AUTHOR AND EDITOR INFORMATION

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INTRODUCTION

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Background

Globe rupture occurs when the integrity of the outer membranes of the eye is disrupted by blunt or penetrating trauma. Any full-thickness injury to the cornea, sclera, or both is considered an open globe injury and is approached in the same fashion in the acute setting. Globe rupture represents a major ophthalmologic emergency and always requires surgical intervention. Although the globe's position within the orbit protects it from injury in many situations, damage to the posterior segment of the eye is associated with a very high frequency of permanent visual loss. Early recognition and ophthalmologic intervention are critical to maximizing functional outcome.

Pathophysiology

Globe rupture may occur when a blunt object impacts the orbit, causing anterior-posterior compression of the globe and raising intraocular pressure to a point that the sclera tears. Ruptures from blunt trauma usually occur at the sites where the sclera is thinnest, at the insertions of the extraocular muscles, at the limbus, and around the optic nerve. Sharp objects or those traveling at high velocity may perforate the globe directly. Small foreign bodies may penetrate the eye and remain within the globe. The possibility of globe rupture should be considered and ruled out during the evaluation of all blunt and penetrating orbital traumas as well as in all cases involving high-speed projectiles with potential for ocular penetration.

Frequency

United States

More than 2 million eye injuries occur in the United States annually, with more than 40,000 resulting in some degree of permanent visual impairment. One third of all cases of childhood blindness result from ocular trauma.

Mortality/Morbidity

• Globe rupture and posterior segment injury have always been associated with a high frequency of visual loss, but recent advances in microsurgical techniques have greatly improved the prognosis for some patients.
• Generally, blunt injuries have a somewhat better visual outcome than penetrating or perforating injuries.
• Patients should not be given a hopeful prognosis until full, usually operative, evaluation is complete. At presentation, reduced or absent vision, anterior chamber deformity, pupillary irregularity, chemosis, hyphema, vitreous hemorrhage, and decreased intraocular pressure worsen the prognosis.

Race

• No racial predilection exists.

Sex

• Because of occupational and recreational preferences, globe rupture is more common in males than in females.

Age

• Globe rupture is more common in younger patients, with most cases occurring in those younger than 40 years.
• A high percentage of occurrences are in adolescent boys.

CLINICAL

Section 3 of 11  

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History

• Mechanism of injury
• • Blunt, penetrating, or perforating
  • Nature of object suspected
  • Assess the likelihood of foreign bodies within the globe and/or orbit.
  • Eye injuries occurring at construction or metalworking sites should be assumed to include metallic intraorbital foreign body until ruled out.
  • Organic foreign bodies, such as wood, carry a particularly high infection rate.
  • Bite and scratch wounds carry a high risk for infection with common and species-specific agents.
• Circumstances of injury
• • Exact time of the injury
  • Location where injury occurred
  • Use of corrective or protective lenses
  • Eyewear may protect or contribute to harm in acute injury.
  • Severely myopic eyes may be more vulnerable to injury from anterior-posterior compression.
  • Use of seat belt or airbag deployment in motor vehicle crash
• Medical history
• • Ocular history
    • Previous eye surgery or injury - Tissues may be more susceptible to rupture.
    • Preinjury vision in both eyes
  • Preexisting diseases
  • Medications (including eye drops) and allergies
  • Tetanus status
• Symptoms
• • Pain
    • Pain may be difficult to assess in patients with obtundation or distracting injuries.
    • Pain may not be severe initially in sharp injuries, with or without intraocular foreign body.
  • Vision - Usually greatly decreased
  • Diplopia
    • If present, diplopia is usually due to entrapment and dysfunction of extraocular muscles with associated orbital floor blowout fractures.
    • Diplopia may be due to traumatic cranial nerve palsy from associated head injury.
    • Monocular diplopia may be due to associated lens dislocation or subluxation.

