To establish an objective, standardized system for assessment of ocular injuries and prognosis, Kuhn and colleagues developed the Ocular Trauma Score (OTS) from an analysis of 2,500 eye injuries.9 The OTS can be easily calculated following the initial examination or surgery and can assist in clinical decision-making and patient discussion. Do NOT measure intraocular pressure. If the wound is angled, the first suture is placed at the angle and if the wound crosses the entire cornea, the Rowsey-Hays technique is recommended where sutures with large bites are first placed at the two ends followed by gradually smaller bites as the sutures approach the center in a centripetal fashion.[14]. Retrieved August 21, 2017, from http://eyewiki.org/Seidel_Test. In this, a purse-string suture is used to prevent trauma to spices of laceration and a diamond knife is used for incising the corneal stroma to half the thickness at all the edges. Globe Rupture - JETem Zone I trauma involves the cornea and limbus. Ophthalmic Emergencies: Open Globe Injuries - Eyes On Eyecare Axial computed tomography of the orbits demonstrating an abnormal posterior globe contour and loss of globe volume, consistent with a posterior globe rupture. It is essential to carefully assess the conjunctiva, looking for defects, visible foreign bodies, or lacerations. Differentiating open globe injuries from corneal abrasions, hyphema, and other ocular injuries is critical. 2003 Mar; [PubMed PMID: 12701861], Yeh S,Colyer MH,Weichel ED, Current trends in the management of intraocular foreign bodies. The physician noted the following physical examination findings: the right eye had no light perception, a 3+ injection, and a large corneal laceration with uveal prolapse (Figure (Figure11). In clinical models, pressures of greater than 7000 mm Hg may be needed to rupture the globe.[12]. Blowout fractures are caused by a high-speed blunt force trauma to the globe or infra-orbital rim. 17 (5): 664-73. Prompt assessment of the type and extent of the injury is critical to ensure timely management. 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. 2008 Feb; [PubMed PMID: 18249259], Iyer MN,Kranias G,Daun ME, Post-traumatic endophthalmitis involving Clostridium tetani and Bacillus spp. Saarbrcken, Germany 2023: Best Places to Visit - Tripadvisor 2).1 Penetrating trauma has an entry point into the globe but no clearly defined exit wound, whereas perforating ocular injuries have both entrance and exit wounds through the eyewall. [6] Local anesthesia is avoided because the volume of fluid instilled around the eye from a block may cause further prolapse of intraocular content, however, if a local block is performed, a retrobulbar block is most likely to provide good anesthesia with akinesia with a prudently small injection volume. At the time the article was last revised Yuranga Weerakkody had The patient subsequently underwent enucleation of the affected eye. Zeiter JH, Shin DH. [9] In terms of wound integrity after penetrating keratoplasty, the highest risk period was found to be the month following surgery when the wound strength is derived almost entirely from sutures and the month following removal of sutures being the second high-risk period. [5] Rupture of the globe posterior to the spiral of Tillaux (surgical landmark delineated by connecting the rectus muscle insertions which approximate the underlying ora serrata) is normally accompanied by choroidal rupture and hemorrhage which may percolate through the retina to present as a vitreous hemorrhage. Fibrous proliferation occurs along the damaged vitreous between the entrance and exit wounds, which often closes the wounds within a week following the trauma. [14], Suturing of this wound must be watertight and be as close to normal corneal anatomy as possible where scars will interfere with visual rehabilitation and edema interferes with vitreoretinal surgery. 3 Casson RJ et al. Lambrou FH, Kozarsky A. Globe rupture, whether from penetrating or blunt trauma, is an ophthalmologic emergency that requires immediate specialist consultation. 