Blunt injury to the eye can lead to various intrinsic eye injuries. Globe rupture and retrobulbar hematoma are two emergent entities that are of importance. Common symptoms of globe rupture include eye deformity, eye pain, and vision loss, though depending on the clinical suggestion the deformity may not be readily apparent on the exam. This activity explains the risk factors, evaluation, and management of blunt eye trauma and highlights the importance of the interprofessional team in enhancing care for affected patients.
Describe the clinical presentation of patients with blunt eye trauma.
Outline the evaluation of patients with blunt eye trauma.
Explain the treatment strategies for patients with blunt eye trauma.
Employ interprofessional team strategies for improving care coordination and communication to advance the evaluation and management of blunt eye trauma and improve patient outcomes.
Blunt injury to the eye can lead to various intrinsic eye injuries. Globe rupture and retrobulbar hematoma are two emergent entities that the clinician may encounter, and these are the focus of this section. Typical symptoms of globe rupture include eye deformity, eye pain, and vision loss, though depending on the clinical suggestion the deformity may not be readily apparent on the exam. Similarly, a retrobulbar hematoma may present with eye pain and vision loss, but proptosis helps to clinch this diagnosis. Both are vision-threatening diagnoses and require emergency ophthalmologic consultation for definitive measures.
Globe rupture occurs when there is a defect in the cornea, sclera, or both structures. Most often, globe rupture occurs after direct penetrating trauma; however, if sufficient blunt force is applied to the eye, the intraocular pressure can increase enough to rupture the sclera.
A retrobulbar hematoma is frequently associated with orbital trauma and associated orbital floor fractures. This trauma may also occur iatrogenically during sinus surgery, ocular surgery, or other eye procedures. In the setting of anticoagulation, this may occur in rare scenarios with increases in Valsalva (e.g., from vomiting, straining, or coughing).
The incidence of globe injuries is quoted as 3.5 eye injuries per 100,000 persons, with males constituting about 80% of open globe injuries. Injuries in the pediatric population are more often with sharp objects directly penetrating the globe (e.g., writing utensils, scissors, or knives). In the adult population, the cause is often blunt trauma (e.g., motor vehicle collisions, altercations, or work-related injuries involving hammering). In the elderly, globe rupture is most often a result of falling.
The incidence of retrobulbar hematoma is rare; it has been quoted as less than 1%. However, there is a strong association between this diagnosis and subsequent blindness.
Globe rupture occurs when there is a defect in the cornea, sclera, or both structures. Most often globe rupture occurs after direct penetrating trauma; however, if sufficient blunt force is applied to the eye, the intraocular pressure can increase enough to rupture the sclera. The rupture site is most commonly near the globe’s equator posterior to the insertion of the rectus muscles, which is where the sclera is weakest and thinnest.
A retrobulbar hematoma occurs when there is an accumulation of blood in the retrobulbar space. As blood collects behind the eye, there is increased intraocular pressure, which can subsequently cause stretching of the optic nerve. Within a matter of several hours, decreased ocular perfusion can lead to permanent blindness.
History and Physical
High suspicion for globe injury should be suspected in any patient reporting any direct eye trauma, continuing eye pain, and vision deficit. The mechanism of the injury should be elicited as well as the time it occurred. It is important also to inquire about any anticoagulant use.
In globe rupture, physical examination findings may reveal decreased vision or frank vision loss, the irregular contour of the globe, teardrop pupil, hyphema, or a shallow anterior chamber on the slit-lamp exam. The Seidel sign is positive in globe rupture, indicating the flow of aqueous humor from the injury site in the fluorescein-stained eye. However, if the globe rupture is obvious, testing for the Seidel sign should be avoided.
The clinical presentation of retrobulbar hematoma is classical with proptosis and severe eye pain. As in globe rupture, vision loss may be reported.
There may be associated periorbital swelling, ecchymosis, or subconjunctival hemorrhage in either of these entities depending on the mechanism of the injury.
Visual acuity should be checked in each of the eyes separately, if possible, taking care not to manipulate any possible intrinsic globe injury. Pupillary defects should also be noted.