Physical

• Physical examination
• • Globe rupture may be immediately apparent on examination but is frequently occult, as the most frequent sites of rupture are not easily visualized and more superficial injuries may block examination of the posterior segment.
  • Examination of the injured eye should proceed systematically but always with the goal of identifying and protecting a ruptured globe.
  • It is critical to avoid putting pressure on a ruptured globe to minimize potential extrusion of intraocular contents and to avoid further damage.
• Visual acuity and eye movement
• • Visual acuity should be documented as accurately as possible for the injured and uninjured eye, even if it is limited to "counts fingers at 18 inches" or "light perception only."
  • Extraocular movement should be evaluated to rule out entrapment from an associated orbital floor fracture. Often, those with scleral ruptures beneath a rectus muscle avoid gazing in the field of action of that muscle.
• Orbits
• • Orbits should be examined for bony deformity, foreign body, and globe displacement.
    • Orbital rim fractures may be palpable and raise suspicion for entrapment and possible associated globe rupture.
    • Orbital crepitus indicates subcutaneous emphysema from an associated sinus fracture.
    • Orbital foreign bodies that may have impaled or perforated the globe should be left undisturbed until surgery.
    • A ruptured globe may present with enophthalmos (recession of the globe within the orbit).
    • An associated retrobulbar hemorrhage may cause exophthalmos, even with an occult scleral rupture.
• Eyelid
• • Eyelid and lacrimal injuries should be evaluated with the major goal of identifying and protecting possible deep injuries to the globe.
  • Even small lid lacerations may conceal vision-threatening globe perforations.
  • Lid repairs should not proceed until globe injury is ruled out.
• Conjunctiva
• • Conjunctival lacerations may overlie more serious scleral injuries.
  • Severe conjunctival hemorrhage (often covering 360 degrees of bulbar conjunctiva) may indicate globe rupture.
• Cornea and sclera
• • A full-thickness laceration to the cornea or sclera constitutes a globe perforation, and it should be repaired in the operating room.
  • Prolapse of the iris through a full-thickness corneal laceration may be visible as a dark discoloration at the site of injury.
  • Scleral buckling is indicative of rupture with extrusion of ocular contents.
  • Intraocular pressure will likely be low, but measurement is contraindicated to avoid pressure on the globe.
• Pupils
• • Pupils should be examined for shape, size, light reflex, and afferent pupillary defect (APD).
  • A peaked, teardrop-shaped, or otherwise irregular pupil may indicate globe rupture.
• Anterior chamber
• • Slit lamp examination in the cooperative patient may show associated injuries such as iris transillumination defect (red reflex obscured by vitreous hemorrhage); corneal lacerations; iris prolapse; hyphema from ciliary body disruption; and lens injuries, including dislocation or subluxation.
  • A shallow anterior chamber may be the only sign of occult globe rupture and is associated with a worse prognosis. A posterior rupture may present with a deeper anterior chamber due to extrusion of vitreous from the posterior segment.
• Other findings
• • Vitreous hemorrhage after trauma suggests retinal or choroidal tear, optic nerve avulsion, or foreign body.
  • Retinal tears, edema, detachments, and hemorrhage may accompany globe rupture.

Causes

• Globe rupture in adults may occur after blunt injury during motor vehicle accidents, sports activity, assault, or other trauma.
• Globe penetration or perforation may occur with gunshot and stab wounds, workplace accidents, and other accidents involving sharps or projectiles.
• Be particularly suspicious of eye injuries caused by metal striking metal (eg, hammer and chisel).
• One third of eye injuries occurring in children and adolescents ( <16 years) are sports related.
• Basketball, water sports, baseball, racquet sports, martial arts, wrestling, and archery are frequently implicated.
• BB and pellet guns present an extreme hazard to all age groups.
• Eye injuries from paintball weapons are becoming increasingly reported, with globe rupture occurring in 5% of injuries.

