Diagnosis
Globe rupture R eye
Discussion
Differential Diagnosis:
This patient presents with a full-thickness cornea laceration in the R eye after trauma. Other etiologies for full-thickness corneal defects include wound dehiscence (if patient has a history of prior corneal surgery) or corneal perforation due to dellen, scleritis, neurotrophic keratopathy, corneal ulcer, chronic topical anesthetic abuse or environmental exposure (crack smoking). Suspect child abuse in any child with unexplained globe rupture and initiate the appropriate evaluation.
Definition:
A full-thickness laceration is a through-and-through defect of the eye wall (corneal or scleral) that causes the globe to be open to the environment. Other instances of open globe include blunt trauma resulting in rupture of previous surgical wounds and perforating trauma (with an entry and exit wound of the eye). It is important to inquire as to the nature of trauma or foreign body (vegetable matter vs. glass vs. metal).
Examination:
Typical symptoms of globe rupture are pain, redness, tearing and decreased vision. Exam findings include: other lid or orbital trauma (ex. lid laceration – examination of the eye under a lacerated eyelid is imperative), conjunctival hemorrhage and/or swelling, corneal abrasion and/or laceration, flat or shallow anterior chamber, anterior chamber cell, hyphema, peaked pupil and/or iris rupture, high or low IOP, lens opacity, vitreous hemorrhage, retinal tear and/or detachment, choroidal rupture and/or intraocular foreign body. The eye exam should be comprehensive, but limit the manipulation of the affected eye (ex. avoid IOP check). Ensure the unaffected eye is examined (with dilation). The seidel test is a 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. An orbital CT scan is indicated in most cases to identify any foreign body, to examine the sclera for shape abnormalities (posterior ruptures can be missed on clinical exam) and to examine the orbital bones for fractures. In instances when the posterior pole can't be examined a B-scan could indicate intraocular foreign body, retinal detachments or vitreous hemorrhage but care should be placed not to put undo pressure in the eye.
Treatment:
Prompt surgical repair of the laceration is necessary to restore ocular integrity. The patient should receive anti-emetic, pain and antibiotic intravenous medication, a shield over the affected eye and tetanus prophylaxis while waiting for surgical repair. Outcomes are unpredictable and depend on the extension of the injury. An important prognosticator of final visual acuity is presenting visual acuity. Injured eyes require lifelong monitoring. Sympathetic ophthalmia is an inflammatory condition where the immune system attacks the uninjured eye, most likely due to systemic exposure of ocular antigens. In eyes with no possibility of vision recovery, enucleation can decrease the risk of immune activation and also resolves severe eye pain. Lifelong monocular precautions - using protective eye wear at all times - is recommended.
