Globe Perforation

Aka: Globe Perforation, Globe Rupture, Mechanical Globe Injury

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II. Epidemiology

  1. Incidence: 3.5 per 100,000 persons annually in United States

III. Risk Factors: Strongly consider referral to Ophthalmology in these high risk cases regardless of exam

  1. See Eye Injury in Sports
  2. Significant Blunt Eye Trauma (thrown ball, airbag deployment)
  3. Rotating machinery is high risk for occult perforation
  4. High velocity Trauma (in which high speed small shrapnel could pierce globe)
  5. Corneal or Conjunctival Laceration (esp. if greater than 1 cm, e.g. knife)

IV. Types

  1. Closed Globe Rupture
  2. Open Globe Rupture
    1. Full thickness tear through the Sclera and Cornea
    2. Common cause of blindness

V. Symptoms

  1. Severe Eye Pain
  2. Decreased Visual Acuity
  3. Eye tearing

VI. Signs

  1. Significant changes
    1. Hyphema (anterior chamber bleeding)
    2. Altered Red Reflex on Funduscopic Examination
    3. Uvea with dark pigmentation
    4. Tear shaped pupil
    5. Iris prolapse through Corneal or Scleral wound
    6. Decreased Visual Acuity
    7. Limited Extraocular Movement
    8. Globe deformation or collapse (may be absent in closed Globe Rupture)
    9. Protruding foreign body (do not remove if suspicion for Globe Rupture)
  2. Subtle signs
    1. Subconjunctival Hemorrhage (especially if involves 360 degrees around Cornea)
    2. Loss of Anterior Chamber Depth
    3. Conjunctival Laceration

VII. Exam

  1. Precautions
    1. Exercise a high level of suspicion for Globe Perforation (findings may be subtle)
    2. Do not perform Tonometry
    3. Do not dilate pupil
    4. Apply no pressure to eye surface
  2. See Eye Evaluation in Trauma
  3. Seidel Test
    1. Perform Slit Lamp exam with cobalt blue light and eye stained with Fluorescein
    2. Fluorescein dye diluted by aqueous fluid
    3. Darker, diluted Fluorescein dye streams from Globe Rupture site

VIII. Imaging: CT Head and Orbits (both coronal and axial views)

  1. Orbital Wall Fracture
  2. Intraocular foreign body
  3. Hyphema
  4. Open globe injury
    1. Ocular CT has poor Test Sensitivity of 75%, but better Test Specificity (79 to 100%)
    2. Crowell (2017) Acad Emerg Med 24(9): 1072-9 +PMID:28662312 [PubMed]

IX. Management: Immediate Management

  1. Emergent, immediate referral to Ophthalmology
    1. Early Ophthalmology removal of foreign body and globe repair (<24 hours)
    2. Early repair is associated with lower Endophthalmitis risk
  2. Do not remove protruding foreign bodies
  3. Metal Shield to eye for protection
  4. Keep NPO
  5. Prevent Valsalva (increases Intraocular Pressure and further aqueous leakage)
    1. Ensure adequate analgesia with scheduled Pain Medications (e.g. Opioids)
    2. Prevent Vomiting with scheduled Antiemetics (e.g. Ondansetron)
    3. Antitussives if cough is present
    4. Anxiolytics (e.g. Benzodiazepines, Olanzapine) as needed

X. Management: Prevent Endophthalmitis

  1. Tetanus Prophylaxis if not current
  2. Start Antibiotics within 6 hours of injury
  3. Adult first line protocols
    1. Fluoroquinolones (excellent vitreous penetration)
      1. Levofloxacin (Levaquin) 500 mg every 12 hours or
      2. Moxifloxacin (Avelox) 400 mg every 12 hours
    2. Alternative Parenteral regimens
      1. Vancomycin 1 g every 12 hours AND
      2. Ceftazidime 1 g every 8 hours OR Ciprofloxacin 400 mg IV
  4. Other regimens used for Endophthalmitis prevention
    1. Adult typical Antibiotic coverage
      1. Cefazolin 1 gram IV every 8 hours AND
      2. Ciprofloxacin 400 mg IV every 12 hours
    2. Child typical Antibiotic coverage
      1. Cefazolin 25-50 mg/kg/day divided every 8 hours IV AND
      2. Gentamicin 2 mg/kg IV every 8 hours
  5. Modify Antibiotic coverage in special circumstances
    1. Dog Bite (add Eikenella corrodens coverage)
    2. Cat Bite (add Pasteurella multocida coverage)
    3. Hay, leaves or other organic material (add fungal coverage)
      1. Fluconazole (Diflucan) 200 mg orally or IV twice daily OR
      2. Voriconazole (Vfend) 200 mg orally every 12 hours

XI. Complications

  1. Permanent Vision Loss
  2. Endophthalmitis (intraocular infection)
  3. Sympathetic Ophthalmia
    1. Rare, but potentially blinding condition with intraocular inflammation of the uninjured eye

XII. Prognosis

  1. Best prognostic factors
    1. Initial Visual Acuity better than 20/400
    2. Lacerations of 10 mm or less
  2. Poor prognostic factors
    1. Posterior wound
    2. Posttraumatic Endophthalmitis
    3. Afferent Pupillary Defect with paradoxical Pupil Dilation to bright light
      1. Suggests severe Retinal or Optic Nerve injury

XIII. References

  1. Dreis (2020) Crit Dec Emerg Med 34(7):3-21
  2. Rubasamen in Yanoff (2004) Ophthalmology, Ch. 140
  3. Gelston (2020) Am Fam Physician 102(9):539-45 [PubMed]
  4. Gelston (2013) Am Fam Physician 88(8): 515-9 [PubMed]
  5. Pokhrel (2007) Am Fam Physician 76:829-36 [PubMed]

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