional team strategies for improving care coordination and communication to advance the management of patients with globe rupture and improve outcomes.

Introduction

Globe rupture, globe laceration, globe perforation, or open globe injuries are forms of ocular trauma that require urgent diagnosis and treatment. Globe rupture is the common term used to describe all potential types of open globe injuries. Two primary mechanisms can disrupt the integrity of the globe - penetration/perforation/laceration and rupture due to blunt force.  A penetrating injury is when an object penetrates the eye, but the object does not go all the way through the eye. In these cases, there can be an intraocular foreign body that remains in the eye. If there is an entrance and an exit wound, then this is considered a perforating injury. In the United States, estimated cases of globe rupture are approximately 3 per 100000.[1] Diagnosis of globe rupture is based on history and clinical ophthalmologic examination, typically consisting of the slit lamp and fundoscopic evaluation. Imaging may not be reliable to diagnose a globe rupture but should be obtained as a supplement to the workup. When there is a high index of suspicion, an immediate consultation with an ophthalmologist for evaluation is the recommended course of treatment.

Etiology

In children, sharp objects like scissors are the most likely cause of ocular globe rupture. The majority of these injuries happen at home.[2] In adults, workplace injuries, assaults, and motor vehicle accidents are common causes. In the elderly, ground-level falls are the most common causes of globe rupture.[3][4] A large study from China found that if the patient has a penetrating or perforating injury with an intraocular foreign body, it is most commonly due to an explosive in patients under ten, and more likely due to a foreign body if over ten years of age.[5] Other potential etiologies of globe rupture include gunshots, sporting injuries, stab wounds, and blast wounds.[6][7][8]

Epidemiology

Globe rupture is more common in males than in females.[9] Among males, globe rupture is nearly twice as common in those under 40 years of age when compared to those over the age of 40. In adult males under 40 years of age, assault and workplace injuries are the most common causes of globe rupture. In the population over the age of 75, globe ruptures are most commonly caused by ground-level falls.[3] In indirect trauma, the most common location of rupture is at the superior-nasal quadrant close to the limbus. Globe rupture can happen at any location of penetration and along any of the meridians of the eye.[10] Substance abuse is associated with higher rates of ocular trauma.[11] 

Pathophysiology

Globe rupture can either occur due to an object penetrating the ocular tissues or by blunt trauma. Blunt trauma can cause an acute rise in intraocular pressure and cause a rupture in the location where the eye is the weakest. In eyes that have not had surgery, the rupture is most commonly posterior to the extraocular muscles where the sclera is the weakest. In eyes that have had previous intraocular surgery, the rupture is often at the prior incision site. The eye also commonly ruptures at the limbus in blunt trauma. In clinical models, pressures of greater than 7000 mm Hg may be needed to rupture the globe.[12]

History and Physical

The history of patients presenting with globe rupture should focus on the etiology of the ocular and/or periocular trauma. The patient may present with sudden eye pain and vision loss after a potentially penetrating injury. Common penetrating causes of globe rupture may include glass or metal fragments, shotgun or bb pellets, and wood shavings from wood grinding. Globe rupture resulting from blunt trauma may result from mechanical falls, syncope, seizures, motor vehicle accidents with airbag deployment, or assaults with blunt objects. 

The physical exam on patients with potential globe rupture requires a detailed ophthalmologic assessment. Careful evaluation of the patient’s baseline visual acuity is critical. A slit-lamp examination should be performed to assess the anterior portion of the globe and the anterior chamber. It is essential to carefully assess the conjunctiva, looking for defects, visible foreign bodies, or lacerations. Particular attention should be paid to the equatorial sclera immediately posterior to the insertion of the rectus muscles, as this area is one of the most common locations for globe rupture because the sclera is thinnest at this location.[13] The pupil should be examined for reactivity and shape, taking note of any irregularities in the roundness of the pupil. No pressure must be applied to the globe during evaluation; this means tonometry and eversion of the lids should not be part of the initial assessment. 

Evaluation

Evaluation of the eye to assess for a globe injury after trauma is possible once an assessment of the patient’s airway, breathing, and circulation has taken place. Patients will often have decreased visual acuity, and this can be assessed using a Snellen chart or near card. In patients with severe visual impairment, acuity evaluation is by the patient's ability to count fingers (CF), see a moving hand (HM), or flashes of light (LP). Inspection of the eye using a slit lamp enhances the ability to detect penetrating foreign bodies, scleral or corneal lacerations, uveal prolapse, or iris abnormalities such as peaked or “tear-drop” pupil. A Seidel sign may also be present when performing fluorescein staining of the cornea and sclera as a stream of clear aqueous fluid originating from the globe wound site, although the globe can be open even if this sign is negative.[14] Seidel testing is contraindicated in cases of obvious globe rupture.

