Globe Rupture

A full thickness break in the corneoscleral envelope caused by blunt force, in which a sudden rise in intraocular pressure (inside out mechanism) causes the globe to burst at its weakest points. The structural contents prolapse or are expelled.

• Common causes: fists and fingers, balls (squash, tennis, cricket, football), fireworks, falls, road traffic accidents, bungee cords, airbag deployment, and blunt objects.
• Sites of rupture: limbus (corneoscleral junction, especially superiorly and nasally), equator beneath rectus muscle insertions (where the sclera is thinnest, 0.3 mm), near the optic nerve (posterior), and previous surgical wounds (cataract incisions, keratoplasty, radial keratotomy, trabeculectomy), which may open after minor trauma.
• Associated damage: lens dislocation or expulsion, vitreous loss, retinal detachment, choroidal haemorrhage, hyphaema, and angle injury.

• Profound loss of vision (often light perception or worse), pain, and marked soft tissue swelling.
• Hypotony (low pressure), distorted or irregular globe shape, deep or very shallow anterior chamber, 360 degree haemorrhagic chemosis with dark uvea or vitreous under conjunctiva, hyphaema, extruded lens, peaked pupil, vitreous haemorrhage, loss of red reflex, limited motility (muscle splinting towards rupture site), and relative afferent pupillary defect.
• Occult posterior ruptures show only chemosis, limited movements, low pressure and vitreous haemorrhage.

• Clinical suspicion when there is profound visual loss, hypotony, a distorted globe, 360 degree haemorrhagic chemosis or uveal prolapse; do not measure intraocular pressure, apply pressure, or open the lids forcefully.
• CT orbits (thin cuts, axial and coronal): deformed or irregular globe contour ("flat tyre" sign), reduced anterior chamber depth, intraocular air, haemorrhage, dislocated lens, scleral discontinuity; B-scan ultrasound with minimal pressure and thick gel when needed (choroidal detachment, vitreous haemorrhage, retinal detachment).
• Surgical exploration is the definitive test when imaging is non-diagnostic and suspicion is high.
• Rule out associated orbital and facial fractures and intracranial injury.

• Immediate protection with a rigid shield, supine at 30 degrees, nil by mouth, tetanus prophylaxis, antiemetics, analgesia, and systemic antibiotics (moxifloxacin 400 mg daily or vancomycin 1 g every 12 hours with ceftazidime 1 g every 8 hours) for 5 to 7 days.
• Urgent surgical exploration and repair within 24 hours under general anaesthesia:
  • Conjunctival peritomy in 360 degrees with isolation of each rectus muscle (tagging sutures) and inspection of the sclera beneath muscle insertions.
  • Repair of the wound with interrupted 8-0 or 9-0 nylon or polypropylene sutures, starting at the limbus and working posteriorly; leave posterior wounds (more than 10 to 12 mm behind the limbus) unsutured if they cannot be reached safely and cover with conjunctiva.
  • Gently replace uveal tissue, remove only prolapsed vitreous, avoid expression of the lens, and fill the anterior chamber with viscoelastic.
  • Lens removal only if the lens is extruded or severely disrupted; preserve capsule support if possible.
  • Intravitreal antibiotics (vancomycin 1 mg, ceftazidime 2.25 mg) if wound contamination is suspected.
• Postoperative: topical moxifloxacin 0.5 percent and prednisolone acetate 1 percent four to eight times daily, atropine 1 percent twice daily, intraocular pressure control, shield at night.
• Delayed vitrectomy at 7 to 14 days for vitreous haemorrhage, retinal detachment, or choroidal detachment; vitrectomy with silicone oil for proliferative vitreoretinopathy.
• Primary enucleation or evisceration is rarely indicated and is done only for obvious unsalvageable globes with grossly disorganised contents; secondary enucleation within 14 days for painful blind eyes or high sympathetic ophthalmia risk.
• Prognosis: poor when rupture extends posteriorly, retina is detached or when there is initial no light perception; final acuity of 6/60 or better in about 20 to 30 percent.