2018 Aug; [PubMed PMID: 30083651], Yuan WH,Hsu HC,Cheng HC,Guo WY,Teng MM,Chen SJ,Lin TC, CT of globe rupture: analysis and frequency of findings. In anticipation of possible surgery, patients should be kept on NPO status (no food or liquids by mouth). A ruptured globe is classified as secondary to blunt trauma when an impact from a blunt object results in a momentary increase of the intraocular pressure resulting in an inside-out injury mechanism. An 85-year-old woman with a past medical history of osteoarthritis, hypertension, type 2 diabetes, hyperparathyroidism (status post parathyroidectomy), and presbyopia presented with a red globule protruding from the front of her right eye after a fall from her couch. The diagnosis is obvious when orbital contents spill from the globe itself. Emergency medicine clinics of North America. 202 (5): 1100-7. Ask whether the patient has any prior history of eye surgery or trauma. This topic provides an approach to diagnosis and initial treatment of eye injuries. Contributed with Permission by Michael . Injuries: Part 1 Mechanical Injuries. An open globe injury (OGI) involves a full-thickness defect in the eyewall, comprised of the sclera and cornea, resulting from penetrating or blunt trauma. Full-thickness laceration(s) of the cornea or sclera, Prolapse of intraocular contents (e.g., uveal tissue like the iris or ciliary body), Severe 360 subconjunctival hemorrhage and/or chemosis (conjunctival edema), Flat, shallow or deflated looking anterior chamber compared to the fellow eye (always examine the other eye to rule out injury and for comparison). Ehlers, J. P., & Shah, C. P. [29]Patients may also be started on systemic antibiotics for additional prevention against endophthalmitis. . 2013 Sep; [PubMed PMID: 24104709], Lieb DF,Scott IU,Flynn HW Jr,Miller D,Feuer WJ, Open globe injuries with positive intraocular cultures: factors influencing final visual acuity outcomes. [6] Peritomy just anterior to the rectus muscle insertions provides a large circumferential conjunctival opening that facilitates exposure. A thorough review of the patients past ocular and surgical history is important in evaluating the visual potential; moreover, prior surgical sites may be predisposed to rupture. Ophthalmology. The OTS is a point system based on factors that have strong prognostic significance. No MRI should be performed if there is suspicion of an intraocular foreign body or if metal may have caused the globe injury. If globe rupture is suspected, no pressure should be placed on the eye to reduce the risk of further extravasation of intraocular contents. Objectives: Summarize the epidemiology of globe rupture. Following proper cleaning, repositioning is the goal except for vitreous prolapse which is preferably cut with the vitrectomy probe and every attempt should be made to preserve the iris even if the injury is over 24 hours old. Evaluationof the eye to assess for a globe injury after trauma is possible once an assessment of the patients airway, breathing, and circulation has taken place. [17]Magnetic resonance imaging (MRI) is contraindicated in ocular trauma with suspected ferromagnetic foreign bodies due to concern for the worsening of the injury. government site. McGwin G Jr, Owsley C. Epidemiology of blinding trauma in the United States Eye Injury Registry. [14] Unless the wound is in the limbus, interrupted sutures should be used to avoid flattening the corneal dome shape with 10-0 nylon. Seidel Test. In the elderly, ground-level falls are the most common causes of globe rupture. [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. Yuan WH, Hsu HC, Cheng HC, Guo WY, Teng MMH, Chen SJ, Lin TC. Measurement of IOP should be delayed until an OGI is ruled out to avoid further damage and extrusion of intraocular contents. The initial symptoms following the trauma should be noted, as well as any significant changes such as increasing pain or worsening vision, which could indicate the development of endophthalmitis. 