IGNACIO, Richelle Angelika E. Dr.

Sheila Jimenez
2017-0116 Ophthalmology
APRIL 15, 2020 PAPER CASE
Salient Features
This is a case of a 20-year-old male tricycle driver, previously well, seen in the ER for head-on collision due to an MVA
wherein patient was reported to be thrown forward into the plastic windshield of his tricycle and landed a few feet
away from the wreckage. Ocular history unknown. Upon examination, patient has reduced level of consciousness.
Severe swelling of the left eye and bruising on the right eye were seen; no visible glass or plastic shards in the eyes or
fornices. Left eye shows chemotic and hyperemic conjunctiva with subconjunctival hemorrhage and corectopic pupil.
Prolapsed uveal tissue is suspected but cannot be appreciated in the image. No hyphema or corneal laceration grossly
visible. Visual examination deferred due to reduced LOC.

ANSWERS TO GUIDE QUESTIONS

1. What does the CT scan of the orbits show?

In the axial CT scan, upon drawing an interzygomatic line, proptosis of the left eye is observed since its posterior sclera
is almost touching the line as compared to the right. Marked edema of the left periorbital tissues is also evident.
Change in the globe contour of the left eye with accompanying subluxation of lens is also observed. A discontinuity in
the media wall of the left orbit is seen, which may signify a fracture; other walls of the orbit are intact. No evidence of
focal accumulation of fluid or blood is seen posterior to the globe but vitreous volume loss is evident. Furthermore,
brain window of the left eye shows a hypodense area within the globe which may be attributed to intraocular air or a
foreign body (i.e. wood).

2. What is your diagnosis? (Differential Diagnoses, Clinical Impression, and Case Analysis)
My initial impression is open globe rupture of the left eye with medial wall orbital fracture, and subconjunctival
hemorrhage secondary to blunt trauma. Basing from the patient’s symptoms and the high impact nature of the
accident, he is most likely to have an open globe rupture secondary to a high impact blunt trauma. This happens when
a blunt object impacts the orbit consequently compressing the globe; causing an increase in IOP to the point that the
sclera tears. It usually happens where the sclera is weakest, which is near the equator posterior to the insertion of the
rectus muscles. In the patient’s case, the bleed seems to be coming from the insertion of the lateral rectus muscle but
it cannot be fully appreciated. Upon gross eye examination, there is no corneal laceration observed, however, given
that the accident is high impact with involvement of glass or plastic shards, this should also be highly suspected as a
penetrating injury is not far to happen. Moreover, sharp objects like glass may create tiny wounds that are difficult to
visualize. On the other hand, subconjunctival hemorrhage is evidently seen upon gross eye examination. This results
from the bleeding of the conjunctival or episcleral blood vessels into the subconjunctival space secondary to several
causes (i.e. spontaneous, traumatic, or associated with a systemic illness). In the patient’s case, it is most likely
traumatic. Moreover, a blowout fracture may be seen as a discontinuity along the medial orbital wall, which is another
common condition in high impact blunt trauma. Upon seeing the result of the brain window, it is most likely intraocular
gas rather than an intraocular foreign body (IOFB) given its density and since no foreign bodies were seen externally.
However, an IOFB is also likely to happen in this kind of accident.

3. What is the immediate management? (Diagnostics and Treatment)

Upon arrival to the emergency room, initial trauma assessment should be done which includes ABCDE (airway,
breathing, circulation, disability, and exposure); and if possible, assessment for systemic comorbidities, allergies to
medications, and time of last meal. Other life- or limb-threatening traumatic lesions elsewhere in the body should be
evaluated initially.

With a high suspicion for global rupture, visual examination is disregarded to avoid incurring eye manipulation and
possibly worsening the situation. Also, in the patient’s case, he has reduced LOC hence it may not be helpful at all.
However, if tonometry was done, it would most likely reveal low IOP. Rigid eye shield should be placed over the
affected eye. Administration of stains and topical eye solutions are also avoided, hence, a Seidel test, which would
assess possible globe leaks and corneal perforations, also cannot be done. Analgesics are administered as needed;
antiemetics are also given to prevent Valsalva maneuvers. Head should also be kept elevated to avoid increase in
intraocular pressure. Prophylactic antibiotics should also be administered to prevent endophthalmitis. With no
knowledge on the patient’s immune status, tetanus injection should be administered as open globe lacerations are
tetanus-prone. Patient should also be kept nil per orem (NPO) because in emergency cases like this, surgical repair is
expedited. Urgent ophthalmology consultation is warranted for definitive treatment. Prior to surgery, coagulation
studies and complete blood count should be done in case patient have an underlying bleeding diatheses. Once global
rupture is addressed, other conditions such as corneal laceration may be managed by suturing. However, it will need
to be corrected with corneal transplant eventually as suture forms scars. For subconjunctival hemorrhage, tranexamic
acid may be given. Medial wall fracture should also be surgically repaired.

REFERENCES
Acerra, J. (2019, November 12). Globe rupture: Background, pathophysiology, epidemiology. Diseases & Conditions - Medscape
Reference. https://emedicine.medscape.com/article/798223-overview
Andreoli, C., & Gardiner, M. (2020, February 4). Open globe injuries: Emergency evaluation and initial
management. https://www.uptodate.com/contents/open-globe-injuries-emergency-evaluation-and-initial-
management?search=globe%20rupture&source=search_result&selectedTitle=1~23&usage_type=default&display_ran
k=1
Gardiner, M. (2020, March). Conjunctival injury. https://www.uptodate.com/contents/conjunctival-
injury?search=subconjunctival%20hemorrhage&source=search_result&selectedTitle=1~106&usage_type=default&dis
play_rank=1#H4258403