Picture Blog: Answer

Patient presentation:

A 65-year-old woman presents to your ED complaining of pain in her left eye. She says that she was walking past a construction site and suddenly felt left eye pain. She says that she cannot see out of her left eye at all and is very concerned.

What is your concern based on the presentation and image?

Globe rupture. Globe rupture can be caused by penetrating trauma such as a high-speed projectile, the classic example being someone who is woodworking or hammering metal without eye projection. Blunt trauma to the eye can create a sudden increase in intraocular pressure which can also cause rupture; this often occurs at the insertions of the intraocular muscles, as this is the thinnest and thus weakest part of the sclera.

You ask your patient about her vision, what do you expect her answer to be?

The patient will likely have decreased visual acuity, if any vision at all. If the patient is unable to discern a standard Snellen chart, the ability to count fingers, motions, or just light perception should be assessed.

When you examine her eye what do you expect to see? How should you perform the examination?

If you are concerned about a globe rupture you must avoid all examination procedures that increase intraocular pressure. This includes retracting eyelids and tonometry measurement. Findings include relative afferent pupillary defect (affected eye will dilate after light is shined in eye after swinging the light from the opposite eye), teardrop-shaped pupil, extrusion of vitreous, and tenting of the cornea or sclera. Fluorescein dye may show a positive Seidel test if a corneal defect has not sealed itself. If you must retract the lids, make sure to only apply pressure to the bony parts of the orbit.

As you call optho what measures should you take to protect the patient?

Every effort should be taken to avoid extra pressure on the globe to avoid extrusion of ocular contents. These measures include an eye shield, avoiding eye manipulation, avoiding optic solutions such as tetracaine, antiemetics to prevent vomiting, pain medication, and sedation if necessary. If there is a globe rupture, the patient is at risk of endophthalmitis and antibiotics should be started in consultation with ophthalmology.

Is imaging necessary in this patient?

If there is concern for retained foreign body or diagnostic uncertainty then imaging is warranted. CT is the test of choice. MR should be avoided since a metallic foreign body can be moved by the scanner magnets and cause more damage. Ocular ultrasound also should not be attempted since even the slightest pressure from the probe could extrude the contents of the globe exacerbating the injury.{/expand]

What is the definitive management for this patient?

Visual outcomes are often poor, however, early surgical closure within 24 hours and prompt antibiotics give the patient the best chance at retaining vision in the affected eye.

References:

1. Uptodate: Open Globe injuries: Emergency evaluation and initial management

2. Zhang Y et al. Intraocular foreign bodies in China: clinical characteristics, prognostic factors and visual outcomes in 1421 eyes. Am J Ohthalmol. 2011:152:66-73

3. Colby K. Management of open globe injuries. Int Ophthalmol Clin 1999; 39:59.

4. Romaniuk VM: Ocular trauma and other catastrophes. Emerg Med Clin North Am 2013; 31: pp. 399-411