2005. [21]In unstable patients or where intubation is required, it is essential to choose systemic medications that do not raise intraocular pressure. Globe Rupture | The Atlas of Emergency Medicine, 5e | AccessEmergency Maneuvers that will increase intraocular pressure should be avoided (i.e., tonometry, lid retraction, or ocular ultrasound). This fibroblastic proliferation can lead to retinal detachments, epiretinal membranes, and proliferative vitreoretinopathy, leading to loss of vision. [29], The Ocular Trauma Score is often used to predict visual outcome of patients after open-globe ocular trauma ranging from 1 (most severe injury and worst prognosis at 6 months follow up) to 5 (least severe injury and least poor prognosis at 6 months) with globe rupture holding the worst prognosis followed by endophthalmitis, perforating injury, retinal detachment, and relative afferent pupillary defect in that order. [ [14] Of note, an occult globe rupture may be present without a visible scleral defect on slit lamp. At the time the article was created Mohamed Ahmed had no recorded disclosures. When suspected, cover eye with metal or protective eye shield. In general, hypotony is highly suggestive of OGI; however, a normal IOP does not eliminate the possibility of OGI. official website and that any information you provide is encrypted Colby K. Management of open globe injuries. 2005 Jul; [PubMed PMID: 16096559], Kumar K,Figurasin R,Kumar S,Waseem M, An Uncommon Meridional Globe Rupture due to Blunt Eye Trauma. Ophthalmol Clin North Am. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. 59(1):175-178. 2018; [PubMed PMID: 30319823], Wong TY,Klein BE,Klein R, The prevalence and 5-year incidence of ocular trauma. Produced by the Moran Eye Center in partnership with the Eccles Library, Home/Basic Ophthalmology Review/Trauma, Title: How to Assess Whether a Globe is Ruptured [2]In adults, workplace injuries, assaults, and motor vehicle accidents are common causes. Ophthalmology. Cornea. [16][17][18][19] Tetanus status should be addressed and prophylaxis given if appropriate. 2018;18(1):138. [23][24]Initial surgical management of a globe rupture includes microsurgical corneal and/or scleral wound repair. An overview of eye injuries and the evaluation and management of selected injuries are discussed separately: (See "Overview of eye injuries in the emergency department" .) 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]. Globe rupture | Radiology Reference Article | Radiopaedia.org No ocular ultrasound should be performed to avoid an increase in ocular pressure. 2010 Jan; [PubMed PMID: 19692359], Thevi T,Abas AL, Role of intravitreal/intracameral antibiotics to prevent traumatic endophthalmitis - Meta-analysis. American journal of ophthalmology. 1 A globe rupture refers to a full-thickness eyewall wound caused by a blunt object, while a laceration refers to a full-thickness eyewall wound caused by a sharp object. Pieramici DJ. 2022 2009 Apr [PubMed PMID: 19365034], Mohseni M,Bragg BN, Blunt Eye Trauma 2019 Jan; [PubMed PMID: 29261988], Couperus K,Zabel A,Oguntoye MO, Open Globe: Corneal Laceration Injury with Negative Seidel Sign. The worldwide incidence of OGI has been estimated at 3.5 injuries per 100,000 persons, with more than 203,000 cases occurring each year.2 Men and boys make up approximately 80% of patients with OGI, with those aged 10 to 30 years being at greatest risk.3 Young men are more likely to sustain perforating or penetrating injuries, particularly during occupational activities. Introduction: An open globe or ruptured globe is an eyeball with a full-thickness defect in part of the eyes wall, and is a true ophthalmic emergency. 2016 Sep-Oct; [PubMed PMID: 26994871], Jindal A,Pathengay A,Mithal K,Jalali S,Mathai A,Pappuru RR,Narayanan R,Chhablani J,Motukupally SR,Sharma S,Das T,Flynn HW Jr, Endophthalmitis after open globe injuries: changes in microbiological spectrum and isolate susceptibility patterns over 14years. 1 Kuhn F et al. Zone III trauma extends more than 5 mm posterior to the limbus, involving the posterior segment (e.g., the retina, optic nerve, and choroid).2. Decrease in vision following trauma. Care should be taken to minimize manipulation of the globe whenever an OGI is suspected. When a patient presents with ocular trauma, the clinician should first evaluate for life-threatening injuries. Eisner principle- Another variation of the suturing technique was suggested by Eisner to close a stellate laceration. [23] This study suggested the following for primary surgery; (1) prolapsed iris, choroid, and retina should be repositioned after complete irrigation and the prolapsed vitreous body can be removed otherwise retinal incarceration and closed tunnel detachment will result in poor visual acuity and severe proliferative response. Contributed with Permission by Michael Mohseni, MD From: Globe Rupture Copyright 2023, StatPearls Publishing LLC. 