What is the treatment for a perforated globe?

Management of Perforated Globe

Immediate surgical intervention is the treatment of choice for perforated globe to preserve vision and prevent complications such as endophthalmitis, retinal detachment, and vision loss. 1

Initial Assessment and Management

• Obtain immediate imaging, preferably CT scan, which is more sensitive than standard radiographs for detecting the extent of damage 2
• Laboratory tests including white blood cell count and C-reactive protein should be performed to assess inflammatory response 2
• Initiate broad-spectrum antibiotics covering gram-negative, gram-positive, and anaerobic organisms to prevent endophthalmitis 3, 4
• Provide aggressive fluid resuscitation and correction of electrolyte imbalances 2

Surgical Management

• Primary surgical repair of the ocular wound should be performed as soon as possible 1
• Prophylactic scleral buckling is recommended in cases involving the posterior segment 1
• For small perforations, simple closure may be sufficient 5
• For larger defects or complex injuries:
  • Vitrectomy should be performed to remove vitreous hemorrhage and intraocular foreign bodies 1
  • Temporary perfluorocarbon and permanent silicone oil tamponade may be used to achieve stable retinal attachment 1
  • Scleral patch grafting may be necessary for large scleral lacerations with uveal prolapse 6

Special Considerations Based on Etiology

• For perforations due to corneal melting, treatment options range from corneal gluing to corneal transplantation, depending on location, size, and underlying cause 7
• In cases of severe scleral necrosis where conventional patching methods have failed, tarsoconjunctival 'Hughes' flap may provide tectonic support and help restore globe integrity 5
• For perforations during strabismus surgery (iatrogenic), immediate recognition and repair is essential 6

Risk Factors for Poor Outcomes

• Presence of retinal and choroidal injury 1
• Poor initial visual acuity after injury 1
• High myopia (>-6.00 D) increases risk of perforation during ocular surgery 6
• Previous extraocular muscle surgery doubles the risk of perforation during subsequent procedures 6

Post-operative Management

• Serial clinical and imaging monitoring should be performed every 3-6 hours in the immediate postoperative period 2
• Continue broad-spectrum antibiotics until clinical improvement 2
• Monitor for signs of endophthalmitis, retinal detachment, cataract, glaucoma, and phthisis bulbi 6
• Advanced surgical techniques have significantly reduced the incidence of enucleation and improved visual outcomes 1

Follow-up Care

• Regular follow-up examinations to monitor healing and detect complications early 2
• Multidisciplinary team approach may be necessary for complex cases 2