Globe rupture

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Globe rupture
Other namesOpen globe, globe laceration, globe penetration, globe perforation
Specialty Ophthalmology

Open-globe injuries (also called globe rupture, globe laceration, globe penetration, or globe perforation) are full-thickness eye-wall wounds requiring urgent diagnosis and treatment. [1]

Contents

Classification

In 1996 Kuhn et al. created the Birmingham eye trauma terminology (BETT) to standardize the language used to describe traumatic ocular injuries internationally. [2] The BETT schema classifies open globe injuries as a laceration or a rupture. A ruptured globe occurs when rapid intraocular pressure elevation secondary to blunt trauma results in eyewall failure. [3] The rupture site may be at the point of impact but more commonly occurs at the weakest and thinnest areas of the sclera. [4] Regions prone to rupture are the rectus muscle insertion points, optic nerve insertion point, limbus, and prior surgical sites. [1] [4] Globe lacerations occur when a sharp object or projectile contacts the eye causing a full-thickness wound at the point of contact. Globe lacerations are further sub-classified into penetrating or perforating injuries. [3] Penetrating injuries result in a single, full-thickness entry wound. In contrast, perforating injuries produce two full-thickness wounds at the entry and exit sites of the projectile. [3] A penetrating globe injury with a retained foreign object, called an intraocular foreign body, has a different prognosis than a simple penetrating trauma. Therefore, intraocular foreign body injuries are considered a distinct type of ocular injury. [4]

Open-globe injuries are also classified by the anatomic region or zone of injury:

Anatomy

Blausen 0388 EyeAnatomy 01.png

The eye wall is composed of three layers that lie flat against each other to form the eyeball. The external layer is a tough, white membrane called the sclera with a clear dome at the front of the eye called the cornea . The line where the sclera and cornea converge is known as the limbus. [5] The middle layer consists of the colored part of the eye known as the iris , a muscular structure behind the iris responsible for focusing the lens known as the ciliary body , and a layer of blood vessels known as the choroid . The retina is the innermost layer of the eye. The retina contains nerve cells responsible for sensing light and sending visual information to the brain. [6]

The eye can also be divided into three chambers:

Epidemiology

There are an estimated 3.5 eye injuries per 100,000 people annually worldwide. [5] The most frequently reported mechanism of injury was trauma by foreign objects (metal, sand, wood), shotgun injuries, motor vehicle accidents, and falls in the home. All mechanisms of injury were more prevalent in males except domestic falls, where a majority of patients were female. [8] Males comprise 80% of open globe injuries, with men between 10 and 30 years of age at the most significant risk. [5]

The mechanism and classification of open-globe injury may also vary by age. Penetrating eye lacerations due to pellet-gun, sport, motor vehicle, or fight-related injuries are more common in adolescent males. Whereas young men tend to sustain penetrating or perforating eye injuries at work, during an assault, or due to alcohol and drug-related accidents. Globe rupture is more common than eyewall lacerations in older patients, with ground-level falls the most common mechanism in those over 75 years of age. [5]

Signs and Symptoms

Symptoms of an open-globe injury include eye pain, foreign body sensation, eye redness, and blurry or double vision. [9] While globe injuries are commonly associated with peri-ocular trauma that may obstruct diagnosis, [4] several signs suggest open-globe damage:

Diagnosis

Life-threatening-injuries should be evaluated first in those with eye injuries, with life-saving treatments provided before an eye examination. [3] When examining a known or suspected open-globe injury, it is vital to avoid applying pressure to the eye. A sudden increase in intraocular pressure could cause the extrusion of ocular contents. [4] Therefore, the initial assessment does not involve tonometry or eversion of eyelids. [1]

Examination

A Snellen chart or near card may be used to test visual acuity. If visual impairment is significant, evaluation can be done by evaluating the ability to count fingers, see hand movement, or perceive light. [1] Visual acuity assessment might not be possible due to age and developmental capability in children or preexisting visual impairment in older patients. [5]

A slit lamp exam allows a detailed inspection of the conjunctiva and sclera and improves the detection of globe injury. Slit lamp exam findings like decreased anterior chamber depth or damage to posterior chamber structures indicate open-globe injury. [3]

A seidel test detects more subtle or partially self-sealing open-globe injuries. Fluorescein dye is applied to the eye's surface to detect leakage of clear fluid originating from the wound using a Wood's lamp or blue light. [4] This test is avoided in obvious globe injury. [1]

Imaging

Non-contrast maxillofacial computed tomography (CT) is the imaging modality recommended for ocular trauma. However, CT scan findings should are not the sole determining factor for identifying open-globe injuries. CT scans have a 50 – 80% sensitivity and 90 - 100% specificity for open-globe injuries. [4] CT scan findings to suggest open globe injury include:

Magnetic resonance imaging (MRI) is avoided during the initial evaluation, particularly if metallic foreign bodies are suspected. [1] Ultrasound can detect intraocular foreign bodies and evaluate posterior chamber structures. However, direct pressure on the globe during an ultrasound can worsen the injury. [3]

