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 More than meets the eye

Test your diagnostic skill with visual case studies 

This is a 34-year-old female who was struck in the eye with a tennis ball. She reported immediate pain in the eye followed by complete vision loss. She reports no other trauma, has no other past medical or surgical problems and takes no medications. She has no allergies and her physical examination is grossly unremarkable except what is pictured in the photograph.

A ruptured globe is a full-thickness injury of the cornea, sclera or both, usually resulting from blunt or penetrating trauma. In the setting of blunt trauma, a sudden increase in intraocular pressure (IOP) classically leads to rupture at sites where the sclera is thinnest. This may be at the insertions of the extraocular muscles, at the limbus or at the point of entry of the optic nerve. Penetrating globe injury may be caused by sharp objects or those traveling at high velocity.

A good history should include asking patients about the mechanism and circumstances of the injury, especially the likelihood of intraocular foreign bodies. Organic items are more important to identify than inert materials due to their high risk of becoming infected. The patient’s past ophthalmologic history is another important piece of information to obtain as those with severe myopia or previous eye surgery are at greater risk for globe rupture. Finally, always ask patients with suspected globe injury about their tetanus status.

A complete eye examination should be performed while avoiding any maneuvers that place direct pressure on the globe which may raise IOP. Be sure to examine the orbits for bony deformity or focal tenderness and note any globe displacement or shape changes. Beware of severe conjunctival hemorrhage or a teardrop-shaped pupil as these findings may suggest an occult globe rupture.

CT scan is the most sensitive imaging study to detect globe rupture and also helps to identify any intraocular foreign bodies. However, nonmetallic objects such as wood, glass or plastic may be difficult to identify on CT scan due to the fact that they have a similar density to eye structures. Although ultrasound is a useful diagnostic tool to identify other occult soft tissue foreign bodies, it should not be employed acutely in the setting of possible globe rupture due to the increased risks of extruding eye contents associated with direct pressure on and around the globe.

Globe rupture is an ocular emergency and immediate ophthalmology consultation is required. The patient with a suspected globe rupture should refrain from any oral intake in case immediate surgery is planned. They should remain sitting upright and antiemetics may help decrease the likelihood of retching in the nauseous patient which can also increase IOP. Tetanus prophylaxis should be updated if necessary and prophylactic antibiotics should be initiated to prevent post-traumatic endophthalmitis, an infection of the deep structures of the eye. Antibiotics should cover the common pathogens implicated in causing endophthalmitis, including Staphylococcus, Streptococcus, and Bacillus species.

Questions still remain about the role of succinylcholine for intubating patients with a globe injury. Classic teaching has advised against using succinylcholine for paralysis in patients with globe disruption due to the fact that it may raise IOP resulting in worsening of the pre-existing injury. However, these findings have not been well-documented in the literature. Although the use of succinylcholine in patients with globe injury remains controversial, if an airway is required in a patient with a ruptured globe, then the benefits of obtaining an airway usually outweigh the risks of increasing IOP.