Ruptured Globe

59 yo male who was assaulted and sustained blunt trauma to the left orbit. • Xray of the Week

Figure 1. What are the important findings in each image.

Figure 2. A: Coronal CT image demonstrates normal contour of the right globe (green arrow) and a shrunken left globe (orange arrow), which is suggestive of globe rupture.

B: Axial CT image demonstrates normal contour of the right globe (green arrow) and abnormal contour left globe (orange arrow), suggestive of globe rupture. Note the mushroom shape due to extruded vitreous. The hyperattenuation of the left globe (orange arrow) is consistent with vitreous hemorrhage.

C: Sagittal CT image demonstrates normal contour in the right globe (green arrow).

D: Sagittal CT image demonstrates a shrunken left globe (orange arrow), which is suggestive of globe rupture.

Globe Rupture:

Ruptured globes are an ocular emergency that could lead to permanent vision loss if not treated quickly. Penetrating and blunt trauma, in addition to chemical exposure, account for the majority of cases. High intraocular pressure leads to ruptures at weak areas in the eye wall, including rectus muscle insertion sites, the limbus, and the optic nerve.1

Imaging:

Computed tomography (CT) is the recommended imaging modality for evaluating orbital trauma. Thin-section axial CT scans followed by multiplanar reformations can visualize ruptured globe contour, which can present as a “mushroom” (Figs. 1-2) or “flat tire” shape.2 Vitreous hemorrhage increases the attenuation of the vitreous on CT as well.3 Other findings of open globe injuries include a thick posterior sclera, hazy globe contour outline, abnormal anterior chamber size, and the presence of intraocular gas or foreign bodies. CT detects open globe injuries with a sensitivity of 90-100%, specificity of 50-80%, and interrater reliability of κ > 60%. 4 Prompt identification of ruptured globes is necessary to guide management.

Treatment:

Immediate surgery and empiric systemic antibiotics are needed to preserve vision and reduce the risk of intraocular infection.3 Once an open globe rupture is suspected, the patient should remain NPO and wear a protective eye device on the affected eye.5 Additionally, physicians should avoid maneuvers, including lid retraction and tonometry, or systemic medications that increase intraocular pressure.6 A semi-recumbent head position, anti-emetics, pain management, and removal of other stressors help prevent increases in intraocular pressure. Patients with open globe injuries should receive a tetanus booster if their immunization history is uncertain. Surgery on the ruptured globe and removal of ocular foreign objects should be performed once patients are stabilized. Following surgery, patients should begin antibiotic coverage of pathogens associated with endophthalmitis per recommendations provided by their institution’s infectious disease specialist.7

Prognosis:

Ruptured globes maintain a poor prognosis. The patient’s presenting visual acuity is a major determinant of their post-surgical visual acuity. The Ocular Trauma Score (OTS) metric proposed by Kuhn et al can be used to determine the functional outcome of injured eyes.8

References:

1. Murata N, Yokogawa H, Kobayashi A, Yamazaki N, Sugiyama K. Clinical features of single and repeated globe rupture after penetrating keratoplasty. Clin Ophthalmol. 2013;7:461-465. doi:10.2147/OPTH.S42117

2. Kubal WS. Imaging of orbital trauma. Radiographics. 2008;28(6):1729-1739. doi:10.1148/rg.286085523

3. Zhou Y, DiSclafani M, Jeang L, Shah AA. Open Globe Injuries: Review of Evaluation, Management, and Surgical Pearls. Clin Ophthalmol. 2022;16:2545-2559. doi:10.2147/OPTH.S372011

4. Crowell EL, Koduri VA, Supsupin EP, et al. Accuracy of Computed Tomography Imaging Criteria in the Diagnosis of Adult Open Globe Injuries by Neuroradiology and Ophthalmology. Acad Emerg Med. 2017;24(9):1072-1079. doi:10.1111/acem.13249

5. Ritson JE, Welch J. The management of open globe eye injuries: a discussion of the classification, diagnosis and management of open globe eye injuries. J R Nav Med Serv. 2013;99(3):127-130. https://www.ncbi.nlm.nih.gov/pubmed/24511795

6. Bord SP, Linden J. Trauma to the globe and orbit. Emerg Med Clin North Am. 2008;26(1):97-123, vi - vii. doi:10.1016/j.emc.2007.11.006

7. Blair K, Alhadi SA, Czyz CN. Globe Rupture. StatPearls Publishing; 2022. Accessed June 5, 2023. https://www.ncbi.nlm.nih.gov/books/NBK551637/

8. Kuhn F, Maisiak R, Mann L, Mester V, Morris R, Witherspoon CD. The Ocular Trauma Score (OTS). Ophthalmol Clin North Am. 2002;15(2):163-165, vi. doi:10.1016/s0896-1549(02)00007-x

Eric Errampalli is a passionate medical student at the University of Missouri – Kansas City Six-Year BA/MD Program, with a steadfast commitment to becoming a radiologist. His fascination with the field stems from its integral role in healthcare and the endless possibilities for technological advancements waiting to be made. At UMKC, Eric has made significant contributions to the Radiology Interest Group, serving in various executive roles and currently as the interventional radiology chair. His leadership has inspired his peers to explore the field and discover the boundless opportunities for growth and impact. Beyond UMKC, Eric's interests have risen to a national level, as he serves on the Society of Interventional Radiology Medical Student Council Education Committee and TheRadRoom IR Team. Through these platforms, he has been instrumental in shaping the future of interventional radiology education and promoting awareness of the field among medical students.

Eric's passion for innovation extends beyond the classroom, as he strives to help drive change in the field of radiology through his medical entrepreneurial ventures. He believes that entrepreneurship can unlock untapped potential in the field and pave the way for transformative breakthroughs that can improve patient outcomes and revolutionize healthcare.

To stay up to date on Eric's journey and learn more about his work, follow Eric on Twitter @EricErrampalli and connect with him on LinkedIn www.linkedin.com/in/eric-errampalli/

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Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone who he has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson.

Follow Dr. Rice on Twitter @KevinRiceMD

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