Globe rupture

1. History

• Mechanism of injury is paramount: blunt trauma (ball, fist, airbag, fall) causes rupture; sharp/penetrating objects (nail gun, knife, projectile) cause laceration [1]
• Hammering or chiseling metal on metal is classically associated with occult globe perforation and intraocular foreign body (IOFB) [4]
• Timing of injury — delay >24 hours to repair is an independent risk factor for endophthalmitis [5]
• Eye protection use at time of injury
• Tetanus immunization status
• Prior ocular surgery (weakened sclera at surgical sites, e.g., prior cataract surgery)
• Up to 20% of ruptured globes lack readily apparent signs of perforation; vision may remain excellent initially [4]

2. Alarm Features

• Irregular or keyhole-shaped pupil (iris prolapse) — virtually pathognomonic of anterior segment rupture [6-7]
• Visible intraocular contents extruding through wound
• Positive Seidel test (streaming fluorescein dilution under cobalt blue light confirming aqueous leak) [1][4]
• Hyphema — must be considered a ruptured globe until proven otherwise [4]
• Afferent pupillary defect (APD) — indicates poor visual prognosis [1]
• Sudden loss of vision or light perception
• "Soft eye" on gentle palpation (though palpation should be avoided) [6]
• Deeper-than-normal anterior chamber with posteriorly retracted iris — virtually pathognomonic of occult posterior rupture [7]

3. Medications

4. Diet

• NPO — all patients with confirmed or suspected globe rupture should be kept nil per os in anticipation of emergent surgical repair under general anesthesia
• Avoid straining, coughing, or Valsalva maneuvers (stool softeners if needed postoperatively)

5. Review of Systems

• Visual changes: acuity, floaters, flashes, field cuts, diplopia
• Neurologic: headache, loss of consciousness, facial numbness (concomitant head/facial trauma)
• ENT: epistaxis, CSF rhinorrhea, malocclusion (orbital floor fracture)
• Nausea/vomiting — both a symptom and a risk for worsening injury via Valsalva
• Extremity/body trauma — globe rupture often occurs in polytrauma; life-threatening injuries take priority [2]

6. Collateral History and Family History

• Witnesses to mechanism (especially in assault, pediatric, or altered patients)
• Workplace safety context: was eye protection worn? What material was being worked on?
• In pediatric or elderly patients, consider non-accidental trauma
• Prior ocular surgical history (prior radial keratotomy, cataract surgery, or corneal transplant creates weak points prone to rupture at lower force)
• Family history is generally not contributory

7. Risk Factors

• Male sex (majority of cases) [2][10]
• Occupational exposure: metalworking, construction, nail guns, grinding [1][4]
• Recreational/sports injuries (ball sports, paintball, BB guns)
• Assault and interpersonal violence
• Falls (most common mechanism in women and elderly) [2][10]
• Motor vehicle accidents / airbag deployment
• Prior ocular surgery (weakened sclera/cornea)
• Lack of protective eyewear
• Rural/agricultural setting (higher contamination risk, delayed access to care) [11]

8. Differential Diagnosis

• Closed-globe injury (contusion, lamellar laceration) — no full-thickness defect; globe integrity maintained [12-13]
• Traumatic hyphema without rupture — blood in anterior chamber but intact globe; must rule out occult rupture [4]
• Orbital wall fracture without globe injury — enophthalmos, diplopia, infraorbital numbness
• Retrobulbar hemorrhage — proptosis, elevated IOP, APD; intact globe
• Subconjunctival hemorrhage (benign) — can mask underlying scleral rupture; diffuse chemotic hemorrhage is a red flag [4]
• Corneal abrasion — superficial, positive fluorescein uptake but no Seidel sign
• Traumatic iritis — photophobia, cell/flare, but intact globe
• Lens subluxation/dislocation — can occur with or without rupture
• Retinal detachment — can coexist or mimic; floaters, flashes, curtain-like field loss

Key pearl: Any hyphema after trauma should be treated as a ruptured globe until proven otherwise. [4]

9. Past Medical History

• Prior ocular surgery (cataract, LASIK, radial keratotomy, glaucoma surgery, corneal transplant) — surgical wounds are weak points
• History of prior globe injury
• Anticoagulant or antiplatelet use (increases hemorrhagic complications)
• Connective tissue disorders (Ehlers-Danlos, Marfan) — thinner sclera
• Diabetes, immunosuppression (increased infection risk)

10. Physical Exam

Critical rule: Minimize manipulation. Stop the exam if globe rupture is confirmed or strongly suspected.