Treatment

Open-globe injuries require urgent evaluation by an ophthalmologist. Initial treatment includes bed rest with a 30-degree elevation of the head, proactive management of pain and nausea, and placement of an eye shield. These measures prevent further damage and limit increases in intraocular pressure. [1] [4]

Endophthalmitis or internal eye infection occurs at a rate as high as 30% especially in cases complicated by an intraocular foreign body. [10] Management with 48 hours of intravenous antibiotics decreases the rate of post-traumatic endophthalmitis and its potentially devastating consequences. [10] Vancomycin plus ceftazidime cover infections caused by common organisms (e.g. Bacillus species, coagulase-negative Staphylococcus, Streptococcal species, and gram-negative organisms). [4] [11] Tetanus prophylaxis may be considered, depending on the type of injury and the time since the last immunization. [4]

Surgical repair of an open-globe injury within 24 hours of injury is ideal. [4] After surgical repair, patients should avoid strenuous activities like heavy lifting and exercise and wear an eye shield or other protective eyewear. [3]

Related Research Articles

<span class="mw-page-title-main">Ophthalmology</span> Field of medicine treating eye disorders

Ophthalmology is a surgical subspecialty within medicine that deals with the diagnosis and treatment of eye disorders. A former term is oculism.

<span class="mw-page-title-main">Cornea</span> Transparent front layer of the eye

The cornea is the transparent front part of the eye that covers the iris, pupil, and anterior chamber. Along with the anterior chamber and lens, the cornea refracts light, accounting for approximately two-thirds of the eye's total optical power. In humans, the refractive power of the cornea is approximately 43 dioptres. The cornea can be reshaped by surgical procedures such as LASIK.

<span class="mw-page-title-main">Eye surgery</span> Surgery performed on the eye or its adnexa

Eye surgery, also known as ophthalmic surgery or ocular surgery, is surgery performed on the eye or its adnexa. Eye surgery is part of ophthalmology and is performed by an ophthalmologist or eye surgeon. The eye is a fragile organ, and requires due care before, during, and after a surgical procedure to minimize or prevent further damage. An eye surgeon is responsible for selecting the appropriate surgical procedure for the patient, and for taking the necessary safety precautions. Mentions of eye surgery can be found in several ancient texts dating back as early as 1800 BC, with cataract treatment starting in the fifth century BC. It continues to be a widely practiced class of surgery, with various techniques having been developed for treating eye problems.

<span class="mw-page-title-main">Aqueous humour</span> Fluid in the anterior segment of the eye

The aqueous humour is a transparent water-like fluid similar to blood plasma, but containing low protein concentrations. It is secreted from the ciliary body, a structure supporting the lens of the eyeball. It fills both the anterior and the posterior chambers of the eye, and is not to be confused with the vitreous humour, which is located in the space between the lens and the retina, also known as the posterior cavity or vitreous chamber. Blood cannot normally enter the eyeball.

<span class="mw-page-title-main">Phacoemulsification</span> Method of cataract surgery

Phacoemulsification is a cataract surgery method in which the internal lens of the eye which has developed a cataract is emulsified with the tip of an ultrasonic handpiece and aspirated from the eye. Aspirated fluids are replaced with irrigation of balanced salt solution to maintain the volume of the anterior chamber during the procedure. This procedure minimises the incision size and reduces the recovery time and risk of surgery induced astigmatism.

<span class="mw-page-title-main">Corneal endothelium</span> Single layer of endothelial cells on the surface of the cornea

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<span class="mw-page-title-main">Eye injury</span> Physical or chemical injuries of the eye

Physical or chemical injuries of the eye can be a serious threat to vision if not treated appropriately and in a timely fashion. The most obvious presentation of ocular (eye) injuries is redness and pain of the affected eyes. This is not, however, universally true, as tiny metallic projectiles may cause neither symptom. Tiny metallic projectiles should be suspected when a patient reports metal on metal contact, such as with hammering a metal surface. Corneal foreign body is one of the most common preventable occupational hazard. Intraocular foreign bodies do not cause pain because of the lack of nerve endings in the vitreous humour and retina that can transmit pain sensations. As such, general or emergency department doctors should refer cases involving the posterior segment of the eye or intraocular foreign bodies to an ophthalmologist. Ideally, ointment would not be used when referring to an ophthalmologist, since it diminishes the ability to carry out a thorough eye examination.

<span class="mw-page-title-main">Red eye (medicine)</span> Eye that appears red due to illness or injury

A red eye is an eye that appears red due to illness or injury. It is usually injection and prominence of the superficial blood vessels of the conjunctiva, which may be caused by disorders of these or adjacent structures. Conjunctivitis and subconjunctival hemorrhage are two of the less serious but more common causes.

<span class="mw-page-title-main">Ocular tonometry</span>

Tonometry is the procedure eye care professionals perform to determine the intraocular pressure (IOP), the fluid pressure inside the eye. It is an important test in the evaluation of patients at risk from glaucoma. Most tonometers are calibrated to measure pressure in millimeters of mercury (mmHg), with the normal eye pressure range between 10 and 21 mmHg (13–28 hPa).

