Elsevier

Survey of Ophthalmology

Volume 63, Issue 5, September–October 2018, Pages 694-699
Survey of Ophthalmology

Major review
Occult globe rupture: diagnostic and treatment challenge

https://doi.org/10.1016/j.survophthal.2018.04.001Get rights and content

Abstract

Occult globe rupture is a traumatic dehiscence of the sclera at or posterior to the rectus muscle insertions without a visible eye wall defect on slit lamp examination. Occult scleral ruptures are important because they can be difficult to diagnose, but normally require preoperative protection against external pressure to reduce risk of herniation of ocular contents through the rupture and then urgent surgical repair to restore eye wall structural integrity and achieve optimum prognosis. A deeper-than-normal anterior chamber with posteriorly retracted plateau iris seen immediately after acute ocular trauma is virtually pathognomonic of posterior globe dehiscence. Three additional less specific signs are helpful: extensive chemosis that is often hemorrhagic, relative hypotony, and vitreous hemorrhage. Although the diagnosis is normally clinical, made by history of direct severe ocular trauma and careful anterior-segment slit lamp examination, computed tomography and ultrasonography can be helpful when thorough slit lamp examination is not possible. Strong suspicion of occult rupture should engender surgical exploration. Vitreous hemorrhage, vitreous or retinal incarceration, and retinal tears or detachment may necessitate subsequent pars plana vitrectomy or other vitreoretinal surgery. When pars plana vitrectomy is indicated, special precautions are suggested if watertight closure of the globe rupture has not been possible.

Introduction

Occult rupture of the globe is a traumatic dehiscence of the sclera at or posterior to the rectus muscle insertions without a visible eye wall defect detected neither on slit lamp examination nor on fundus examination because of vitreous hemorrhage.31, 38 Posterior globe rupture is often difficult to diagnose but is important for at least three reasons.22, 31 First, preoperative protection against external pressure with a shield is normally required to reduce risk of herniation of ocular contents through the rupture. Second, urgent surgical repair is usually indicated to restore eye wall structural integrity and achieve optimum prognosis.19, 25, 37 Undue delay in closing the eye wall defect predisposes to herniation of intraocular contents through the rupture which may occur from inadvertent pressure on the globe or from coughing and sneezing. The prolonged hypotony that may be associated with the rupture predisposes to ciliochoroidal effusion and delayed choroidal hemorrhage, which also may be precipitated in a soft eye by sneezing or coughing. Third, pars plana vitrectomy (PPV) with special precautions or other vitreoretinal surgery may be necessary after repair of the eye wall defect to treat dense vitreous hemorrhage, vitreous or retinal incarceration, and retinal tears or detachment. We discuss the importance and difficulty of diagnosis, the characteristics, a practical diagnostic approach, and outline treatment of occult globe rupture.

Posterior globe rupture is often difficult to diagnose for several reasons.

Scleral rupture at or posterior to the rectus muscle insertions is often not visible on slit lamp examination, hence “occult.” Even if anterior to the conjunctival fornices, a scleral rupture may be hidden from view by overlying Tenon fascia and oculorotary muscles as well as by hemorrhagic chemosis.10, 38

Traumatic lid edema and hematoma may prevent thorough ocular examination, particularly if delays in examination allow development of increasing edema and hemorrhage in the first day or so after contusional ocular trauma.

Traumatic hyphema, frequently present and severe, may obscure slit lamp visualization of the anterior chamber (AC), which otherwise would provide the most valuable sign of posterior rupture, as well as the fundus.38

Vitreous hemorrhage arising from ciliochoroidal rupture, retinal tear, and trauma to the ciliary body and/or iris often prevents fundus visualization of a posterior rupture.

Although the intraocular pressure (IOP) is usually lower in the contralateral uninjured eye, IOP may be normal or even elevated, giving the false impression of an intact eye wall.38 Low IOP is strongly suggestive of globe rupture.22

The AC is typically deeper than normal, a most important sign, in contrast to eyes with corneal and limbal ocular wall defects that tend to have shallowing of the AC. Deepening of the AC, although first described 46 years ago, is not well known, having received little subsequent attention in the ophthalmic literature.10, 22, 36 It should be noted that the AC may be deep if vitreous protrudes out of a full-thickness scleral defect which causes a decrease in vitreous volume; however, if there is severe vitreous hemorrhage, the posterior vitreous volume may not change, and the AC may not deepen. Also, if there is little or no protrusion of vitreous at the rupture, AC depth will not be affected.

Section snippets

Pathophysiology

Rupture of the globe is typically caused by blunt ocular trauma causing hyperacute compression of the eye filled with incompressible liquid and tissue.6, 30 Scleral rupture may be direct, located close to the site of impact, or indirect, at a site remote from the impact, particularly where the sclera is weakened or thinned, such as the limbus, extraocular muscle insertions, surgical incisions, staphylomata, and entrance of the optic nerve.10, 31 Rupture of the globe posterior to the spiral of

Diagnosis

Diagnosis of posterior globe rupture is usually clinical, based on history and physical examination.11, 16, 28

CT scanning

CT with fine slices is usually not necessary to establish the diagnosis of occult rupture of the globe, but can be useful when periorbital edema and hemorrhage, blepharospasm, or hyphema prevents a thorough ocular examination of the anterior segment.1, 2, 20, 23 CT is not as reliable as a clinical examination when the anterior segment is visible,17 but helpful radiologic signs include 1) deepening of the AC; 2) alteration of globe contour with scleral folds; 3) a discontinuity in the scleral

Preoperative care

If posterior rupture is suspected while the patient is being cleared and prepared for surgery, the eye should be protected with a shield to prevent pressure on the globe causing expulsion of the ocular contents through the eye wall rupture, but pressure patching should be avoided. Topical antibiotic corticosteroids and cycloplegics are usually administered to treat traumatic uveitis associated with the injury.

Anesthesia

Many would avoid local anesthesia because the volume of fluid instilled around the eye

Other traumatic occult scleral wall defects

Rarely, occult defects in the scleral wall may be caused by small direct lacerations or perforations by a sharp object and ocular perforations by a tiny foreign body. Once again, careful history and physical examination are indicated. Seemingly, minor lid lacerations may overlie an ocular perforation, so the surface of the globe beneath a lid laceration or puncture should be examined carefully along with careful funduscopy.

Conclusions

A deeper-than-normal AC with posteriorly retracted plateau iris diagnosed immediately after acute ocular trauma is virtually pathognomonic of posterior globe rupture. Three additional less specific signs in conjunction are suggestive of occult ocular rupture: marked chemosis, relative hypotony, and vitreous hemorrhage. Although diagnosis is normally made based on the history of significant ocular contusion and careful clinical examination, CT and ultrasonography can be important diagnostic aids

Method of literature search

Medline searches were performed with each of the following terms: “ruptured globe,” “scleral rupture,” “scleral dehiscence,” and “open globe injury.” Articles in French and German were included. The reference lists of relevant articles were reviewed for additional potentially useful references. We included all articles that contributed information about characteristics, diagnosis, or treatment of posterior scleral rupture.

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    This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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