In ocular trauma, injuries can be initially classified as either closed globe or open globe where an open globe injury is defined as a full-thickness wound. From there, an open globe injury can be described as secondary to blunt trauma or due to a laceration. A ruptured globe is classified as secondary to blunt trauma when an impact from a blunt object results in a momentary increase of the intraocular pressure resulting in an inside-out injury mechanism. A laceration is classified as an open-globe injury that is full-thickness usually caused by a sharp object with the wound occurring at the impact site by an outside-in mechanism. Furthermore, lacerations are defined as either a penetrating injury, intraocular foreign body, or a perforating injury. A penetrating injury is defined as a single laceration with no exit wound and if there is more than one entrance wound, each must be caused by a different agent. An intraocular foreign body is defined as a retained foreign object causing an entrance laceration; of note, an intraocular foreign body is technically a penetrating injury but is grouped separately since there are different clinical implications due to the object. A perforating injury is defined as two full-thickness lacerations both entrance and exit usually caused by a sharp object or projectile where both wounds are caused by the same agent.
The eye is filled with incompressible liquid and when a blunt object with sufficient momentum creates energy transfer over a large surface area, this greatly increases the intraocular pressure causing the eyewall to give way at its weakest point, which may or may not be at the impact site. The actual wound is thus produced by an inside-out force and tissue herniation is very frequent and can be substantial. The site of rupture commonly occurs where the sclera is thinnest and weakest near the equator directly behind the insertion of the rectus muscles. Other regions prone to rupture include the limbus, insertion of the optic nerve, and sites of prior eye surgery. Once a ruptured globe occurs, it may result in diffuse injury, hemorrhagic choroidal and retinal detachment leading to a vigorous healing response that can lead to additional injury. Rupture of the globe posterior to the spiral of Tillaux (surgical landmark delineated by connecting the rectus muscle insertions which approximate the underlying ora serrata) is normally accompanied by choroidal rupture and hemorrhage which may percolate through the retina to present as a vitreous hemorrhage.
There is an increased chance of blunt globe rupture after ocular surgery such as large incision cataract removal, corneal transplant, glaucoma filtering procedures, or LASIK. In one study, of 139 penetrating keratoplasties performed, the incidence of traumatic rupture following keratoplasty was 5.8% with 37.5% of those occurring in the first postoperative month while the rupture rate for extracapsular cataract surgery was 0.45% and 0/6450 for phacoemulsification. In terms of wound integrity after penetrating keratoplasty, the highest risk period was found to be the month following surgery when the wound strength is derived almost entirely from sutures and the month following removal of sutures being the second high-risk period. In the 6 months following this, wound strength is similar to the first postoperative year. The first month wound strength was found to be 38% that of the unoperated eye, a sutured wound followed for 6 months were found to have only 70% of its preoperative strength and overall, the cornea never regains its preoperative strength and remains at risk for traumatic rupture for the remainder of the patient’s life following penetrating keratoplasty. In another study evaluating ruptured globes following radial and hexagonal keratotomy, ruptures occurred up to 10 years after surgery further suggesting the risk of a weakened eye for life. Globe rupture is also more common than globe laceration in elderly patients with the cause typically being from a fall with an open globe injury at the site of prior eye surgery. While men are more likely to sustain an open globe injury compared to women, men were more likely to experience penetrating injuries while women were more likely to experience blunt globe rupture. In this study, women were more likely to be elderly (median age 73) and injured from falls while men were younger (median age 36) and likely injured from projectiles at work or home improvement.
Patients with a history of significant ocular and periocular blunt trauma should be considered ruptured until proven otherwise since the diagnosis can be difficult due to swelling and wounds may be occult. The mechanism of an injury must always be investigated. A thorough review of medical/surgical history with a focus on prior surgery, trauma, and any previous or existing eye disease.
A complete ocular exam must be performed when possible starting with measurement of the visual acuity and testing for the presence of a relative afferent pupillary defect. Next, gross confrontational visual field testing, identifying any relative difference in subjective brightness perception, and checking color vision should be performed. If eye drops are necessary, prefer the use of new medication bottles and preservative-free variants. If clinical suspicion of a ruptured globe is high, any medication such as tetracaine or diagnostic eye drops such as fluorescein should be avoided. Most open globe injuries can be diagnosed with a simple penlight examination; however, smaller wounds may require a slit-lamp examination for confirmation and to rule out associated injury, intraocular foreign body, and endophthalmitis. In 74% of eyes, the wound is scleral or corneoscleral with typically a conjunctival wound. The following signs may help to establish the diagnosis: the presence of thick subconjunctival hemorrhage, scleral step sign, presence of a circumscribed mass under the conjunctiva from the expulsed lens, peaked pupil with the angle pointing toward the site of the scleral wound, loss of the iris, lens, or red reflex. Of note, an occult globe rupture may be present without a visible scleral defect on slit lamp. A deeper-than-normal anterior chamber with posteriorly retracted plateau iris seen immediately after acute ocular trauma is pathognomonic of posterior globe dehiscence. Additionally, extensive chemosis often hemorrhagic, relative hypotony, and vitreous hemorrhage may also be present in occult globe rupture. If the presence of a wound is confirmed, evaluation should be stopped so that fine details of the injury are best determined during surgery to avoid causing additional tissue extrusion or bleeding.