A maxillofacial computed tomography (CT) scan can aid in the management of globe rupture, although it should never replace an ophthalmic evaluation.[15][16] A CT scan is the preferred imaging technique to assess for the presence of intraocular foreign bodies.[17] Magnetic resonance imaging (MRI) is contraindicated in ocular trauma with suspected ferromagnetic foreign bodies due to concern for the worsening of the injury. If CT is negative for metallic intraocular objects, but the clinician still suspects an intraocular foreign body, magnetic resonance imaging or plain film radiography are options. Ultrasound can be used to detect intraocular foreign bodies as well; however, it is relatively contraindicated as direct pressure on the globe can cause extrusion of the intraocular contents and worsen the initial injury.

Treatment / Management

Once globe rupture is suspected, urgent ophthalmologic consultation is required. The patient should first be treated for any other potentially life-threatening injuries and remain NPO (nothing by mouth). The affected eye should be protected using a Fox shield, cup, or another protective device.[18] Removal of any foreign bodies should not occur until the patient is in surgery. Maneuvers that will increase intraocular pressure should be avoided (i.e., tonometry, lid retraction, or ocular ultrasound).[19] In patients who are awake and alert, it is recommended to reduce stressors that may increase intraocular pressure. Antiemetics, pain control, and bed rest with elevation of the head of the bed to 30 degrees will aid in this process.

Open globe injuries are tetanus-prone wounds, and patients should receive a booster if their immunization history is uncertain or incomplete.[20] Although no specific prophylactic antibiotic regimen exists, preservative-free, topical antibiotic drops before surgery can be given prophylactically to theoretically decrease the risk of endophthalmitis.[21] In unstable patients or where intubation is required, it is essential to choose systemic medications that do not raise intraocular pressure.[22] Some common anesthetic agents may increase IOP. There is evidence that ketamine raises intraocular pressure, but studies are conflicting. Succinylcholine has been found to raise the intraocular pressure, although this is reducible with subsequent remifentanil administration. Rocuronium has been found not to raise the intraocular pressure as much as succinylcholine and is suitable as a muscle relaxer in ruptured globe cases.

Surgical management by an ophthalmologist should commence as soon as the patient can safely undergo surgery, a delay in surgical intervention may lead to worse final visual outcomes and increase the risk of postoperative endophthalmitis.[23][24] Initial surgical management of a globe rupture includes microsurgical corneal and/or scleral wound repair. Corneal lacerations can be closed with 10-0 nylon interrupted sutures. Corneal suture knots should be buried to prevent postoperative complications. Scleral wounds may be closed with 7-0, 8-0, or 9-0 nonabsorbable sutures, and an attempt should be made to burry or cover these suture knots as well. Before closure, incarcerated uvea must be reposited or excised, and prolapsed vitreous should be excised from the wound. The anterior chamber should also be reformed and repressurized to an appropriate IOP. Following wound repair, intravitreal or intracameral antibiotics are necessary, as they have been shown to decrease the risk of endophthalmitis following a traumatic globe rupture.[25][26]

If there is a perforating injury that affects that eye posteriorly, further surgical intervention may be necessary. While anterior wounds require suturing, the surgeon may choose to leave the posterior wound unrepaired so that extrusion of vitreous or retinal disruption during attempted closure is avoidable. Fibrous proliferation occurs along the damaged vitreous between the entrance and exit wounds, which often closes the wounds within a week following the trauma. This fibroblastic proliferation can lead to retinal detachments, epiretinal membranes, and proliferative vitreoretinopathy, leading to loss of vision. Indications for a vitrectomy include signs of developing transvitreal detachment, the presence of moderate to severe vitreous hemorrhage, phacoanaphylactic uveitis, and damage to other tissue requiring repair. If there is an intraocular foreign body, removal with culture is often necessary, especially if the material is toxic to the eye over time.[27][28]

Following surgical repair, patients will start on topical antibiotics covering the most common pathogens for endophthalmitis following globe rupture - Bacillus cereus and gram-negative organisms.[29] Patients may also be started on systemic antibiotics for additional prevention against endophthalmitis. Oral levofloxacin (500 mg once a day for 7 to 10 days) covers many of the most common causative organisms except pseudomonas and has some intravitreal penetration.[30] Fungal coverage is also an option in patients with an appropriate history. As recommendations for antibiotic selection can differ depending on the mechanism of injury and changes in the microbiological spectrum, consult recent references of an infectious disease specialist.