DIFFERENTIALS

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Other Problems to be Considered

Subconjunctival hemorrhage
Conjunctival laceration

WORKUP

Section 5 of 11  

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Lab Studies

• Coagulation studies and complete blood count are appropriate in patients who are likely to have underlying bleeding diatheses.
• Otherwise, laboratory studies are indicated as appropriate for coexisting trauma and other active medical problems.

Imaging Studies

• Computerized tomography
• • CT scanning is the most sensitive readily available imaging study to detect occult rupture, associated optic nerve injury, and small foreign bodies, as well as to visualize the anatomy of the globe and orbit.
  • Axial and coronal views of the brain and orbits with 1- to 1.5-mm cuts should be obtained.
  • Some nonmetallic foreign bodies, such as wood, glass, or plastic, may be difficult to visualize acutely on CT.
• Radiography
• • Orbital plain films are less useful than CT scan but may be more readily available.
  • A 3-view plain film series is most useful in evaluating the bony orbits and the sinuses and in identifying radiopaque foreign bodies.
  • Waters projection provides the best view of the orbital floor and detects air-fluid levels in the maxillary sinuses.
  • Caldwell or anteroposterior view visualizes the medial orbital wall, the lateral and superior orbital rims, as well as the ethmoid and frontal sinuses.
  • The third projection, or lateral view, is most useful in visualizing the orbital roof, maxillary and frontal sinuses, zygoma, and sella turcica.
• MRI
• • MRI is excellent in identifying injuries of the soft tissues of the globe and orbit.
  • MRI can be particularly helpful in localizing a nonmetallic foreign body, such as wood, that appears similar to soft tissue or air on CT scan.
  • MRI is contraindicated if metallic foreign body is suspected.
• Ultrasonography
• • Ocular ultrasonography has no role for the emergency physician acutely because of the risks associated with direct pressure on and around the globe.
  • Ultrasonography is becoming an increasingly important diagnostic tool for ophthalmology, and it may be needed to localize the rupture site or sites and to rule out intraocular or intraorbital foreign body.

Other Tests

• Other coexisting life-threatening and limb-threatening injuries should be evaluated and treated as usual.

Procedures

• Procedures such as repair of eyelid or conjunctival laceration are deferred until globe rupture is ruled out.

TREATMENT

Section 6 of 11  

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Prehospital Care

• A suspected or obvious ruptured globe should be protected from any pressure or inadvertent contact with a rigid shield during transport.
• Impaled foreign bodies should be left undisturbed.
• Eye patches are contraindicated.

Emergency Department Care

• Avoid all pressure on or around the injured eye to prevent extrusion of intraocular contents. Continue to protect the eye with a rigid shield. If a shield is not available, the bottom of a Styrofoam cup works well.
• Administer antiemetics (eg, promethazine [Phenergan], prochlorperazine [Compazine]) to prevent Valsalva maneuvers.
• Administer analgesics as indicated.
• Administer prophylactic antibiotics, ideally within 6 hours of the injury, to prevent endophthalmitis. This potentially devastating complication occurs in about 5% of penetrating trauma cases and in as many as 10% of trauma cases from a foreign body. Skin organisms, such as Streptococcus species, Staphylococcus aureus, and Staphylococcus epidermidis are most frequently involved. Attention should be given to species-specific pathogens if injury is due to bites (ie, dysgonic fermenter type 2 [DF2] and Eikenella for dog bites; Pasteurella multocida for cat bites) or if organic material is likely to have been introduced (ie, gram-negative organisms or fungi in a farming injury).
• Document tetanus immune status and update as indicated.
• Ascertain what time was the last meal. The patient should be kept NPO.
• Consult an ophthalmologist, and admit the patient to the hospital on bedrest with bathroom privileges.
• Surgical repair should be expedited. If repair is impossible, enucleation usually is necessary, either initially or within the first 7-14 days after the trauma.
• Ocular steroids have no role in the acute setting of a ruptured globe.

