An 81 year old male with a past medical history of Alzheimer’s dementia, a-fib on coumadin and coronary artery disease presents to the emergency department via EMS after being punched in left eye at his rehab facility. History was obtained from wife secondary to the patient’s advanced dementia.
She reports that this morning while her husband was at breakfast, another resident walked up to him and punched him in the left eye. She did not witness the event. It is unknown if there was a loss of consciousness. She reports that her husband is already blind out of his right eye. A recent vision test showed 20/20 acuity in left eye s/p cataract surgery in 2019. Patient does not participate in history taking. It is unknown if he is experiencing any changes in vision. Review of systems was subsequently unable to be obtained.
Vital Signs: BP 151/81, HR 58, RR 16, SpO2 97% on RA ,Temp 36.8 C
Exam
Obvious eyelid swelling of left eye
Ecchymosis of medial upper eyelid
Opens eye to command
Inferior hemorrhagic chemosis
Pupil completely obscured by grade IV hyphema
Serosanguinous drainage from globe
Possible proptosis
Does not cooperate with visual acuity or EOM movement on command, avoid IOP measurement due to concern for globe rupture
Plan:
Pre-op Labs
CT head/facial bones/c-spine
Ophthalmology consult
Pain control
Imaging confirmed globe rupture, no other traumatic injuries identified. The patient received IV ciprofloxacin for traumatic endopthalmitis prevention and his tetanus updated. He went to the operating room for globe repair with ophthalmology.
Take Away #1
Globe rupture - serious ophthalmologic emergency that requires STAT ophthalmology evaluation
Open globe = full thickness break of eye wall (sclera & cornea)
Caused by blunt or penetrating trauma
Penetrating trauma causes laceration to the cornea & sclera
Blunt trauma increases the IOP causing rupture of the sclera `
Rupture occurs usually posterior to where rectus muscles insert as this is where the sclera is the thinnest
Exam
Decreased visual acuity or blindness
EOM impairment (may be due to globe rupture or concomitant injury)
”Teardrop pupil” - points to the rupture site
Hemorrhagic chemosis or severe subconjunctival hemorrhage
”Seidel’s sign” - fluorescein washes away (avoid if rupture is obvious)
Flattened anterior chamber from fluid leak
Scleral laceration & extrusion of contents
Treatment
Hard shield over the eye
Pain and nausea control
Update tetanus if necessary
IV antibiotics - UpToDate recommends IV Ceftazadine and Vancomycin as they cover the majority of organisms that are related to traumatic endopthalmitis
Ophtho consult → OR for surgical repair
Take Away #2
If exam is concerning for ruptured globe do not continue to manipulate eye, cover with heard shield and treat accordingly. DO NOT measure IOP!
Take Away #3
Look for other injuries → open globe is the result of blunt trauma to the eye, if the force is large enough there may be other injuries
Blow out fracture w/ muscle entrapment
Orbital hemorrhage w/ proptosis
Orbital compartment syndrome (from retrobulbar hematoma) → rapid expanding hematoma results in increased IOP which compresses the retinal artery causing ischemia and can lead to rapid permanent blindness
Hyphema → depending on grade of traumatic hyphema may need to be drained surgically
CT orbits/facial bones w/o contrast evaluates for these other injuries.
Amanda Correia, DO is a current first year resident at Stony Brook Emergency Medicine.
References:
Edited by Bassam Zahid, MD