Differential Diagnosis

Globe rupture should be a consideration whenever a patient presents with blunt or penetrating facial trauma. An open globe should also be suspected whenever a patient presents with pain or vision loss after injury. The differential diagnosis for globe rupture should include:[3]

• Subconjunctival hemorrhage
• Orbital wall or floor fracture
• Corneal abrasion
• Orbital hemorrhage
• Corneal ulceration
• Glaucoma
• Traumatic iritis

Prognosis

The most important factor influencing the patient's final visual acuity following globe rupture is the patient's presenting visual acuity.[27][31] Other factors leading to a worse final visual acuity include posterior globe involvement of the injury, the existence of a relative afferent pupillary defect, vitreous prolapse through the wound, longer wound length, vitreous hemorrhage, hyphema, endophthalmitis, and retinal detachment.[32][33][34][35] For providers wanting to predict the functional outcome following a serious eye injury, the Ocular Trauma Score was created in 2002 to use for prognostic purposes.[36]

Complications

Globe rupture may result in a variety of complications, including permanent blindness, endophthalmitis, and chronic pain. Delayed complications of a penetrating injury include cyclitic membrane formation, tractional retinal detachment, choroidal rupture, and phthisis bulbi.[37][38] Sympathetic ophthalmia is another devastating complication where there is a diffuse bilateral granulomatous panuveitis following immune system sensitization to the intraocular contents of the traumatized eye. To decrease the risk of sympathetic ophthalmia, several sources recommend enucleation or evisceration within two weeks of an open globe injury if the visual prognosis is poor.[39]

Retained intraocular foreign bodies can cause chronic disease in the eyes. Copper foreign body toxicity is called chalcosis and causes the complications of a sunflower cataract, chronic uveitis, vitreous opacification, and copper deposition in the macula. Iron toxicity from a retained intraocular foreign body is called siderosis bulbi and causes the complications of retinal degeneration, iris heterochromia, loss of accommodation, nyctalopia, and loss of visual field.[40]

Consultations

When there is any suspicion of a globe rupture, it requires an ophthalmology consult.[41] If there is involvement of the eye posteriorly, a retinal specialist will need to be involved in patient evaluation and management.[42] A radiologist should evaluate any imaging for the presence of intraocular foreign bodies. Anesthesia will be needed if the patient needs to go to the operating room.

Deterrence and Patient Education

The patient should receive education in the use of proper eye protection and avoidance of potentially harmful lifestyle choices that may increase their chances of ocular injury. Patients should also understand that they have a higher risk of globe rupture following a penetrating keratoplasty, and thus should not partake in any strenuous activities if they undergo that procedure.[43][44]

Enhancing Healthcare Team Outcomes

Management of globe rupture is a surgical emergency until proven otherwise. Patients with this condition typically present to the emergency department, and it is important that the triage team recognize the emergent nature of this presentation and immediately activate a trauma assessment. The patient must be placed in a room promptly evaluated by a physician who is familiar with the patient's presentation and chief complaint. Prompt history, physical exam, and visual acuity will give the physician some initial guidance and direction before consulting ophthalmology or considering CT imaging. Some evidence suggests that earlier surgical repair reduces the risk of endophthalmitis.[23][24][45] [Level 5] Thus, repair of open globe injuries should be undertaken within 24 hours if at all possible.

Once globe rupture is safely ruled out, other potential causes of acute ocular pain, including corneal abrasions or ulcerations, can undergo an evaluation and the patient appropriately treated. Management of acute ocular pain requires a coordinated interprofessional effort between nursing staff, ER clinicians, pharmacists, and ophthalmologic specialists to coordinate an accurate and prompt diagnosis that will result in appropriately directed management and treatment. 

Nursing will assist both during the evaluation period, as well as during any operative procedures, providing clinician support, administering medications, and answering patient questions. If antimicrobial therapy is necessary, an infectious disease board-certified pharmacist can be an invaluable resource, assisting with agent selection based on the latest antibiogram data available. This type of interprofessional teamwork is necessary for globe rupture injuries, to guide patients to the best possible outcomes.