A thorough evaluation of any concomitant intracranial and facial bony injury should be pursued. A high number of globe ruptures and retrobulbar hematomas are associated with fractures, in particular of the orbital floor. Extra-ocular motility testing may be decreased in the affected eye because of entrapment, intrinsic globe deformity, or retrobulbar hematoma.
Laboratory evaluation should be pursued as the clinical situation dictates in the setting of trauma or anticoagulant use. Computed tomography (CT) imaging can rule out any additional maxillofacial injuries while confirming the diagnosis. In addition to globe deformity and retrobulbar hematoma, CT imaging can evaluate for foreign bodies, scleral disruption, and even vitreous hemorrhage.
Treatment / Management
For globe rupture, emergency department treatment includes supportive measures to prevent worsening of the injury or extrusion of intraocular contents. Hence, antiemetics should be provided to prevent Valsalva from vomiting, which could lead to increased intraocular pressures and subsequent loss of aqueous fluid. Analgesia should be provided as needed. A rigid eye shield should be placed, and additional manipulation of the eye should be avoided. The patient should be placed in a semi-recumbent position.
Similarly, in retrobulbar hematoma, analgesia and antiemetic should be provided. Definitive therapy, however, is immediate decompression with a lateral canthotomy and inferior cantholysis. This can be performed by the emergency medicine provider or the ophthalmologist if there are no delays in the consultant being able to perform this procedure. Vision prognosis is time-sensitive in this setting with poorer outcomes seen in delays of greater than 4 hours from the time of symptoms. Prophylactic antibiotics can be used to prevent secondary endophthalmitis.
In the setting of globe injury or retrobulbar hematoma, emergent consultation with ophthalmology is warranted. Definitive management in these diagnoses is surgical repair by the appropriate ophthalmologic specialist.
The differential diagnosis of blunt trauma to the eye includes globe rupture, retrobulbar hematoma, traumatic glaucoma, hyphema, orbital blowout fracture with entrapment, foreign body, scleral disruption, and vitreous hemorrhage.
The prognosis of blunt eye trauma depends heavily on the sequela of the trauma. One study showed that ocular trauma, in general, resulted in monocular blindness in one-quarter of patients.  In kids, research has shown that visual acuity is generally better in blunt ocular injury compared to penetrating ocular injury, although rates of glaucoma may be higher in blunt ocular trauma.  If the eye is ruptured, however, blunt ocular trauma may lead to the worst visual prognosis, since that most likely means the trauma occurred at a high velocity. Other factors that may lead to a worse visual prognosis include a relative afferent pupillary defect, absence of a red reflex, initial visual acuity worse than 20/200, and an eyelid laceration. In another study, in patients with commotio retinae or sclopetaria retinae from blunt ocular trauma, a quarter of patients had a visual acuity worse than 20/30 in the eye that had the trauma.  Visual acuity is worse after blunt ocular trauma if there is a hyphema, retinal detachment, and/or vitreous hemorrhage.  Traumatic optic neuropathy also portends a poor visual outcome.
The extent of the initial injury and the mechanism of injury often predicts whether poor outcomes might be expected. To give the best prognosis of an individual's visual prognosis following, the Ocular Trauma Score is a verified method to predict the functional outcome of an eye after trauma. 
Depending on the type and extent of the trauma to the eye, complications may vary from based on the location and depth of injury. Corneal scarring may occur with more superficial injuries, while choroidal rupture, post-traumatic glaucoma, cataracts, retinal detachment, and endophthalmitis may all occur with deeper injuries. Varying degrees of vision loss may also occur. In severe trauma not amenable to ophthalmologic surgical repair, enucleation may be required.
Deterrence and Patient Education
Patients should be educated on the importance of wearing eye protection when doing any activity where ocular trauma commonly occurs. This includes sports and riding motorized vehicles, among many other things. Eye protection has been found to reduce the occurance of severe ocular injuries in combat operations.  Patient's should be encouraged to wear ocular protection at all times if they are monocular, due to trauma to the eye with vision potentially leading to blindness. Many cases of ocular trauma occur within the home, so consideration should be made to educating patients on ocular protection at all times, and not just traditional high risk activities such as sports. 
