What are the diagnostic criteria and initial management for globe rupture in a patient with blunt or penetrating ocular trauma?

Globe Rupture Diagnosis and Initial Management

Globe rupture requires immediate recognition through clinical examination and should be protected with a rigid eye shield without delay, followed by urgent ophthalmology consultation for surgical repair—CT orbit without contrast is the imaging study of choice when the diagnosis is uncertain or to assess extent of injury, but should never delay surgical consultation when the diagnosis is clinically obvious. 1

Clinical Diagnostic Criteria

Hard Signs of Globe Rupture

• Active bleeding from the eye indicates penetrating ocular injury requiring immediate surgical intervention 1
• Visible full-thickness corneal or scleral laceration with or without iris prolapse 2
• Irregular or peaked pupil pointing toward the site of rupture 3
• Shallow or flat anterior chamber compared to the contralateral eye 4
• Obvious globe deformity or collapse on examination 4

Soft Signs Requiring High Suspicion

• Severe subconjunctival hemorrhage with chemosis obscuring view of the sclera (may hide occult rupture) 5
• Marked reduction in visual acuity (e.g., from 6/6 to 6/12 or worse) 3
• Significantly decreased intraocular pressure compared to fellow eye 1
• Difference in anterior chamber depth between eyes is highly diagnostic 4
• Hyphema (blood in anterior chamber) 1
• Lens dislocation or destruction 4

Common Rupture Sites

• Limbus (corneoscleral junction) is the most common site 6
• Equatorial sclera at extraocular muscle insertions where sclera is thinnest 7
• Previous surgical incision sites (e.g., cataract surgery, radial keratotomy)—risk persists lifelong, even 20+ years post-surgery 8, 5

Immediate Management Algorithm

Step 1: Protect the Eye (Do NOT Delay)

• Apply rigid eye shield immediately without applying any pressure to the globe 1
• Avoid all eye manipulation: no lid eversion, no pressure, no forced duction testing 3, 1
• Keep patient NPO (nothing by mouth) in preparation for urgent surgery 2

Step 2: Systemic Medications

• Administer prophylactic systemic antibiotics (typically IV broad-spectrum coverage) 2
• Consider antifungals if organic matter exposure (e.g., vegetable matter, soil) 2
• Update tetanus prophylaxis if indicated 2
• Antiemetics to prevent Valsalva and increased intraocular pressure 2

Step 3: Urgent Ophthalmology Consultation

• Immediate consultation for surgical exploration and primary wound closure 1
• Surgery should occur within hours, not days—delayed closure increases endophthalmitis risk 5

Step 4: Imaging (When Appropriate)

• CT orbit without contrast with thin cuts and multiplanar reconstructions is the imaging study of choice 6, 1
• CT has 76% sensitivity and 85% specificity for globe rupture detection 4
• Do NOT delay surgical consultation for imaging if diagnosis is clinically obvious 1
• CT is indicated when:
  • Diagnosis is uncertain despite clinical examination 4
  • Intraorbital foreign body is suspected (94.9% sensitivity for metallic foreign bodies) 6, 3
  • Need to assess extent of globe damage and surrounding structures 6
  • Concurrent orbital fracture or intracranial injury suspected 6

Step 5: Associated Injuries Assessment

• Monitor for oculocardiac reflex (bradycardia, heart block, nausea, vomiting) which indicates muscle entrapment requiring urgent surgery 1
• Assess for traumatic brain injury, especially in children with orbital roof fractures 6
• Document visual acuity, pupillary responses, and extraocular movements before shielding 1

Critical Pitfalls to Avoid

Diagnostic Errors

• Massive subconjunctival hemorrhage can hide scleral rupture—when in doubt after severe blunt trauma, perform 360-degree limbal and scleral exploration 5
• CT is not 100% sensitive (only 76%)—clinical suspicion trumps negative imaging 4
• Intraocular gas on CT is highly specific for globe rupture 4
• Globe wall irregularity and intraocular hemorrhage are significant CT findings 4

Management Errors

• Never apply pressure to a suspected ruptured globe—use rigid shield, not eye patch 1
• Never perform forced duction testing in primary care if open globe is possible 1
• MRI is absolutely contraindicated when metallic intraorbital foreign body is suspected 6, 9
• Delayed wound closure significantly increases risk of expulsive choroidal hemorrhage, persistent hypotony, epithelial ingrowth, and endophthalmitis 5

High-Risk Populations

• Previous intraocular surgery increases rupture risk 27-fold 5
• Myopic patients, elderly, and females have increased risk 5
• Children with high-velocity projectile injuries (hammering, metal work) 3

Prognostic Factors

Poor Visual Prognosis Indicators

• Lacerations ≥5 mm 1
• Ciliary body detachment 1
• Intraocular foreign bodies 1
• Vitreous hemorrhage 1
• Endophthalmitis 1
• Initial visual acuity of light perception or worse 1

When to Consider Primary Enucleation

• Bilateral trauma with one eye having dismal prognosis 1
• Globe subluxation into maxillary sinus 1
• Massive tissue destruction with no potential for vision 1