Consultations

• Ophthalmologist
• • Consult an ophthalmologist immediately.
  • Avoid any further manipulation of the injured eye while protection with a rigid shield is maintained, pending evaluation by an ophthalmologist.

MEDICATION

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The goal of pharmacotherapy is to prevent infections and pathophysiologic complications.

Drug Category: Antibiotics

Prophylactic systemic antibiotics are indicated in all cases of globe rupture. The risk of posttraumatic endophthalmitis is greatest when a penetrating injury exists, particularly with a retained intraorbital foreign body. Skin flora are the most common organisms, but contamination with soil, farm or animal flora, human saliva, or nonsterile water may introduce gram-negative organisms, anaerobes, and fungi. A complete list of antibiotics and their spectrum of activity is beyond the scope of this article. An example regimen is listed:

For adults, give cefazolin 1 g IV q8h plus ciprofloxacin 400 mg IV q12h. Newer fluoroquinolones, gatifloxacin and moxifloxacin, may have better vitreous penetration and anaerobic activity.

For children <12 years, give cefazolin 25-50 mg/kg/d IV divided tid plus gentamicin 2 mg/kg IV q8h.

If surgery must be delayed for any reason or if foreign body and/or organic contamination are considered likely, antibiotics with better penetration of the vitreous should be used prophylactically.

The list below provides examples of potential antibiotic choices and is not an exhaustive discussion. The ultimate choice of antibiotics is based on the individual characteristics of the injury and the patient, the determination of the degree of risk for infection and the likely organisms involved, and a specific drug's intraocular penetration characteristics.

Drug Name	Ciprofloxacin (Cipro)
Description	Provides excellent coverage against staphylococcal organisms and Pseudomonas, but it is not a good antibiotic for streptococci or anaerobes. Has excellent penetration of the eye in IV form. Anaerobic coverage can be achieved with addition of clindamycin, which also covers streptococci, except for enterococci.
Adult Dose	400 mg IV q12h
Pediatric Dose	<18 years: Not recommended >18 years: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy

Drug Name	Tobramycin (Nebcin)
Description	Aminoglycoside used as an alternative for children allergic to penicillin or for breastfeeding or pregnant women. Add clindamycin if anaerobic contamination is likely.
Adult Dose	1.5-2 mg/kg IV loading dose; followed by 1.5-1.7 mg/kg IV q8h maintenance dose
Pediatric Dose	4-5 mg/kg/d IV divided q8h
Contraindications	Documented hypersensitivity
Interactions	Increases effects of neuromuscular blockers and potentiates effect of extended-spectrum penicillins; concurrent administration with amphotericin B, cephalosporins, and loop diuretics increases risk of nephrotoxicity
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Caution in renal impairment, in preexisting auditory or vestibular impairment, and in patients with neuromuscular disorders; aminoglycosides are associated with nephrotoxicity and ototoxicity

Drug Name	Clindamycin (Cleocin)
Description	Often added to ciprofloxacin or tobramycin for coverage of anaerobes and streptococci.
Adult Dose	600-900 mg IV q8h
Pediatric Dose	20-40 mg/kg/d IV divided q6-8h
Contraindications	Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
Interactions	Increases duration of neuromuscular blockade, induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis

Drug Name	Imipenem-cilastatin (Primaxin)
Description	A penicillin-type antibiotic with broad coverage of gram-positive, gram-negative (including Pseudomonas), and anaerobic infections. Imipenem penetrates the aqueous and vitreous humor in high concentrations even without the presence of active inflammation.
Adult Dose	1 g IV q6h
Pediatric Dose	<12 years: Do not administer >12 years: 12 mg/kg IV q6h; not to exceed 4 g/d
Contraindications	Documented hypersensitivity
Interactions	Coadministration with cyclosporine may increase CNS side effects of both agents; coadministration with ganciclovir may result in generalized seizures
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Adjust dose in renal insufficiency

