Trauma

Globe Perforation

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Globe Perforation, Globe Rupture

  • Epidemiology
  1. Incidence: 3.5 per 100,000 persons annually in United States
  • Risk Factors
  • Strongly consider referral to Ophthalmology in these high risk cases regardless of exam
  1. See Eye Injury in Sports
  2. Rotating machinery is high risk for occult perforation
  3. High velocity Trauma (in which high speed small shrapnel could pierce globe)
  4. Conjunctival Laceration (esp. if greater than 1 cm)
  • Symptoms
  1. Severe Eye Pain
  2. Decreased Visual Acuity
  3. Eye tearing
  • 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
  2. Subtle signs
    1. Subconjunctival Hemorrhage (especially if involves 360 degrees around Cornea)
    2. Loss of Anterior Chamber Depth
    3. Conjunctival Laceration
  • Exam
  1. Precautions
    1. Do not perform tonometry
    2. Do not dilate pupil
    3. 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
  • Imaging
  • CT Head and Orbits (both coronal and axial views)
  1. Orbital Wall Fracture
  2. Intraocular foreign body
  3. Open globe injury
    1. Ocular CT has poor Test Sensitivity of 75%
    2. Crowell (2017) Acad Emerg Med 24(9): 1072-9 +PMID:28662312 [PubMed]
  • Management
  • Immediate Management
  1. Emergent, immediate referral to Ophthalmology
  2. Do not remove protruding foreign bodies
  3. Metal Shield to eye immediately
  4. Keep NPO
  5. Prevent Valsalva (increases Intraocular Pressure and further aqueous leakage)
    1. Ensure adequate analgesia with scheduled pain medications
    2. Prevent Vomiting with scheduled Antiemetics (e.g. Ondansetron)
    3. Antitussives if cough present
  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 400 mg orally or IV daily
  • 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
  • Prognosis
  1. Best prognostic factors
    1. Intact Visual Acuity
    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