Globe Rupture and Open Globe Injury

Risk factors

• Work activities without eye protection (hammering, grinding, welding)
• Recreational sports (paintball, racquet sports without goggles)
• Assault, motor vehicle collisions
• Prior intraocular surgery (weakened wall)
• Connective tissue disease (Ehlers-Danlos, osteogenesis imperfecta — spontaneous rupture rare)
• Children with projectile toys

Pathophysiology

Blunt force suddenly raises intraocular pressure; the globe ruptures at its weakest point — most commonly the limbus, behind the rectus muscle insertions, or at sites of previous surgery (cataract incision). Penetrating injuries breach the wall directly. Wound type and zone (I = cornea only, II = limbus to 5 mm posterior, III = beyond 5 mm posterior) and visual acuity at presentation are key prognostic factors (Ocular Trauma Score).

Clinical presentation

Differential diagnosis

• Closed globe injury with hyphema — Intact wall, blood in AC; pupil reactive, AC formed; slit lamp confirms no full-thickness defect
• Severe subconjunctival hemorrhage with chemosis — Boggy conjunctiva, dark blood under conjunctiva; if 360-degree bullous hemorrhage and posterior trauma, must exclude occult rupture
• Conjunctival or partial-thickness corneal laceration — Wall intact on Seidel testing; chamber formed; managed with antibiotic ± closure
• Orbital fracture without globe injury — Restricted motility, infraorbital numbness, no compromise of globe wall
• Severe orbital contusion — Lid ecchymosis, normal globe; slit lamp and ultrasound confirm intact eye

Diagnostic workup

Diagnostic algorithm

flowchart TD
  A[Eye trauma<br/>+ severe pain/vision loss] --> B{Teardrop pupil,<br/>uveal prolapse,<br/>soft globe, Seidel +?}
  B -->|Yes| C[Open globe<br/>STOP exam]
  B -->|Unclear| D[Gentle slit lamp<br/>+ CT orbit]
  D --> E{Imaging or exam<br/>confirms open globe?}
  E -->|Yes| C
  E -->|No| F[Manage as closed globe injury]
  C --> G[Rigid shield<br/>NPO<br/>head up 30°<br/>antiemetic<br/>analgesia]
  G --> H[IV vancomycin<br/>+ ceftriaxone/cefepime<br/>± fluoroquinolone<br/>tetanus update]
  H --> I[CT orbits<br/>(no MRI if metallic<br/>FB possible)]
  I --> J[Urgent ophthalmology<br/>operative repair<br/>≤12-24 h]

Treatment

Complications

• Endophthalmitis — devastating; rates of 3-17%, much higher with retained organic foreign body or delayed closure
• Sympathetic ophthalmia
• Phthisis bulbi (shrunken, nonfunctional eye)
• Retinal detachment, vitreous hemorrhage, traumatic cataract, glaucoma
• Permanent vision loss; many eyes require enucleation
• Sequestered intraocular foreign body with delayed inflammation or siderosis/chalcosis

PANCE pearls

• If you suspect open globe injury, STOP examining and protect the eye — minimize any manipulation that could elevate IOP and extrude contents.
• Teardrop or peaked pupil is virtually pathognomonic.
• Never measure intraocular pressure or apply ointment when rupture is suspected.
• CT orbit is the imaging study of choice; avoid MRI unless metallic FB excluded; use ultrasound very cautiously.
• Empiric IV antibiotics, NPO, tetanus update, antiemetics, and prompt ophthalmology consult are the minimum bundle.
• Visual acuity at presentation is the strongest prognostic factor; document it carefully.

References

• AAO PPP — American Academy of Ophthalmology Preferred Practice Pattern: Eye Trauma
• Ocular Trauma Score — Kuhn F et al. The Ocular Trauma Score (OTS) (Ophthalmology Clinics of North America, 2002)
• AAOS / ACS — American College of Surgeons ATLS guidelines on ocular trauma; AAO BCSC Trauma volume