Drug Name	Gentamicin (Garamycin, Jenamicin)
Description	Aminoglycoside antibiotic for gram-negative coverage bacteria including Pseudomonas species. Synergistic with beta-lactamase against enterococci. Interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits. Dosing regimens are numerous and are adjusted based on CrCl and changes in volume of distribution, as well as body space into which agent needs to distribute. Dose of gentamicin may be given IV/IM. Each regimen must be followed by at least trough level drawn on third or fourth dose, 0.5 h before dosing; may draw peak level 0.5 h after 30-min infusion.
Adult Dose	Serious infections and normal renal function: 3 mg/kg/dose IV q8h Loading dose and maintenance dose: 1-2.5 mg/kg IV and 1-1.5 mg/kg IV, respectively, q8h Extended-dosing regimen for life-threatening infections: 5 mg/kg/d IV/IM q6-8h Follow each regimen by at least a trough level drawn on third or fourth dose (0.5 h before dosing); may draw a peak level 0.5 h after 30-min infusion
Pediatric Dose	2 mg/kg IV q8h
Contraindications	Documented hypersensitivity; non–dialysis-dependent renal insufficiency
Interactions	Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; because aminoglycosides enhance effects of neuromuscular blocking agents, prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)
Pregnancy	D - Unsafe in pregnancy
Precautions	Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment

Drug Name	Vancomycin
Description	May be used as an alternative to cefazolin for adults allergic to penicillin. Provides excellent gram-positive coverage, including Bacillus. To avoid toxicity, current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dose. Use creatinine clearance to adjust dose in patients with renal impairment.
Adult Dose	1 g IV q12h
Pediatric Dose	40 mg/kg/d IV
Contraindications	Documented hypersensitivity
Interactions	Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in renal failure, neutropenia; red man syndrome is caused by too rapid IV infusion (dose given over a few min) but rarely happens when dose given IV over 2-h administration or as PO or IP administration; red man syndrome is not an allergic reaction

FOLLOW-UP

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Further Inpatient Care

• Further care is at the discretion of the consulting ophthalmologist.

Transfer

• Transfer may be necessary if the patient presents to an institution without ophthalmology consultation services or without the ability to provide the definitive surgical repair.

Deterrence/Prevention

• Proper protective eyewear is the mainstay of prevention of ocular injury.
• Industrial sites are mandated to provide at-risk employees with protective eyewear.
• Physicians should encourage their patients to use eye shields when using lawn-care, woodworking, or metalworking equipment.

Complications

• After globe rupture, delayed postoperative or exogenous endophthalmitis, and infection involving the deep structures of the eye, are always potential complications.
• Depending on the organism involved, endophthalmitis may present within hours of the globe rupture or, as with fungal organisms, the infection may not appear until weeks later.
• Sympathetic ophthalmia is an inflammation that can develop in the uninjured eye weeks to months after the initial injury. Thought to be an autoimmune response to normally isolated tissues of the uvea that are exposed with injury, the condition and its symptoms of pain, decreased visual acuity, and photophobia, may improve after enucleation of the injured eye. Treatment may also include immunosuppressive agents, including steroids.

Prognosis

• The prognosis depends largely on the extent of injury and the time from injury until appropriate surgical treatment.
• The prognosis should be guarded until after surgery.

Patient Education

• For excellent patient education resources, visit eMedicine's Eye and Vision Center. Also, see eMedicine's patient education article Subconjunctival Hemorrhage (Bleeding in Eye).

