Shruthi Suresh, MD [email protected]
Gino Mongelluzzo, MD [email protected]
27 year-old male with eye pain
Page 1 – Contributor information, patient history, images, questions
Our appreciation is extended to Dr. [Shruthi Suresh], [Department of Trauma Surgery] and Dr. Mongelluzzo [Department of Diagnostic Radiology] in [Danville,PA], [United States of America], for contributing this case.
History: 27 year old male who is brought to the trauma bay complaining of severe right eye pain, photophobia and loss of vision. Additional history is purposely withheld.
He subsequently underwent a head CT scan.
Image 1
Image 2
Which choice best characterizes the salient findings?
Calcified Optic glioma
Orbital Cellulitis
Mastoiditis
Globe rupture
What is the salient finding?
Subcutaneous air
Rupture of the right lateral rectus
Intraocular foreign body
Displacement of lens
The differential diagnosis should include which of the following?
Intraocular gas tamponade
Intracranial tumor
Preseptal cellulitis
Optic nerve transection
All of the above
Globe rupture typically occurs exactly at the point of impact when there is blunt trauma to the eye.
F
Severe episcleritis or glaucoma can lead to globe rupture in the absence of trauma. T
There is enlargement of the anterior chamber. T
Page 2 – Additional images and questions (if needed)
Image 3
Image 4
There is an additional foreign body that can be seen. T
What are additional salient findings that can be found?
Dislocation of the lens
Anterior hyphema
Staphyloma
Fracture of the right lateral orbit
All of the above
Image 1: Axial view of right globe rupture with intra-ocular foreign body
Image 2: Frontal view of right globe rupture with intra-ocular foreign body
Image 3: Axial view of a nondisplaced fracture involving the right lateral orbit/zygoma with multiple foreign bodies in the adjacent temporalis muscle
Image 4: Frontal view of a nondisplaced fracture involving the right lateral orbit/zygoma with multiple foreign bodies in the adjacent temporalis muscle
Findings
Differential diagnosis
Penetrating laceration of right globe with rupture and intraocular foreign body from a ricocheted bullet
Intraocular gas tamponade
Emphysematous endophthalmitis
Choroidal Melanoma
Uveal hemorrhage
Diagnosis:
Penetrating laceration of right globe rupture with intraocular foreign body from a ricocheted bullet
What is the Zone of injury?
Zone 1
Zone 2
Zone 3
What is the prognosis with respect to recovery of vision after this type of injury?
Good
Poor
Ocular ultrasound is a useful imaging technique to evaluate for vitreous hemorrhage after the diagnosis of ruptured globe has been made on CT. F
Clinical Presentation and management
Patients typically present with severe eye pain and photophobia
Ophthalmologic emergency that requires urgent surgical treatment and closure, particularly in the setting of a foreign body, which dramatically increases risk of endophthalmitis
If not obvious on physical exam due to posterior rupture or accompanying photophobia a CT is the best imaging study to evaluate for injury.
Typically an eye shield is placed over the eye to avoid further application of pressure, broad spectrum antibiotics are initiated to decrease the risk of endophthalmitis and antiemetic/sedative therapies initiated to avoid actions that may lead to unpredictable increases in intraocular pressure.
Ultrasound of the eye is contraindicated in traumatic globe rupture as additional pressure to the globe may cause herniation of intraocular structures.
CT is more sensitive than ultrasound for globe rupture.
Diagnosis on Imaging
Globe collapse, enlarged anterior chamber, foreign body and intraocular gas are important signs that indicate globe rupture
The enlarged anterior chamber appearance is secondary to the lens leaning on its suspensory ligaments due to a decrease in pressure within the vitreous chamber
Vitreous and choroid detachment are common findings associated with globe laceration.
Prominent choroidal detachment superiorly and inferiorly can produce a kiss sign.
In the presence of foreign bodies it is important to look for damage to surrounding structures (i.e. muscles, nerves and the orbit)
Mechanism, terminology and epidemiology
Mechanical trauma is the most common of electrical, chemical and thermal injuries
Closed globe injury has a far better prognosis than open globe injury and often does not require surgical intervention
The most common cause of globe rupture is secondary to blunt trauma.
Rupture typically occurs secondary to elevated intraocular pressure after trauma and occurs at the thinnest points which is most commonly where the sclera attaches to the limbus or the extraocular muscles (inside-out).
Globe lacerations typically occur due to direct contact with a sharp object or a projectile and the trajectory of injury is outside-in.
Use of BB guns with recreational shooting, glass from car accidents and fights in teenage boys are common causes of these type of injuries.
Injuries may either be penetrating, which means the foreign body enters the globe but does not exit, or perforating where there are both entry and exit sites.
Treatment and Prognosis
The zone of these injuries are crucial to the prognosis of recovery of vision.
Zone 1 occurs at the joining of the cornea and sclera but does not penetrate this region.
Zone 2 injuries refer to laceration or rupture that occur in the anterior 5mm of the sclera.
Zone 3 injuries refer to a full thickness laceration or rupture that extends more than 5mm posteriorly from the limbus.
Zone 3 injuries have the worst prognosis
References
Andreoli CM, Gardiner MF. Open globe injuries: Emergency Assessment and initial management. UpToDate. rupture&source=search_result&selectedTitle=1~22&usage_type=default&display_rank=1#references. Published February 2019. Accessed March 26, 2019
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Accessed March 26, 2019.
Ophthalmology. In: Brunette DD. eds. Extraordinary Cases in Emergency Medicine New York, NY: McGraw-Hill; . Accessed March 26, 2019.
Carvounis PE, Chu YI. Eye. In: Moore EE, Feliciano DV, Mattox KL. eds. Trauma, 8e New York, NY: McGraw-Hill; . Accessed March 26, 2019.
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Kubal, W. S. (2008). “Imaging of orbital trauma.” Radiographics 28(6): 1729-1739.
Lazzaro DR. Chapter 8. Ophthalmology. In: Shah BR, Lucchesi M, Amodio J, Silverberg M. eds. Atlas of Pediatric Emergency Medicine, 2e New York, NY: McGraw-Hill; 2013. Accessed March 26, 2019.
Lyon M, von Kuenssberg Jehle D. Chapter 19. Ocular. In: Ma O, Mateer JR, Reardon RF, Joing SA. eds. Ma and Mateer’s Emergency Ultrasound, 3e New York, NY: McGraw-Hill; 2014. Accessed March 26, 2019
Weaver CS, Knoop KJ. OPHTHALMIC TRAUMA. In: Knoop KJ, Stack LB, Storrow AB, Thurman R. eds. The Atlas of Emergency Medicine, 4e New York, NY: McGraw-Hill; . Accessed March 26, 2019