Board Review: Traumatic Globe Rupture

Image Credit: Flickr

Author: Sophia Johnson, DO
Shane Sergent, DO
Conemaugh Memorial Medical Center
Originally Published: Modern Resident October/November 2014

A 32-year-old male presents to the ED after being struck in the right eye with a ball during a friendly tennis match. He complains of discomfort in the right eye, decreased visual acuity and nausea secondary to pain. Physical exam reveals periorbital ecchymosis, an irregularly shaped pupil and a shallow anterior chamber.

Patients may present with globe rupture after blunt or penetrating injury.[1] They may complain of pain in the eye or decreased visual acuity.[1] Maintain a high index of suspicion in patients who have any injury that may have penetrated the cornea.[1] This includes projectile objects launched while mowing the lawn, weed whacking or working with metal.[1] Blunt trauma to the eyeball or trauma with objects that impact the ocular rim and create a seal around the orbit can cause a rapid peak in intraocular pressure that ultimately leads to globe rupture.[1]

Ocular Emergency: Retinal Artery Occlusion (RAO), A Non-Ophthalmologist Approach to Initial Treatment and Referral

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This post was peer reviewed.
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Author: Fernando Pellerano, MS-V
Universidad Iberoamericana (UNIBE) School of Medicine



Overview
Retinal artery occlusion (RAO) is considered a true ophthalmic emergency requiring immediate assessment and initiation of treatment. Appropriate initial emergency management may be the most important factor in determining visual outcome.[1]

RAO can either be central or branch. Central retinal artery occlusion (CRAO) results from a blockage anywhere between the origin of the artery (off the ophthalmic artery), to its first branch at the entry to the retina.[2] The site of obstruction is therefore not generally visible on ophthalmoscopy and in most cases the entire retina is affected. Branch retinal artery occlusion (BRAO) occurs when the blockage is distal to the optic nerve, within the visible vasculature of the retina. A BRAO can involve as large an area as three quarters of the retina, or as small an area as just a few micrometers.[1]

Epidemiology and Etiology
Incidence of RAO is approximately one per 100,000 per year and increases with age, peaking in the sixth and seventh decades. The central retinal artery is more commonly blocked than the branch retinal artery. [1] Although many systemic diseases are associated with RAO, more than 50 % of all affected patients will manifest no apparent systemic or local causes for the retinal disease.[2] Possible Etiology and Risk Factors for both CRAO and BRAO are listed in Table 1 and Table 2.[3, 4]

Ocular Emergency: Globe Injury, A Non-Ophthalmologist Approach to Initial Treatment and Referral

Author: Fernando Pellerano, MS-4
Medical Student, Universidad Iberoamericana (UNIBE)

This post was peer reviewed.
Click to learn more.

Ocular emergencies are immediate threats to the visual system that can lead to permanent loss of visual function.[1] Emergency medicine physicians should be able to recognize and provide initial treatment for sight-threatening ophthalmologic emergencies, including globe injury, before referral to an ophthalmologist.

Globe rupture should always be considered as a differential diagnosis in a patient with an eye injury. Patients will complain of moderate to severe pain and decreased vision. Visual acuity may be limited to “counting fingers at 18 inches” or “light perception only.” Pupils should be examined for shape, size, light reflex, and afferent pupillary defect. A peaked, teardrop-shaped, or otherwise irregular pupil may indicate globe rupture (see Image A).[2] Hyphema (blood in the anterior chamber: see Image B) or severe conjunctival hemorrhage involving the area around the cornea are also highly suspicious for globe injury.[2] Physicians may perform the Siedel’s Test to detect aqueous humor leaking from a corneal wound. To perform the test, a fluorescein dye is applied to the affected eye and examined under slit-lamp. The test is positive when a stream of fluorescent dye is seen emanating from the affected eye.[3]