MISCELLANEOUS

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Medical/Legal Pitfalls

• Failure to diagnose and operate urgently worsens an already grim prognosis for preservation of visual acuity.
• Endophthalmitis is a frequently devastating complication. Systemic antibiotics are indicated prophylactically.
• Exploration and repair of more obvious, but less serious, injuries may cause further damage to the globe and worsen outcome.
• An obvious globe rupture may present with other life-threatening injuries that could be overlooked.
• Use of succinylcholine
• • The patient with globe rupture may present with other major injuries that necessitate endotracheal intubation.
  • Classic teaching warns that the use of succinylcholine as a paralytic agent in the setting of an open globe injury carries a theoretical risk of extrusion of the ocular contents through a rise in intraocular pressure and spasm of the rectus muscles. Some current anesthesia and ophthalmology texts continue to classify succinylcholine as "contraindicated" in the presence of an open globe injury for this reason, despite a lack of evidence in the literature.
  • The phenomenon of extrusion of ocular contents after administration of succinylcholine in the setting of open globe injury is not well documented in the literature and seems to be limited to anecdotal evidence. Anesthesia induction using succinylcholine has been performed routinely at some eye centers without evidence of ocular extrusion.
  • Some studies suggest that pretreatment with a nondepolarizing agent prior to the administration of succinylcholine eliminates this theoretical risk. In one study with 100 patients with penetrating eye injuries, no adverse events were reported.
  • Although the use of succinylcholine in the setting of open globe injury remains controversial, the need for this agent as a valuable adjunct to airway management should be weighed against the theoretical risk of ocular extrusion. Refer to local practice guidelines at one's institution.

MULTIMEDIA

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Media file 1:  Operating microscope view of a globe rupture secondary to blunt trauma by a fist. Notice the dark arc in the bottom of the photo representing the ciliary body visible through the scleral breach. Subconjunctival hemorrhage of this severity should raise suspicion of occult globe rupture. Photo courtesy of Brian C Mulrooney, MD.
	View Full Size Image
Media type:  Photo

REFERENCES

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• Authors and Editors
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• Brunette DD. Ophthalmology. In: Rosen's Emergency Medicine. Vol 2. 2002:908-927.
• Catalano R. Ocular Emergencies. Philadelphia: WB Saunders;1992.
• Friedberg MA, Rapuano CJ. Office and Emergency Room Diagnosis and Treatment of Eye Disease. Philadelphia:. JB Lippincott;1990.
• Harlan JB, Pieramici DJ. Evaluation of patients with ocular trauma. Ophthalmol Clin North Am. Jun 2002;15(2):153-61. [Medline].
• Khaw PT, Shah P, Elkington AR. Injury to the eye. BMJ. Jan 3 2004;328(7430):36-8. [Medline].
• Kunimoto DY, Kanitar KD, Maker MS. The Wills Eye Manual. 4th ed. 2004.
• Linden JA, Renner GS, Scott. Trauma to the Globe. In: Emergency Medical Clinics of North America: Emergency Treatment of the Eye. Philadelphia: WB Saunders;1995.
• Listman DA. Paintball injuries in children: more than meets the eye. Pediatrics. Jan 2004;113(1 Pt 1):e15-8. [Medline].
• Mader TH, Carroll RD, Slade CS, et al. Ocular war injuries of the Iraqi Insurgency,January-September 2004. Ophthalmology. Jan 2006;113(1):97-104. [Medline].
• Nelson LB. Injuries to the eye. In: Nelson Textbook of Pediatrics. Philadelphia: WB Saunders;1996.
• Poon A, McCluskey PJ, Hill DA. Eye injuries in patients with major trauma. J Trauma. Mar 1999;46(3):494-9. [Medline].
• Rodriguez JO, Lavina AM, Agarwal A. Prevention and treatment of common eye injuries in sports. Am Fam Physician. Apr 1 2003;67(7):1481-8. [Medline].
• Sanford JP, Eliopoulos GM, Moellering RC. The Sanford Guide to Antimicrobial Therapy. Antimicrobial Therapy, Inc; 2005.
• Vachon CA, Warner DO, Bacon DR. Succinylcholine and the open globe. Tracing the teaching. Anesthesiology. Jul 2003;99(1):220-3. [Medline].

Article Last Updated: Feb 16, 2007