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Discussion: Globe Rupture

Definition: Full-thickness defect in eye wall (cornea or sclera)

History: Trauma: Blunt (with rupture of previous surgical wound), Penetrating (involving full thickness rupture of one tissue, ex cornea), Perforating (entry and exit wounds).
Ask nature of trauma or foreign body (vegetable matter vs. glass vs. metal [bb gun pellet])
Suspect child abuse in any child with unexplained globe rupture and initiate the appropriate evaluation.

Symptoms: Pain, Decreased vision, Tearing, Redness, Double vision (restricted movement)
Associated signs and symptoms: Lid or orbital trauma (trauma causing a lid laceration can also have penetrated enough to cause scleral rupture – examination of the eye under the lacerated eyelid is imperative), Wound dehiscence in patients with prior ocular surgery, Corneal abrasion/laceration, Peaked pupil , Flat/shallow AC, AC cell and flare, Hyphema, Iris transillumination defect, Angle recession, Low IOP, Vitreous hemorrhage, Retinal tear/detachment, Choroidal rupture, Intraocular foreign body, Iridodialysis
Hyphema Peaked pupil

Eye exam: Including acuity (in both eyes), IOP (avoid in the eye with globe rupture), pupils (check for APD),EOM, slit lamp, DFE, gonioscopy (to look for foreign bodies)- if a globe rupture is suspected or noticed – limiting manipulation of the eye is important to prevent expulsion of ocular content.
Seidel test: Method of detecting aqueous humor leakage from the cornea by applying fluorescein to the site of laceration in the cornea. If positive a yellow fluid will be seen under cobalt blue light.
Seidel positive (under cobalt blue light)
Orbital CT: Rule out intraocular foreign body, examine sclera for shape abnormalities (posterior ruptures can be missed since anterior segment can look normal), examine for orbital bone fractures
B-Scan: Rule out posterior rupture, endophthalmitis or IOFB (avoid if anterior rupture)

Treatment: Admit for surgical exploration/repair, Protect eye with metal shield, Limit ocular manipulations, Tetanus prophylaxis, nausea prophylaxis

Complications: Corneal scars, Traumatic cataract, Endophthalmitis (infection of many eye layers), Choroidal rupture, Retinal breaks, Traumatic optic neuropathy, Optic nerve avulsion

Prognosis: Best indication of prognosis is visual acuity at presentation

Sympathetic Ophthalmia: Granulomatous uveitis of both eyes after one eye is injured. If there is no chance of vision restoration, enucleation of the injured eye is suggested in the first two weeks after trauma to prevent blindness in the contralateral eye due to inflammation.

References:
Ehlers JP, Shah CP, Fenton GL, et al. The Wills Eye Manual, 5th edition. Lippincott Williams, & Wilkins: Philadelphia, PA. 2008.
Friedman NJ, Kaiser PK, Pineda R. The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology, 3rd edition. Saunders Elsevier: China. 2009.
Kanski JJ. Clinical Ophthalmology: A Systematic Approach, 5th edition. Butterworth Heinemann: St. Louis, MO. 2003.
University of Iowa Department of Ophthalmology and Visual Sciences. http://webeye.ophth.uiowa.edu

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