- Traumatic hyphema
- Orbital fracture
- Closed-globe injury
- Penetrating injury
- Perforating injury
- Orbital compartment syndrome
Role of Imaging
In one study, CT evaluation was found to have an accuracy, sensitivity, and specificity of 81%, 76%, 85% respectively, so while CT is useful in cases of ocular trauma particularly in cases of eyelid hematoma, swelling, intraocular hemorrhage, it can still not be solely relied on due to the potentially catastrophic consequences of an undiagnosed globe rupture. In a study evaluating the use of CT diagnosis of uncertain penetrating globe injuries, CT was found to not be a suitable alternative to surgical exploration which is still mandatory in unclear cases with findings of about one-third of unclear cases with rupture of the globe that were not diagnosed with CT evaluation. For an initial assessment of orbital trauma, MRI is not recommended due to the potential of intraocular ferromagnetic objects and that MRI is insensitive regarding the visualization of foreign objects. If globe rupture is suspected, many recommend proceeding directly to the operating room for exploration and skipping contact B-scan ultrasonography for concern for iatrogenic expulsion of globe contents. In light of these studies on additional imaging modalities, a ruptured globe remains a clinical diagnosis based on history and physical examination.
Once the diagnosis is made, the ophthalmologist must arrange for immediate surgery, the sooner the better. Delays in surgical care can increase the risk of choroidal hemorrhage and/or endophthalmitis. Preoperative protection against external pressure, with a fox shield, to reduce risk of herniation of ocular contents through the rupture must be addressed. Additionally, antiemetics should be given to reduce risk of increased ocular pressure. Patients should receive prophylactic antibiotic treatment with vancomycin and ceftazidime to cover organisms commonly associated with posttraumatic endophthalmitis. Tetanus status should be addressed and prophylaxis given if appropriate. Topical antibiotic corticosteroids and cycloplegics are administered to treat traumatic uveitis associated with the injury.
General anesthesia is indicated in most cases. Local anesthesia is avoided because the volume of fluid instilled around the eye from a block may cause further prolapse of intraocular content, however, if a local block is performed, a retrobulbar block is most likely to provide good anesthesia with akinesia with a prudently small injection volume.
In most cases, the wound edge must first be cleaned of all materials whether they are external (foreign bodies, debris) or internal (intraocular tissue). Following proper cleaning, repositioning is the goal except for vitreous prolapse which is preferably cut with the vitrectomy probe and every attempt should be made to preserve the iris even if the injury is over 24 hours old. The only time when it is permissible to incarcerate tissue in the wound is when an expulsive choroidal hemorrhage occurs. For occult globe rupture, during surgical exploration, a 360 peritomy is indicated to view all four quadrants of the posterior sclera bearing in mind that more than one rupture may be present. Peritomy just anterior to the rectus muscle insertions provides a large circumferential conjunctival opening that facilitates exposure. To allow control and gentle rotation of the eye for inspection, traction sutures are used first by buttonholing tenon fascia in each quadrant between rectus muscles and passing a 4-0 black silk or equivalent suture under and around the insertion of each rectus muscle without denuding the muscle sheaths to reduce scarring around the muscles.
Closure of the scleral wound
If the scleral wound is anterior, it is best to carefully open the conjunctiva so that the entire length of the wound becomes visible. Repairing the scleral defect is performed if possible using a 6-0 to 8-0 Vicryl or 8-0 to 9-0 nylon often using a spatula needle. It is often desirable to place the first suture to close the middle of the rupture and subsequent sutures in the middle of the remaining defects or depending on the exposure of the operative site, defects can be closed by suturing progressively from one or both extremities of the rupture. If the rupture is large, repair may be more detrimental where attempting such a posterior repair requires more force to rotate the globe which can increase extrusion of intraocular contents or risk an expulsive choroidal hemorrhage, the scleral wound is best left open. These wounds may granulate spontaneously. After the conjunctiva is carefully closed, a shield is placed over the eye to prevent external pressure and the wound will close within days bearing in mind that the incarceration of tissues is the rule, not the exception, in these cases and must be addressed from the inside.
Closure of the corneal wound
Suturing of this wound must be watertight and be as close to normal corneal anatomy as possible where scars will interfere with visual rehabilitation and edema interferes with vitreoretinal surgery. Unless the wound is in the limbus, interrupted sutures should be used to avoid flattening the corneal dome shape with 10-0 nylon. The suture should be 100% deep-lying inside the anterior chamber to reduce corneal edema and minimize tissue shift or override. The surgeon should no grasp the cornea with forceps; the conjunctiva should be grasped if counterforce is needed. The 50% rule can be used primarily. If the wound is angled, the first suture is placed at the angle and if the wound crosses the entire cornea, the Rowsey-Hays technique is recommended where sutures with large bites are first placed at the two ends followed by gradually smaller bites as the sutures approach the center in a centripetal fashion.. Eisner principle- Another variation of the suturing technique was suggested by Eisner to close a stellate laceration. In this, a purse-string suture is used to prevent trauma to spices of laceration and a diamond knife is used for incising the corneal stroma to half the thickness at all the edges. Further 10-0 nylon sutures are passed through the adjacent stromal incision and the wound is closed with watertight opposition. The tightening opposes the central stroma and the apices of the laceration.
