Journal of Ophthalmic Medical Technology

Volume 5, Number 2 August 2009 www.JOMTonline.com

Patient Options after a Ruptured Globe

Jennifer Doyle, Medical Student One of the most dreaded eye related emergencies that ophthalmologists and ophthalmic personnel face is a ruptured globe. Patients presenting with a ruptured globe always require a form of surgery and are at increased risk for lifelong eye complications. A ruptured globe is defined as a break in the integrity of the eyes outer membranes; in acute settings, full thickness corneal or scleral injuries are also 1 classified as open globes. These injuries may result due to chemical exposure, blunt injury leading to increased intraocular pressure and rupture or penetrating trauma, with or without retained foreign bodies. The WHO Programme for the Prevention of 2 Blindness estimates that 200,000 open-globe injuries occur each year. There are an estimated 1.6 million people suffering from secondary blindness from all eye 2 injuries worldwide. Open globe injuries are important to address quickly and appropriately because the risk of permanent blindness not only affects the patient and their family, but it becomes a socioeconomic burden due to the ongoing care of the affected individuals. When a patient presents with any type of eye injury the clinical evaluation should involve: type of injury (blunt, penetrating, laceration, ect), how the incident occurred, symptoms (pain, diplopia, vision loss, ect), past ocular history and 1 surgery, past medical history, medications and allergies. An in-depth physical exam should be carried out promptly and carefully. Initially, visual acuity should be 3 performed. Then the external portions should be examined for obvious damage of the orbit. The eyelids, conjunctiva, and sclera should be examined for lacerations, hemorrhage and foreign bodies. On palpation, the orbits should be examined for 2 fractures and possible crepitus ; with palpation, one must be careful not to put direct pressure on the eye as it can lead to prolapse of internal contents. It is also vital to examine pupillary response, extra ocular motility, confrontational visual fields and tonometry. On exam, some findings that indicate an open globe include: 360 degree injection, decreased vision, flat anterior chamber, abnormal shape or position of the pupil, tracks through the lens or a traceable line from passage of a 2 foreign body. The results of these various assessments are involved in determining visual outcome. The visual outcome for the patient is affected by multiple factors and usually should not be predicted until after surgical evaluation of the orbit. At presentation, reduced or absent vision, anterior chamber deformity, pupillary irregularity,

chemosis, hyphema, vitreous hemorrhage and decreased intraocular pressure 4 worsen the prognosis. A retrospective study done at Wilmer Ophthalmic Institute on open globes occurring between 2001-2004, produced a tree analysis showing the visual outcome based on initial presenting exam results. They found that a lack of 4 relative afferent papillary defect was the best predictor of vision survival. This study also looked at the effects of hand movement detection, light perception and no night perception and lid lacerations in those patients who did have a rAPD. Of those studied with rAPD present, highest vision survival occurred with hand movement detection on initial exam. The study created another regression tree looking at the difference in visual survival in ruptured globes based on age. Those under the age of 4 38 had significantly higher continuation of vision. The study created the regression tree to use for potential outcomes as an alternative to the commonly used Ocular Trauma Score (OTS) system. The OTS looks at initial visual acuity, rupture, 5 endophthalmitis, retinal detachment and afferent pupillary defect. This system uses a numerical score based on the presence or absence of these findings to help patients anticipate their type of ultimate recovery potential and several studies 4,5 support its validity. The ability to counsel patients on their projected visual outcome is important because it plays a role in the treatment of these potentially life altering injuries. Although it may take months or even years to determine a patients actual recovery potential, initial discussion is important for the psychiatric and medical well being of the patient. Patients must understand their potential outcome to make informed decisions about how to proceed with treatment. It is especially important for patients to know the risks and benefits of the various treatment options. Prophylactic antibiotics are given due to the high risk of infection associated with open globe injuries. Posttraumatic endophthalmitis risk is highest when there is a penetrating injury with or without a retained foreign body. Prior to going to the operating room, discussion of enucleation or evisceration needs to be discussed and consent should be obtained due to possible massive injury to the globe that is not 6 repairable. However, it should be made clear to the patient and family that, if possible, the eye will be preserved when there is any chance of vision. If the eye is preserved, there are still risks that need to be discussed with the patient. Endophthalmitis continues to be a risk factor and is estimated to occur in 3,7 approximately 4% to 8% of open globe injuries. Various factors increase and decrease the risk after traumatic injury. Delayed primary closure, intraocular foreign body, lens disruption, soil within the injury and age over 50 years increase the risk. Decreased risk occurs with anterior chamber foreign body and no 7 crystalline lens involvement. Sympathetic ophthalmia is another complication that has been estimated to occur in 0.1% to 0.3% of patients who sustain ocular trauma 6 due to exposure of previously sequestered antigens. This inflammatory condition results in pain, decreased vision, light sensitivity and possibly blindness in the eye that was not injured - the sympathetic eye. This condition can manifest weeks to months after the injury. Occasionally, this pain can be relieved with enucleation.