<span class="mw-page-title-main">Anterior chamber of eyeball</span> Space in the eye

The anterior chamber (AC) is the aqueous humor-filled space inside the eye between the iris and the cornea's innermost surface, the endothelium. Hyphema, anterior uveitis and glaucoma are three main pathologies in this area. In hyphema, blood fills the anterior chamber as a result of a hemorrhage, most commonly after a blunt eye injury. Anterior uveitis is an inflammatory process affecting the iris and ciliary body, with resulting inflammatory signs in the anterior chamber. In glaucoma, blockage of the trabecular meshwork prevents the normal outflow of aqueous humour, resulting in increased intraocular pressure, progressive damage to the optic nerve head, and eventually blindness.

<span class="mw-page-title-main">Endophthalmitis</span> Medical condition

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<span class="mw-page-title-main">Intraocular hemorrhage</span> Medical condition

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<span class="mw-page-title-main">Boston keratoprosthesis</span> Prosthetic cornea

Boston keratoprosthesis is a collar button design keratoprosthesis or artificial cornea. It is composed of a front plate with a stem, which houses the optical portion of the device, a back plate and a titanium locking c-ring. It is available in type I and type II formats. The type I design is used much more frequently than the type II which is reserved for severe end stage dry eye conditions and is similar to the type I except it has a 2 mm anterior nub designed to penetrate through a tarsorrhaphy. The type I format will be discussed here as it is more commonly used.

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<span class="mw-page-title-main">Corneal opacity</span> Medical condition

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References

  1. 1 2 3 4 5 6 7 Blair, Kyle; Alhadi, Sameir A.; Czyz, Craig N. (2022), "Globe Rupture", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   31869101 , retrieved 2022-10-14
  2. ↑ Justin, Grant A. (2022-06-07). "Birmingham Eye Trauma Terminology (BETT) - EyeWiki". eyewiki.aao.org. Retrieved 2022-10-14.
  3. 1 2 3 4 5 6 7 8 Wang, Daniel; Deobhakta, Avnish (2020-08-01). "Open Globe Injury: Assessment and Preoperative Management". American Academy of Ophthalmology. Retrieved 2022-10-14.
  4. 1 2 3 4 5 6 7 8 9 10 11 12 Zhou, Yujia; DiSclafani, Mark; Jeang, Lauren; Shah, Ankit A (2022-08-10). "Open Globe Injuries: Review of Evaluation, Management, and Surgical Pearls". Clinical Ophthalmology. 16: 2545–2559. doi: 10.2147/OPTH.S372011 . ISSN   1177-5467. PMC   9379121 . PMID   35983163.
  5. 1 2 3 4 5 6 Andreoli, Christopher M.; Gardiner, Matthew F. (2022-02-15). "Open globe injuries: Emergency evaluation and initial management". www.uptodate.com. Retrieved 2022-10-14.
  6. ↑ "Anatomy of the Eye | Kellogg Eye Center | Michigan Medicine". www.umkelloggeye.org. Retrieved 2022-10-14.
  7. ↑ Kolb, Helga (1995), Kolb, Helga; Fernandez, Eduardo; Nelson, Ralph (eds.), "Gross Anatomy of the Eye", Webvision: The Organization of the Retina and Visual System, Salt Lake City (UT): University of Utah Health Sciences Center, PMID   21413392 , retrieved 2022-10-14
  8. ↑ Kousiouris, Panagiotis; Klavdianou, Olga; Douglas, Konstantinos A A; Gouliopoulos, Nikolaos; Chatzistefanou, Klio; Kantzanou, Maria; Dimtsas, Georgios S; Moschos, Marilita M (2022-01-05). "Role of Socioeconomic Status (SES) in Globe Injuries: A Review". Clinical Ophthalmology. 16: 25–31. doi: 10.2147/OPTH.S317017 . ISSN   1177-5467. PMC   8749045 . PMID   35027817.
  9. ↑ Patel, Sayjal J.; Lim, Jennifer I.; Hsu, Jason; Parker, Paul R.; Murchison, Anna; Shah, Vinay A.; Feldman, Brad H. (2022-08-04). "Ocular Penetrating and Perforating Injuries - EyeWiki". eyewiki.aao.org. Retrieved 2022-10-14.
  10. 1 2 Relhan, Nidhi; Forster, Richard K.; Flynn, Harry W. (2018). "Endophthalmitis: Then and Now". American Journal of Ophthalmology. 187: xx–xxvii. doi:10.1016/j.ajo.2017.11.021. ISSN   0002-9394. PMC   5873969 . PMID   29217351.
  11. ↑ Jindal, Animesh; Pathengay, Avinash; Mithal, Kopal; Jalali, Subhadra; Mathai, Annie; Pappuru, Rajeev Reddy; Narayanan, Raja; Chhablani, Jay; Motukupally, Swapna R; Sharma, Savitri; Das, Taraprasad; Flynn, Harry W (2014-02-18). "Endophthalmitis after open globe injuries: changes in microbiological spectrum and isolate susceptibility patterns over 14 years". Journal of Ophthalmic Inflammation and Infection. 4 (1): 5. doi: 10.1186/1869-5760-4-5 . ISSN   1869-5760. PMC   3932506 . PMID   24548669.
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