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. INTRODUCTION. 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. (3) For patients with anterior chamber hyphema, anterior chamber irrigation after tamponade of viscoelastic could prevent blood staining of the cornea. Patients may present with an open globe after various forms of trauma, from work- and sports-related injuries to falls and motor vehicle accidents. Image 2: Fundus photo of an inferior choroidal rupture versus scleral rupture with a vitreous tracking to the wound. Am J Ophthalmol 2009; 147:601. [13] If eye drops are necessary, prefer the use of new medication bottles and preservative-free variants. When there is a high index of suspicion, an immediate consultation with an ophthalmologist for evaluation is the recommended course of treatment. Prophylactic intravitreal antibiotics reduce the risk of post-traumatic endophthalmitis after repair of open globe injuries. Antiemetics, pain control, and bed rest with elevation of the head of the bed to 30 degrees will aid in this process. As a general principle, primary globe repair should be completed within 24 hours of injury and evaluation. In general, topical ointments should be avoided, although topical nonpreserved antibiotics may be used if there is a delay in getting the patient to the OR. Progress in retinal and eye research. Physical or chemical injuries of the eye can be a serious threat to vision if not treated appropriately and in a timely fashion. The surgeon should no grasp the cornea with forceps; the conjunctiva should be grasped if counterforce is needed. Do not: patch the eye, measure intraocular pressure (e.g., with a Tonopen), or allow the patient to rub the eye. [24] Retinotomy or retinectomy may be preferred according to trauma status and if the lens is not transparent enough, a lensectomy or phacoemulsification is performed first. The slit-lamp exam should include a detailed inspection of the conjunctiva and sclera. [6][7][8], Globe rupture is more common in males than in females. Accessibility [14] Repairing the scleral defect is performed if possible using a 6-0 to 8-0 Vicryl or 8-0 to 9-0 nylon often using a spatula needle. A peaked pupil is often considered pathognomonic for OGI. Globe rupture, globe laceration, globe perforation, or open globe injuries are forms of ocular trauma that require urgent diagnosis and treatment. [14]Seidel testing is contraindicated in cases of obvious globe rupture. 38 (11): E99. Sleeps 4 2 bedrooms 1 bathroom. Until the integrity of the globe is confidently established, do not place external pressure of any sort on the eye of concern. Imaging may not be reliable to diagnose a globe rupture but should be obtained as a supplement to the workup. Examine for shape, size, light reflex, and afferent pupillary defect; Imaging. A penetrating injury is defined as a single laceration with no exit wound and if there is more than one entrance wound, each must be caused by a different agent. EyeWiki. Signs suggestive of a ruptured globe include: 1. Ruptured globe is certain Stop the exam; place eye shield, consult ophtho Hyphema Evidence of significant trauma; consult ophtho Extra-ocular movements Restricted upgaze or lateral gaze suggests orbital fracture with entrapment Obtain CT face Orbital Rim Feel for step-off Sensation Risk factors for motor vehicle collision-related eye injuries. Significant findings: The patient's computed tomography (CT) head demonstrated a deformed left globe, concerning for ruptured globe. 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. His masterpiece is the Lutheran Ludwig's Church, which stands at the centre of a rectangular plaza. 2013; [PubMed PMID: 24511795], Bord SP,Linden J, Trauma to the globe and orbit. 