Closure of a Corneoscleral wound
The initial suture is made at the limbus and should not be full thickness, followed by the closure of the corneal wound, followed by the closure of the scleral wound.
Pars plana vitrectomy may be performed if indicated immediately after repair of the scleral rupture or often about 7-14 days depending on whether the closure of the scleral defect is watertight and on accompanying pathology. Indications include dense vitreous hemorrhage, vitreous or retina incarcerated in the scleral rupture, retinal tears, and retinal detachment. In cases where the rupture cannot be made watertight, up to about 2 weeks may be allowed for unrepaired posterior rupture to seal with early cicatrization and for choroidal detachments to recede while treating the eye with strong corticosteroid therapy and cycloplegia before attempting pars plana vitrectomy, however, there is also increasing evidence that an early pars plana vitrectomy may reduce risks of retinal detachment, scarring, and proliferative vitreous hemorrhage. When performing the pars plana vitrectomy, great care must be taken to insert the infusion cannula into the vitreous and not into the supraciliary space underneath a ciliochoroidal detachment caused by preoperative hypotony with a longer than usual 6-mm cannula preferably or an AC maintainer can be used in these cases until the posterior view is clear enough to confirm placement of the pars plana infusion cannula. If there is a metal intraocular foreign body and infection is suspected, surgery is performed as soon as possible with determination of the incision site and pathway such as a previous wound, corneal scleral incision, and pars plana incision are made according to the foreign body feature, location, and disease characteristics. A complete vitrectomy is performed via a pars plana incision avoiding the injury site. Retinotomy or retinectomy may be preferred according to trauma status and if the lens is not transparent enough, a lensectomy or phacoemulsification is performed first. This study suggested the following for primary surgery; (1) prolapsed iris, choroid, and retina should be repositioned after complete irrigation and the prolapsed vitreous body can be removed otherwise retinal incarceration and closed tunnel detachment will result in poor visual acuity and severe proliferative response. (2) The ends of the ocular rupture wound must be determined carefully and sutured completely to keep IOP normal. (3) For patients with anterior chamber hyphema, anterior chamber irrigation after tamponade of viscoelastic could prevent blood staining of the cornea.
Postoperative and Follow-up
Eyes without watertight closure should be protected from external pressure for several weeks by a shield when glasses are not being worn. Topical antibiotic is often administered in conjunction with topical corticosteroid and strong cycloplegia. Systemic antibiotic is not normally indicated with occult ruptures, but is used if there is a laceration or perforation of the sclera or a more superficial defect that appears to be contaminated. Theoretically, sympathetic ophthalmia can be reduced with several days of systemic corticosteroids, but this is a rare condition. Silicone oil is removed 3 to 6 months postoperatively and artificial lens implantation is performed in patients with good corrected visual acuity.
Follow-up is often arranged for postoperative day 1, week 1, month 1, and month 3 depending on the course with more frequent follow up for complications. Every follow-up examination requires visual acuity, anterior segment and posterior examination. Postoperative complications include secondary cataract, belted corneal degeneration, iris atrophy, or irregular pupil. Complications will vary depending on the extent of injury and mechanism. In addition to globe rupture, an orbital fracture, orbital hemorrhage, or orbital compartment syndrome can occur. Posttraumatic endophthalmitis occurs after penetrating trauma to the globe in 3 to 10 percent of cases. For prevention in cases after open globe penetrating eye trauma, two days of systemic prophylactic antibiotics with intravenous vancomycin with either ceftazidime or ciprofloxacin after the penetrating eye injury if one is present. In a review, a rate of 0.9% of endophthalmitis occurred following two days of prophylactic systemic antibiotics.
The Ocular Trauma Score is often used to predict visual outcome of patients after open-globe ocular trauma ranging from 1 (most severe injury and worst prognosis at 6 months follow up) to 5 (least severe injury and least poor prognosis at 6 months) with globe rupture holding the worst prognosis followed by endophthalmitis, perforating injury, retinal detachment, and relative afferent pupillary defect in that order. The Ocular Trauma Score is used by first determining the patient’s initial visual acuity after injury and their tissue diagnoses then subtracting raw points from each associated diagnosis/complication. Then correspond the raw score with the Ocular Trauma Score to estimate the patient’s probability of attaining a specific visual acuity range at a 6 month follow up. Posttraumatic endophthalmitis is associated with poor visual prognosis with visual acuities of 20/400 or better were preserved only in 37% (75/210) of patients.
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