Ophthalmology · Trauma
The facts most likely to be tested
A teardrop-shaped pupil pointing toward the site of the injury is a pathognomonic sign of a full-thickness globe rupture.
The presence of an afferent pupillary defect (APD) indicates significant damage to the optic nerve or retina and suggests a poor visual prognosis.
Seidel test positivity, characterized by the streaming of aqueous humor away from a wound, confirms a full-thickness corneal or scleral laceration.
Intraocular pressure (IOP) measurement is strictly contraindicated in suspected globe rupture to prevent further extrusion of intraocular contents.
Immediate management requires the placement of a rigid eye shield to prevent external pressure and the administration of antiemetics to prevent Valsalva-induced pressure spikes.
Prophylactic systemic antibiotics and tetanus prophylaxis are mandatory to prevent endophthalmitis following penetrating ocular trauma.
Computed tomography (CT) of the orbits without contrast is the imaging modality of choice to identify foreign bodies and confirm the integrity of the globe.
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A 24-year-old male presents to the emergency department after being struck in the right eye by a metal fragment while grinding steel. On physical examination, the patient has decreased visual acuity and a teardrop-shaped pupil with the apex directed superiorly. There is prolapse of uveal tissue visible through a corneal laceration. The patient is in significant pain and is actively retching.
What is the most appropriate initial step in the management of this patient?
Placement of a rigid eye shield and administration of antiemetics.
The patient presents with classic signs of a globe rupture; the most critical initial steps are to protect the eye from further pressure (rigid shield) and prevent Valsalva maneuvers (antiemetics) that could lead to further extrusion of ocular contents.
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High yield triage
Etiology / Epidemiology
Full-thickness injury to the sclera or cornea caused by blunt or penetrating trauma. High risk in young males and industrial workers.
Clinical Manifestations
Look for teardrop pupil, afferent pupillary defect, and Seidel sign. Decreased visual acuity is universal.
Diagnosis
Non-contrast CT orbit is the gold standard. Avoid tonometry and ultrasound due to pressure risk.
Treatment
Place rigid eye shield, elevate head 30°, and administer IV antibiotics. Do not remove embedded objects.
Prognosis
High risk of endophthalmitis and permanent vision loss. Requires emergent ophthalmology consultation.
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Epidemiology & Etiology
Most commonly occurs from high-velocity projectiles, metallic foreign bodies, or severe blunt force. Frequently associated with occupational hazards or sports-related injuries. Always consider intimate partner violence or child abuse in unexplained ocular trauma.
Pertinent Anatomy
The globe is a closed pressure system; a breach in the sclera or cornea leads to immediate loss of intraocular pressure. The uveal tissue may prolapse through the defect, causing the characteristic pupil distortion.
Pathophysiology
Trauma causes a full-thickness defect, leading to hypotony and potential intraocular content extrusion. The teardrop pupil points toward the site of the rupture. Rapid decompression can lead to expulsive hemorrhage if the globe is manipulated.
Clinical Manifestations
Classic findings include a teardrop pupil, Seidel sign (streaming of aqueous humor), and afferent pupillary defect. Red flags include severe pain, profound vision loss, and orbital ecchymosis. Avoid any pressure on the globe to prevent extrusion of intraocular contents.
Diagnosis
Non-contrast CT orbit is the gold standard to identify foreign bodies and globe contour. Never perform tonometry or use a slit lamp with pressure. Seidel sign is confirmed via fluorescein staining showing aqueous leakage.
Treatment
Immediate placement of a rigid eye shield is mandatory to prevent further pressure. Administer IV antibiotics (e.g., vancomycin + ceftazidime) and tetanus prophylaxis. Do not administer topical drops or attempt to remove foreign bodies; surgical repair by an ophthalmologist is required.
Prognosis
Prognosis is guarded; endophthalmitis is the most feared complication. Long-term monitoring for sympathetic ophthalmia is required if the injury involves the uvea.
Differential Diagnosis
Corneal abrasion: no full-thickness defect
Hyphema: blood in anterior chamber without rupture
Orbital blowout fracture: intact globe, restricted gaze
Chemical burn: history of exposure, no structural rupture
Retrobulbar hematoma: elevated intraocular pressure, not low