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. Therapeutic advances in ophthalmology. [23][24][45] [Level 5]Thus, repair of open globe injuries should be undertaken within 24 hours if at all possible. Inspection starts with an external assessment of the head, face, eyelids, and periocular regions to note any ecchymosis, edema, or superficial lacerations that may be present. Chorioretinectomy for perforating or severe intraocular foreign body injuries. There are advantages and disadvantages to both staged and comprehensive approaches. In cases where ocular examination is limited, ancillary imaging studies are recommended to aid in the structural evaluation of the eye and to rule out the presence of a foreign body. A. Lecler, A. Pinel, P. Koskas. Where the injury took place is also pertinent because contamination of the wound with soil or organic matter is more likely in rural or agricultural settings. Prophylaxis of acute posttraumatic bacterial endophthalmitis: a multicenter, randomized clinical trial of intraocular antibiotic injection, report 2. The first month wound strength was found to be 38% that of the unoperated eye, a sutured wound followed for 6 months were found to have only 70% of its preoperative strength and overall, the cornea never regains its preoperative strength and remains at risk for traumatic rupture for the remainder of the patients life following penetrating keratoplasty. Antibiotics with methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas coverage should be administered (e.g., vancomycin and ceftazidime; in the event of allergies, clindamycin and gentamicin are alternative agents). Once globe ruptureis safely ruled out, otherpotential causes of acute ocularpain, including corneal abrasions or ulcerations,can undergo an evaluation and the patient appropriately treated. [30] Then correspond the raw score with the Ocular Trauma Score to estimate the patients probability of attaining a specific visual acuity range at a 6 month follow up. Ruptured Globe - EyeWiki History. Kuhn F, Pelayes D. Management of the Ruptured Eye. Open Globe Injury: Assessment and Preoperative Management An open globe should also be suspected whenever a patient presents with pain or vision loss after injury. Two primary mechanisms can disrupt the integrity of the globe - penetration/perforation/laceration and rupture due to blunt force. the contents by NLM or the National Institutes of Health. Summarize the epidemiology of globe rupture. The church is not only the city's most renowned landmark but also stands alongside Dresden's Church of Our Lady and St Michael's . Globe rupture should be a consideration whenever a patient presents with blunt or penetrating facial trauma. Saarbrcken C. Street View (Saarland, Germany) - street view Pupils: peaked, teardrop-shaped or irregularly pupils indicate globe rupture. In addition, controversy persists on the ideal timing of the secondary intervention when a staged approach is elected. The danger of this communication is two-way: the eyes internal contents can extrude, and environmental factors (e.g., pathogens) may enter. The Journal of trauma. patients with coexisting severe glaucoma and scleromalacia perforans. Lens position and clarity and the integrity of the lens capsule and zonular fibers should be evaluated. For occult globe rupture, during surgical exploration, a 360 peritomy is indicated to view all four quadrants of the posterior sclera bearing in mind that more than one rupture may be present. After surgical repair, the patient should be directed to wear a protective shield at all times, including while sleeping, and be given careful instructions to refrain from rubbing or touching the eye. Ophthalmology, Northwell Long Island Jewish Medical Center, New York, USA. Care should be taken to avoid pressure on the globe from the probe; however, in many cases, this modality is not recommended prior to globe repair. [6] Additionally, antiemetics should be given to reduce risk of increased ocular pressure. Seidel Test - EyeWiki American journal of roentgenology. [25][26], If there is a perforating injury that affects that eye posteriorly, further surgical intervention may be necessary. Ophthalmology 2011; 118:156. All content published within Cureus is intended only for educational, research and reference purposes. Most open globe injuries can be diagnosed with a simple penlight examination; however, smaller wounds may require a slit-lamp examination for confirmation and to rule out associated injury, intraocular foreign body, and endophthalmitis. Ludwigskirche. The British journal of ophthalmology. [1], The eye is filled with incompressible liquid and when a blunt object with sufficient momentum creates energy transfer over a large surface area, this greatly increases the intraocular pressure causing the eyewall to give way at its weakest point, which may or may not be at the impact