The Case Files

Abstract

A 21-year-old man presented after an unrestrained motor vehicle collision with complaints of a headache and multiple facial lacerations. He was without visual complaints, but an examination revealed an irregular pupil. Extraocular ocular motion, light perception, and visual acuity remained intact. No penetrating injury or foreign body was noted. Blunt trauma causes rupture of the sclera by a sudden elevation in intraocular pressure. This can be easily diagnosed if extraocular contents are seen extruding. The only finding on exam may be a severe subconjunctival hemorrhage covering the entire sclera or bullous chemosis that raises the suspicion for occult rupture significantly. (Rosen's Emergency Medicine. 7th ed. Philadelphia: Elsevier; 2010: 863-4.) Other physical exam findings in globe rupture include an irregular or teardrop-shaped pupil (consistent with rupture at the limbus) as well as afferent papillary defect, shallow anterior chamber, hyphema, a positive Seidel test, and lens dislocation. (Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw Hill; 2011: 1540-1; Rosen's Emergency Medicine. 7th ed. Philadelphia: Elsevier; 2010: 863-4.) Visual acuity may or may not be preserved.Tonometry and ultrasound are contraindicated in the ED if globe rupture is suspected. CT of the orbits (coronal and axial views) will aid in diagnosis and exclude intraocular foreign body and additional trauma to the orbital walls. (Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw Hill; 2011: 1540-1; Am Fam Physician 2007;76[6]:829; Ophthalmol Clin North Am 2002;15[2]:153.) A high suspicion for globe rupture should be maintained in all cases of ocular trauma. The goals are to preserve function and avoid progression to endophthalmitis, a devastating intraocular infection that leads to blindness and occurs after 6.8 percent of globe injuries. (Am Fam Physician 2007;76[6]:829; http://bit.ly/18s5WpX, accessed April 14, 2013; Ophthalmology 2004;111[11]:2015.)Figure: Irregularly shaped pupil noted on physical exam.Emergent management should include rigid shield placement, elevating the head of the bed, broad-spectrum antibiotic coverage for Streptococcus, Staphylococcus, and Bacillus species, gram-negative bacilli, and anaerobes (Am Fam Physician 2007;76[6]:829; Ophthalmol Clin North Am 2002;15[2]:153), tetanus, as well as additional symptomatic management to avoid elevation in intraocular pressure (i.e., analgesia, antiemetics, etc). Most importantly, definitive management by ophthalmology should be expedited.