Major reviewOccult globe rupture: diagnostic and treatment challenge
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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Globe Rupture Diagnosed with Point-of-Care Ultrasound
2023, Journal of Emergency MedicineHigh risk and low prevalence diseases: Open globe injury
2023, American Journal of Emergency MedicineCitation Excerpt :Following this assessment, patients with suspected OGI should undergo a full eye examination, including visual acuity, pupils including afferent pupillary defect (APD), confrontational visual fields, extraocular movements, gross examination with slit lamp or pen light, and fluorescein staining. Potential physical examination findings in OGI include decreased visual acuity, pupillary shape abnormalities such as a teardrop or peaked pupil (Fig. 3), an APD, abnormal extraocular movements (if there is an associated orbital floor fracture with extraocular muscle entrapment syndrome), corneal or scleral defects, and positive Seidel test (a rivulet of fluorescein flowing from a corneal or scleral defect in OGI) (Fig. 4) [14,48]. It is critical to note that assessment of IOP should be avoided as part of the ocular examination in patients with suspected OGI, as placing pressure on the eye may theoretically cause extrusion of orbital contents [48].
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This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.