What is the management of a ruptured globe?

Management of a Ruptured Globe

A ruptured globe requires immediate ophthalmology consultation, placement of a rigid eye shield, administration of prophylactic systemic antibiotics, and tetanus prophylaxis to preserve vision and prevent complications. 1

Initial Assessment and Management

Recognition of Globe Rupture

• Look for signs of globe rupture:
  • Blood in the anterior chamber (hyphema)
  • Irregular pupil
  • Shallow anterior chamber
  • Subconjunctival hemorrhage
  • Extrusion of intraocular contents
  • Decreased visual acuity
  • Hypotony (low intraocular pressure)

Immediate First Aid Measures

1. Do not apply pressure to the eye or attempt to remove any foreign bodies 2
2. Apply a rigid eye shield (not a pressure patch) over the affected eye 2
   • If a commercial eye shield is unavailable, use a paper cup or plastic cup taped over the eye 2
3. Avoid manipulation of the eye to prevent extrusion of intraocular contents
4. Keep the patient NPO in preparation for possible emergency surgery

Medical Management

Medications

1. Systemic antibiotics to prevent endophthalmitis

   • Broad-spectrum coverage (typically a fluoroquinolone plus vancomycin)
   • Start immediately upon diagnosis

2. Tetanus prophylaxis if indicated based on immunization status

3. Pain management

   • Avoid medications that increase bleeding risk

4. Antiemetics to prevent Valsalva maneuver from vomiting

Surgical Management

Timing

• Emergency surgical repair is necessary, ideally within 24 hours of injury 3
• Delayed wound closure increases risk of posttraumatic endophthalmitis 3

Surgical Approach

1. Primary closure of all wounds with watertight sealing 3

   • Exploration after 360-degree peritomy to identify extent of injury
   • Careful wound apposition to avoid expulsive hemorrhage or hypotony

2. Early vitrectomy may be indicated if:

   • Vitreous hemorrhage is present
   • Retinal injury is detected
   • Risk of tractional retinal detachment exists 3

3. Silicone oil instillation may be used to stabilize the central retina 3

Complications and Prognosis

Potential Complications

• Endophthalmitis
• Sympathetic ophthalmia (inflammatory condition affecting the uninjured eye)
• Retinal detachment
• Persistent hypotony
• Epithelial ingrowth
• Vision loss

Prognosis Factors

• Initial visual acuity
• Extent of injury
• Presence of intraocular foreign body
• Time to surgical repair
• Presence of retinal detachment or endophthalmitis

Special Considerations

Sympathetic Ophthalmia

• Historically, enucleation within 14 days was recommended to prevent sympathetic ophthalmia
• Current evidence does not support the "14-day rule" for prophylactic enucleation 4
• Modern approach favors globe preservation when possible, with medical management of sympathetic ophthalmia if it occurs 4

Intraocular Foreign Bodies

• CT imaging is the gold standard for detecting intraocular foreign bodies (94.9% sensitivity) 2
• All metallic foreign bodies should be removed during surgical repair

Follow-up Care

1. Close monitoring for signs of infection or inflammation
2. Visual rehabilitation once the eye has stabilized
3. Psychological support for patients with significant vision loss

Remember that globe rupture is an ophthalmologic emergency requiring immediate intervention to maximize the chance of preserving vision. The primary goals are to prevent infection, avoid further damage to intraocular structures, and restore globe integrity.