Despite adequate treatment and excellent effort to rescue damaged eyes and maintain acceptable visual acuity - defined by one study as 20/60 some patients do 2 suffer complete vision loss. It has been estimated that the prevalence of blindness due
to trauma was 9/100,000 in 1978, which at that time represented 4% of all cases of 2 blindness in the United States.

One of the procedures to remove a non-repairable eye after a traumatic injury is enucleation. The injured eye is removed surgically - the procedure takes close to one hour to perform - and is often performed under general anesthesia. During this procedure, the conjunctiva and Tenons capsule is separated from the sclera. The four rectus muscles are removed from the eye but left in tact and marked with a suture. After continued blunt dissection, the entire globe is removed from the orbital cavity and the optic nerved is transected. This is followed by prosthetic repair. A review of reports showed a range of 2-9% of enucleation taking 2 place after injury. This number included primary enucleation as well as enucleation secondary to sympathetic ophthalmia. A primary enucleation takes place when an optic nerve has been avulsed or the contents of the orbit are not recognizable to the surgeon, thus rendering the eye non-salvageable. Secondary enucleations often result from loss of vision, cosmetic 8 purposes, painful eye or prophylaxis of sympathetic ophthalmia. For patients with a blind, painful eye, one study showed that enucleation had a shorter time frame of 9 post op pain than those who received evisceration. Another indication for enucleation over evisceration is when an infection or abscess exists in the sclera; enucleation is performed to prevent further spread of the infection. One problem that needs to be addressed is the mental state of an enucleation patient. Implants are placed within the conjunctiva and the muscles are attached. The conjunctiva is then sewn over the implant and a conformer is worn to prevent contraction between the eyelid and the implant. Despite the reattachment of 8 muscles, patients may have less movement than with their own injured eye. For cosmetic reasons, patients need to be made aware that after 6-8 weeks they will be able to have a prosthetic eye painted to look symmetrical to their intact eye. A survey of patients who went through traumatic eye injury found there was no difference in the quality of life of enucleated patients versus patients with counting 10 fingers or worse vision who kept their eyes. However, it was also noted that 66% of patients who deferred primary enucleation would have made the same decision, 10 even if it had meant avoiding further surgery. Another option for patients with ruptured globe is evisceration. Evisceration allows the patient to keep his or her eye. The internal contents, including the epithelium and pigment, are removed and the optic nerve is transected. The cornea is often excised, but the option to preserve the cornea exists. The sclera and extraocular muscles also remain in tact. A prosthesis is placed within the scleral

cavity and a conformer is placed on top of the eye to prevent contraction. The surgeon may perform the procedure under general anesthesia or monitored anesthesia care. As with any procedure, risks and benefits need to be discussed with the patient. The patient enjoys the benefit of keeping his or her eye. Evisceration is thought to be more cosmetically pleasing to patients, as some studies have shown 11,6 improved motility in comparison with enucleation. Cosmetic follow up also involves a painted prosthetic over the damaged eye, similar to the process with enucleation. Evisceration is also considered to be a simpler procedure as it does not 11 disrupt the surrounding tissue and may be more cost effective. Infection within the eye is always a major concern following a trauma. If a patient does not respond to antibiotic treatment, an evisceration may be preferred for infections that remain limited to the internal portion of the eye. This would reduce the risk of possible 11, 12 infection spread to the intracranial space. Keeping the outer membranes of the eye in tact after trauma as with keeping the eye completely in tact - has been associated with sympathetic 6 ophthalmia. However, it should be noted that this relationship has not been 11, 13, 6 confirmed in any recent studies. This is considered one of the major disadvantages to the procedure because it could result in eventually having to proceed with enucleation. Another disadvantage of evisceration is the limited space within the sclera for implant. However, recent improvements in procedures make 11 this less of a concern. With both enucleation and evisceration, implants are at risk for exposure and expulsion, enophthalmos, sulcus contour defects, and motility 14 problems. Patients must be monitored for these complications during follow up visits for both procedures. Ocular trauma is a devastating injury. With improved surgical technique, many patients can have a cosmetically pleasing appearance if they must undergo enucleation or evisceration. While the result of open globe injuries often lead to complete visual loss, it is helpful to remember that some patients do maintain vision. Appropriate management and care by ophthalmologists and ophthalmic personal increase the patients prospects for visual recovery. Discussing eye safety practices with patients is also important; it is estimated that up to 90% of all eye 2 injuries could have been prevented. For those that have already suffered injury, protecting the other eye from visual loss becomes a priority. All patients should be told to wear polycarbonate lenses even if they have good visual acuity in their remaining eye. Ruptured globe injury forces patients to make difficult decisions. The long going debate between enucleation and evisceration will likely continue but with recent studies, patients now have more information to guide their decisions. Physicians and others health care professionals providing care to these patients need to be prepared to discuss the prognosis, various treatment options, risks and benefits and future ophthalmic needs.

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