A 45-year-old man complains of right eye pain and decreased vision. He was “cooking meth” when the bottle exploded, but is otherwise amnestic to the events. He does admit to drinking alcohol and recent Xanax use prior to the event. He denies headache, focal weakness, paresthesias, fever, nausea, or vomiting.
On examination of his eye, you note an irregular nonreactive pupil with a moderate hyphema, a corneal laceration, and multiple lacerations with imbedded glass on the face and upper body.
What eye injury are you concerned about? What is the evaluation and management of this condition?
Diagnosis: Ruptured Globe with Intraocular Foreign Bodies
Eye injuries are common presentations to EDs. Violation of the globe integrity, also known as a ruptured globe, is an ocular emergency that universally threatens vision. Prompt recognition and ophthalmologic consultation are prudent. There are an estimated 203,000 cases of open globe injuries worldwide each year. (Ophthalmology 2008;115:202.) More than 90 percent of these injuries occur in male teenagers and young adults. In children, up to 14 percent of ocular traumatic injuries result in severe vision loss or permanent blindness. (Am J Emerg Med 2009;27:530.) It is estimated that as many as 40 percent of globe ruptures are associated with retained intraocular foreign bodies (Ophthalmology 1983;90 :1318), with most being metallic. (Ophthalmology 1988;95:911.)
Blunt trauma can result in globe rupture when the impact disrupts the bony case (orbit) that protects the eye from direct ocular trauma. The globe is prone to rupture at the insertion of the rectus muscles in the sclera, in areas of previous eye surgery, and the optic nerve and limbus (corneal/ scleral junction). Globe lacerations tend to involve the cornea, often with an intraocular foreign body found in the vitreous compartment of the eye. (Ophthalmology 1988;95:911.)
When evaluating a patient with a suspected globe rupture, it is important to manage concomitant injuries by trauma protocols. A history of high velocity, blunt force or sharp object contact mechanisms are concerning for globe rupture. Visual acuity and an examination of the orbit should be performed to identify any corneal or scleral lacerations to find punctures versus a perforating laceration, a deflated globe, an irregular pupil, pupillary response to direct and concentric maneuvers, 360-degree subconjunctival hemorrhage, notation of obvious protruding foreign bodies, or obvious intraocular contents extravasating from the wound.
Care should be taken to decrease iatrogenic increases in intraocular pressure while examining the orbit so Tonopen evaluation should be deferred. Despite the common emergency medicine axiom to identify a positive Seidel sign (fluorescence streaming away from puncture/laceration site), it is preferable for the ophthalmologist to perform this test during a comprehensive ophthalmologic examination because fluorescein used by the EP could potentially distort subsequent evaluations. Computerized tomography (CT) with “thin” (1 to 1.5 mm) cuts to evaluate the orbit and identify radiolucent foreign bodies should be performed emergently.
Patients with suspected globe rupture should be considered preoperative, and appropriate laboratory, evaluation, and nothing by mouth status maintained. Protruding ocular foreign bodies should not be removed by the EP because profound complications can occur. After evaluation, a protective hard eye patch should be placed to prevent further injury, and the head of the bed placed at 30 degrees supine if the patient can tolerate it. Antiemetics, analgesia, and anxiolytics should be used judiciously to prevent potentially harmful increases in intraocular pressure. Pain should be treated with appropriate parenteral analgesia, but topical ocular anesthetics should never be used if globe rupture is suspected. For patients who require intubation in the ED for concomitant injuries, the use of ketamine (Am J Ophthalmol 2007;143: 494) and succinylcholine (Ophthalmol Clin North Am 2006;19:279) are contraindicated because of the potential to elevate intraocular pressure. Recent literature (Br J Anaesth 2008;100: 485) suggests that premedication with dexmedetomidine, an alpha-2 agonist, may blunt the IOP elevation response seen with succinylcholine in the OR, but more prospective studies are needed.
Broad-spectrum intravenous antibiotics and tetanus should be given prophylactically for any ruptured globe because of the risk of endophthalmitis. Intraocular foreign bodies increase the risk of ocular infection to as much as 13 percent. (Ophthalmology 1990;97:1532.) Topical antibiotics are reserved for post-operative therapy, and have no role preoperatively for globe ruptures.
Emergent ophthalmologic consultation should be obtained when globe rupture is suspected or confirmed. Operative repair is recommended within 24 hours so preoperative planning should begin in the ED.
Patients with a poor prognosis tend to be those with poor vision on presentation (less than 5/200), ocular laceration 4 mm or greater in length (Ophthalmology 1988;95:911), those with lens disruption (increased risk of endophthalmitis; Ophthalmology 1995;102:1696), significant orbital/ periorbital trauma, prolonged time to primary closure, metallic foreign body (Am J Ophthalmol 2008;146: 427), and those with endophthalmitis (Am J Emerg Med 2009;27:530.)
This patient was taken urgently to the operating room for removal of the glass foreign bodies and repair of his ruptured globe. On his first postoperative visit, he had finger count vision in the affected eye.