site. (2012) RadioGraphics. New afferent papillary defect following trauma. Ophthalmology. Additionally, a positive Seidel sign, which is performed by instilling fluorescein in the eye and then examining . The physical exam on patients with potential globe rupture requires a detailed ophthalmologic assessment. View Yuranga Weerakkody's current disclosures, see full revision history and disclosures, decreased anterior chamber (AC) depth (and/or collapse), anterior chamber may also contain layering, homogenous echogenic debris consistent with hyphema, scattered echogenicities with "dirty" acoustic shadowing, collapsed globe ("flat tyre" or "mushroom"appearance), presence of intraocular gas or a foreign body, abnormal anterior chamber size (enlarged in posterior rupture, decreased in anterior rupture). Therefore, ocular pressure should not be obtained. Open source ophthalmology education for students, residents, fellows, healthcare workers, and clinicians. Open-globe injuries are rarely hopeless. By Daniel Wang, MD, and Avnish Deobhakta, MD, Open Globe Injury: Assessment and Preoperative Management, Instruction Courses and Skills Transfer Labs, Program Participant and Faculty Guidelines, LEO Continuing Education Recognition Award, What Practices Are Saying About the Registry, Provider Enrollment, Chain and Ownership System (PECOS), Subspecialty/Specialized Interest Society Directory, Subspecialty/Specialized Interest Society Meetings, Minority Ophthalmology Mentoring Campaign, Global Programs and Resources for National Societies, Dr. Richard Mills' Opinions, 2002 to 2016, International Society of Refractive Surgery. Globe rupture Contents 1 Background 1.1 Causes 2 Clinical Features 2.1 Slit-lamp 3 Differential Diagnosis 3.1 Maxillofacial Trauma 4 Evaluation 4.1 Work-Up 5 Management[3] 5.1 Antibiotics[5] 5.1.1 NO intra-ocular foreign body 5.1.2 Intra-ocular foreign body PRESENT 5.1.3 Children 6 Disposition 7 See Also 8 References Background Eye anatomy. A penetrating injury is when an object penetrates the eye, but the object does not go all the way through the eye. Details of the circumstances are important. All layers of the cornea should be thoroughly inspected for superficial abrasions, edema, and lacerations. Ophthalmol Clin North Am 2002; 15:153. Outline the treatment and management options available for globe rupture. The differential diagnosis of globe rupture includes corneal abrasion, corneal ulceration, subconjunctival hemorrhage, hyphema, orbital blowout fracture, traumatic iritis, and retrobulbar hematoma. B-scan ultrasonography may be useful in providing information about the posterior segment, particularly when the funduscopic examination is limited by hazy media resulting from significant hemorrhage or corneal edema. Ocular ultrasound and MRI should be avoided. Ophthalmology was consulted, and the patients vision was deemed unsalvageable. Four-year review of open eye injuries at the Royal Adelaide Hospital. FOIA Facial asymmetry or bony discontinuities are suggestive of concurrent facial fractures. doi: 10.1097/01.ico.0000133996.99520.c4. Visual acuity and pupils. [1]Diagnosis of globe rupture is based on history and clinical ophthalmologic examination, typically consisting of the slit lamp and fundoscopic evaluation. Int Ophthalmol Clin 1999; 39:59. IV vancomycin (15 mg/kg; maximum dose, 1.5 g) and a third-generation cephalosporin such as ceftazidime (50 mg/kg; maximum dose, 2.0 g) may be given. [2] Other regions prone to rupture include the limbus, insertion of the optic nerve, and sites of prior eye surgery. 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. Occult presentations manifest as a tiny rent in the sclera. Feel free to get in touch with us and send a message. CT findings that can be present in a globe rupture include 1: ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Once the diagnosis is made, the ophthalmologist must arrange for immediate surgery, the sooner the better. [15] In a study evaluating the use of CT diagnosis of uncertain penetrating globe injuries, CT was found to not be a suitable alternative to surgical exploration which is still mandatory in unclear cases with findings of about one-third of unclear cases with rupture of the globe that were not diagnosed with CT evaluation.
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