Pearls and Other Issues
Avoid any unnecessary manipulation of the globe (including tonometry) to prevent any extrusion of intraocular contents.
Obtain appropriate imaging to rule out concomitant bony injury or intracranial trauma.
Provide analgesia and antiemetics to prevent Valsalva maneuvers that may worsen globe rupture or retrobulbar hematoma.
A protective rigid eye shield should be utilized to prevent any additional injury; eye patches are contraindicated.
Provide prophylactic antibiotics to help prevent endophthalmitis.
Seek emergent Ophthalmology consultation for definitive measures, but do not delay lateral canthotomy for patients with known retrobulbar hematoma.
Enhancing Healthcare Team Outcomes
Eye trauma is very common resulting in loss of vision in many people. Without vision, one becomes handicapped and getting a suitable job is difficult. In many cases, ocular eye injury is preventable and the onus is on all clinicians to educate patients on eye safety. An interprofessional team is probably the best way to educate and monitor patients with eye trauma. Because of a serious shortage of eye surgeons, most patients are followed up by the primary care provider or nurse practitioner as outpatients.
Eye trauma commonly presents to the emergency department. However, in the ED asides from a superficial exam including a visual acuity test, analysis of deeper injury to the eye is not always possible. Hence, healthcare workers including nurse practitioners should always consult with the ophthalmologist on call to assess the eye.
The emergency department physician may treat superficial laceration around the eye but all patients with vision loss should be referred to the ophthalmologist. During follow up the nurse practitioner and primary care provider should communicate with the eye surgeon if there are any vision-related problems.
Missing eye injuries can lead to permanent visual loss and may include prolonged litigation.
Finally, all clinicians should educate patients on eye safety such as wearing face helmets and safety goggles when working with splashing liquids or flying debris.  [Level 5]
(Click Image to Enlarge)
Retrobulbar hematoma (ultrasound image)
Contributed by Harry J. Goett, MD
(Click Image to Enlarge)
Traumatic globe rupture
Image courtesy S Bhimji MD
(Click Image to Enlarge)
Teardrop pupil with vitreous extrusion in globe rupture.
Contributed with Permission by Michael Mohseni, MD
(Click Image to Enlarge)
Retrobulbar hematoma with proptosis noted on CT imaging
Contributed with Permission by Michael Mohseni, MD
Vukovic AA,Poole MD,Hoehn EF,Caldwell AK,Schondelmeyer AC, Things Are Not Always What They Seem: Two Cases of Child Maltreatment Presenting With Common Pediatric Chief Complaints. Pediatric emergency care. 2018 Nov 26 [PubMed PMID: 30489490]
Jolly R,Arjunan M,Theodorou M,Dahlmann-Noor AH, Eye injuries in children - incidence and outcomes: An observational study at a dedicated children's eye casualty. European journal of ophthalmology. 2018 Oct 1 [PubMed PMID: 30270661]
Sen E,Celik S,Inanc M,Elgin U,Ozyurt B,Yılmazbas P, Seasonal distribution of ocular conditions treated at the emergency room: a 1-year prospective study. Arquivos brasileiros de oftalmologia. 2018 Apr [PubMed PMID: 29846426]
Puodžiuvienė E,Jokūbauskienė G,Vieversytė M,Asselineau K, A five-year retrospective study of the epidemiological characteristics and visual outcomes of pediatric ocular trauma. BMC ophthalmology. 2018 Jan 18 [PubMed PMID: 29347941]
Ram J,Verma N,Gupta N,Chaudhary M, Effect of penetrating and blunt ocular trauma on the outcome of traumatic cataract in children in northern India. The journal of trauma and acute care surgery. 2012 Sep [PubMed PMID: 22929502]
Desai P,MacEwen CJ,Baines P,Minassian DC, Incidence of cases of ocular trauma admitted to hospital and incidence of blinding outcome. The British journal of ophthalmology. 1996 Jul [PubMed PMID: 8795369]