• Visual acuity — document before any intervention; initial VA >20/400 is a favorable prognostic sign; no light perception (NLP) portends poor outcome [1][10]
• Pupil exam: Irregular/teardrop/keyhole pupil (iris prolapse); check for APD (swinging flashlight test) [1][4]
• Penlight/slit lamp (gentle):
  • Subconjunctival hemorrhage (360° or bullous/chemotic = high suspicion) [4]
  • Shallow or deepened anterior chamber [7]
  • Hyphema
  • Visible wound, tissue prolapse, or protruding foreign body (do NOT remove) [1]
  • Traumatic cataract (lens opacification)
• Seidel test: Fluorescein strip applied near suspected wound → streaming clear aqueous under cobalt blue light confirms full-thickness penetration [1][4]
• Do NOT perform: Tonometry, forced duction, direct pressure, or pharmacologic dilation [1]
• Assess for concomitant facial/orbital fractures, lid lacerations involving the canalicular system

11. Lab Studies

• Routine preoperative labs (CBC, BMP, coagulation studies) in anticipation of emergent OR
• Type and screen if significant hemorrhage or polytrauma
• Blood glucose (diabetic patients)
• No specific lab test diagnoses globe rupture — this is a clinical and imaging diagnosis

12. Imaging

• CT orbits (thin-cut, axial and coronal, without contrast) — first-line imaging [1][14]
  • Evaluates for: IOFB, orbital wall fractures, change in globe contour, intraocular air, vitreous hemorrhage, lens dislocation, retinal/choroidal detachment
  • Most predictive CT findings: change in globe contour and vitreous hemorrhage (specificity >98%) [14]
  • Sensitivity is limited (51–77%); CT cannot definitively exclude an open globe [2][14]
• MRI is contraindicated if metallic IOFB is suspected
• POCUS: Highly sensitive/specific for some findings but controversial due to risk of pressure on the globe causing content extrusion [2]
• Plain radiographs: May detect radiopaque foreign bodies but largely supplanted by CT

13. Special Tests

• Seidel test — gold standard bedside test for aqueous leak [1][4]
• Ocular Trauma Score (OTS): Validated prognostic tool using initial VA, globe rupture, endophthalmitis, perforating injury, retinal detachment, and APD to predict visual outcome [10]
• Birmingham Eye Trauma Terminology (BETT): Standardized classification system — rupture (blunt), penetrating, perforating, IOFB [12-13]
• Zone classification of injury: [12]
  • Zone I: Cornea and limbus
  • Zone II: Up to 5 mm posterior to limbus
  • Zone III: >5 mm posterior to limbus (worst prognosis)

14. ECG

• Not routinely indicated for isolated globe rupture
• Obtain if polytrauma, significant mechanism (MVC, fall from height), or pre-anesthetic evaluation requires it
• Consider in elderly patients or those with cardiac history prior to emergent general anesthesia

15. Assessment

Globe rupture is a sight-threatening emergency requiring immediate recognition and protection of the eye. Key prognostic factors include: [1][10][15]

• Presenting visual acuity — strongest predictor; VA >20/400 associated with favorable recovery
• Wound location — posterior wounds carry worse prognosis
• APD — indicates poor visual outcome
• Vitreous hemorrhage and retinal detachment — independent predictors of worse outcome [10]

Complications include endophthalmitis (up to 16.5% of open globe injuries; higher with IOFB, delayed repair, rural setting), [11][15] proliferative vitreoretinopathy (PVR), retinal detachment, and the rare but devastating sympathetic ophthalmia (autoimmune inflammation of the contralateral eye). [1][16]

Up to 20% of cases are occult — a deeper-than-normal anterior chamber with plateau iris after blunt trauma is virtually pathognomonic of posterior scleral dehiscence. [7]

16. Treatment Plan

17. Disposition

• All confirmed or suspected globe ruptures require admission for emergent surgical repair [2-3]
• Transfer to a facility with ophthalmologic surgical capability if not available on-site
• Approximately 54.5% of trauma centers worldwide routinely admit patients postoperatively for observation [17]

18. Follow Up / Return Precautions

• Postoperative follow-up with ophthalmology within 1–2 days, then frequently as directed
• Monitor for endophthalmitis (increasing pain, worsening vision, hypopyon, vitritis) — typically presents within first week [8][11]
• Monitor for sympathetic ophthalmia — bilateral granulomatous uveitis that can occur weeks to months after injury; any new visual symptoms in the contralateral eye require urgent evaluation [1][16]
• Monitor for PVR and retinal detachment — may require secondary vitrectomy [15]
• Return precautions for patients: Seek immediate care for increasing pain, worsening or new vision loss in either eye, increasing redness, fever, or purulent discharge
• Expected recovery varies widely based on injury severity; despite severe injuries, approximately 25% of ruptured globes achieve final VA >20/200 [10]
• Long-term protective eyewear counseling for the uninjured eye