Patient Presentation
A pediatrician was hiking in a backcountry mountainous location with her family and a guide. During a rest break, the guide reminded everyone to drink lots of fluid and to eat a snack to maintain energy and avoid dehydration. He also checked with everyone to make sure that equipment was fitting well and no hot spots or blisters were developing on people’s feet. The youngest boy took off his sunglasses during the break and the guide asked him to please put them back on. The boy said, “The sun’s not out and I can see fine.” The guide said, “I know that but there are small branches on the trees right at head height that could poke you, or a branch could snap back or you could even fall. Your glasses won’t prevent everything, but can still give you some eye protection.” He went on to say, “In over 20 years of guiding, I’ve only had one serious injury. Someone caught a branch in their eye. Once a globe is ruptured, the vision is not coming back. I’ve always felt bad about it.” The boy put the glasses back on immediately.
Discussion
Acute eye injuries usually need medical evaluation after the injury to assess the injury extent. Some can be appropriately treated by non-ophthalmologists such as corneal abrasions or minor chemical splashes. Serious or indeterminant injury needs ophthalmological evaluation. Acute globe rupture requires immediate ophthalmological care, often requiring emergency surgery.
Globe rupture is defined as any full-thickness injury to the sclera, cornea or both. It can be caused by penetrating or blunt trauma. Penetrating injuries including scissors, knifes, sticks, nails, projectiles (i.e. BBs, paintballs etc.). Blunt injuries can include sports, traffic accidents, child maltreatment, falls, and there has even been one report of an injury from a mobile videogame console (e.g. WiiTM game system). Blunt injuries are caused when sclera tears from increased intraocular pressure; thus these injuries occur usually where the sclera is thinnest such as the limbus, insertion of the extraocular muscles or previous surgical sites. These sites are often difficult to see because of location.
Globe injuries occur more commonly in males than females because of occupational and recreational activities. Men have more penetrating injuries and women have more blunt injuries. Globe injuries can be obvious or more difficult to diagnose. Globe rupture may be indicated by a visible foreign body or wound or extruded eye contents, self-sealing tract (e.g. discoloration from the sclera or iris closing the wound), decreased mobility of eye, shallow anterior chamber, pupillary irregularity, and chemosis or hemorrhage (particularly circumferential). Using protective eyewear for occupational and recreational activities is the prevention mainstay.
Learning Point
Emergency first aid treatment for a ruptured globe includes:
- No eye manipulation including no irrigation or instillation of eye drops or other medicines, and no further physical examination of the eye.
- Placing a rigid surface object such as an eye shield over the eye and securing it to the bony surfaces around the eye. No pressure should be put on the eye so that eye contents remain in the globe and are not extruded or further extruded.
A foam cup for example can be used. An eye patch is contraindicated because it can put pressure on the globe. - Keeping the person calm, again so pressure (ie. valsalva maneuver) does not increase and extrude eye contents. If available in the proper setting, sedation may be used especially in young children.
- If a foreign body is in the globe, leave it in place.
- Transporting the patient to a center with ophthalmological care as soon as possible.
- Keep the patient NPO.
- Treatment of other injuries as appropriate.
- Check the tetanus status and administration of tetanus vaccine as appropriate.
Surgical treatment depends on the location, extent, foreign body, etc. and other injuries. Initial surgical treatment includes primary closure along with possible lentectomy andvitrectomy. Other surgical treatments can include intraocular lens implantation, keratoplasty, endolaser, scleral buckle and silicone oil.
Antibiotics to try to prevent endophthalmitis is necessary.
Visual outcome depends much on the extent of the initial injury. Open globe injuries have worse visual outcomes in children. For open globe injuries in children, other poor prognostic factors include young age, poor initial visual acuity, relative afferent papillary defect, absent red reflex, cataract, and the number and types of surgeries.
Questions for Further Discussion
1. What are the common organisms causing endophthalmitis?
2. What are common causes of monocular vision loss in children?
3. What are the possible complications of an acute globe rupture?
Related Cases
- Disease: Globe Rupture | Eye Injuries
- Symptom/Presentation: Eye Pain | Trauma | Eye Trauma
- Specialty: Emergency Medicine | Ophthalmology
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Eye Injuries
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Burns GA. Primary Repair of the Posterior Segment: Penetrating, Performating and Blunt Rupture Injures. In Ophthalmic Care of the Combat Casualty. US Army Medical Department Borden Institute. Office of the Surgeon General of the Army. 2003:211-223.
Available from the Internet at http://www.bordeninstitute.army.mil/published_volumes/ophthalmic/OPHch13.pdf (rev. 2003, cited 3/19/2012).
Lee CH, Lee L, Kao LY, Lin KK, Yang ML. Prognostic indicators of open globe injuries in children. Am J Emerg Med. 2009 Jun;27(5):530-5.
Gupta A, Rahman I, Leatherbarrow B. Open globe injuries in children: factors predictive of a poor final visual acuity. Eye (Lond). 2009 Mar;23(3):621-5.
Golden DJ. Doren SC. Globe Rupture. Medscape. Available from the Internet at http://emedicine.medscape.com/article/798223-overview (rev. 2/18/2010, cited 3/19/2012).
Yalcin Tok O, Tok L, Eraslan E, Ozkaya D, Ornek F, Bardak Y, Prognostic factors influencing final visual acuity in open globe injuries. J Trauma. 2011 Dec;71(6):1794-800.
Skarbek-Borowska SE, Campbell KT. Globe rupture and nonaccidental trauma: two case reports. Pediatr Emerg Care. 2011 Jun;27(6):544-6.
Razavi H, Lam G. Wii eye injury: self-inflicted globe rupture and vision loss in a 7-year-old boy from a video game accident. J AAPOS. 2011 Oct;15(5):491-2.
ACGME Competencies Highlighted by Case
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 