OcuLearning › Trauma

Ruptured Globe / Open Globe

CRITICAL — Trauma

Symptoms

  • sudden ocular pain and significant decrease in vision
  • fluid loss: feeling of "warm liquid" running down the cheek after trauma
  • mechanism: hammering metal-on-metal, projectile (BB/pellet), or blunt force
  • note: patient report of vision often underestimates the severity of injury

Clinical Findings

Cardinal signs

  • seidel-positive wound: fluorescein stream washing away from a corneal/scleral site
  • 360° subconjunctival hemorrhage: "hemorrhagic chemosis" can hide a rupture
  • peaked pupil: the iris points toward the site of the full-thickness wound
  • chamber depth: shallow AC (anterior rupture) or deep AC (posterior rupture)

Direct visualization

  • uveal prolapse: dark/brown tissue (iris or choroid) protruding through the wound
  • hyphema or vitreous hemorrhage: blood filling the anterior or posterior segments

Occult rupture

  • low iop + irregular pupil + blunt trauma: highly suspicious for posterior rupture

Etiology

Mechanisms of injury

  • penetrating/perforating: sharp objects, glass, or high-velocity projectiles
  • blunt rupture: severe impact causes the globe to burst at its thinnest points (limbus/equator)
  • iatrogenic/surgical: prior surgeries like RK or large-incision cataract surgery weaken the eye
  • hammering: classic history for an intraocular foreign body (IOFB)

Red Flags

  • do not measure iop: any pressure on the globe can express intraocular contents
  • do not force eyelids open: if the globe is open, external pressure is catastrophic
  • seidel sign: indicates a continuous leak of aqueous from the eye
  • 360° blood: always assume a hidden scleral rupture until proven otherwise

Investigations

Imaging

  • ct orbits (thin cuts): the "gold standard" to rule out IOFB and localize the rupture
  • mri: STRICTLY CONTRAINDICATED if there is any chance of a metallic foreign body
  • b-scan: generally avoided in the acute phase to prevent pressure on the globe

Clinical assessment

  • assess light perception (LP) and pupil function before any surgical manipulation

Treatment

Surgical management

  • primary repair within 24 hours to significantly reduce the risk of endophthalmitis
  • suturing: watertight closure of corneal (10-0 nylon) and scleral (8-0/9-0 silk/nylon) wounds
  • uveal tissue: restore viable tissue or excise if severely necrotic/contaminated

Systemic support

  • tetanus prophylaxis based on immunization history
  • post-operative antibiotics and close monitoring for signs of infection

Clinical Pearl

In any suspected open globe: cover with a rigid shield, no pressure, NPO, tetanus, IV antibiotics, and to the operating room. Do NOT measure IOP, force open eyelids, or apply topical drops. Seidel-positive wound, 360° subconjunctival hemorrhage, peaked pupil, and deep or shallow AC are the cardinal signs — any one warrants CT and surgical exploration.

Differential Diagnosis

  • • conjunctival laceration (intact sclera underneath)
  • • corneal abrasion or non-full-thickness laceration
  • • retrobulbar hemorrhage (proptosis and high IOP, but globe remains intact)

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