History
A 53-year-old white woman was transported to the emergency room following a fall. After gross inspection of her face, the attending physician ordered an ocular consult.

Her ocular history was significant for recent phacoemulsification with intraocular lens implant in her left eye. The IOL implantation resulted in chronic pseudophakic bullous keratopathy, which required treatment via penetrating keratoplasty.

Her systemic history was remarkable for hypertension, for which she was compliant and properly medicated. She reported no known allergies.

Diagnostic Data   
Her best-uncorrected visual acuity measured 20/20 O.D. and 20/400 O.S. using a near point card.

Her extraocular muscles were intact, with no obvious entrapment. There was no evidence of afferent pupillary defect. Her intraocular pressure measured 14mm Hg O.U.

The anterior and posterior segment examinations of the right eye were normal. We postponed the dilated fundus examination of the left eye, however, due to the acute nature of her injury.

Your Diagnosis
How would you approach this case? Does this patient require additional testing? What is your diagnosis? How would you manage this patient?

Discussion

External view of our 53-year-old patient who was taken to the ER following a fall.

The most important consideration in this case was to ensure that the patient received proper ocular first aid. We contacted the original IOL surgeon and explained the situation. We covered the eye with a high-vaulting Fox Eye Shield, and then made no further attempts at examination or manipulation. Following clearance and stabilization from her emergency room trauma team, arrangements were made to have the patient transported to the local eye hospital where her operating physician was on staff, and a team of experts performed the repair.

The diagnosis in this case is open-globe IOL subluxation secondary to cornea-to-corneal-graft interface failure O.S. following blunt trauma that was precipitated by a fall.

Globe rupture is one potential complication and consequence of blunt force trauma. A history of previous corneal surgery increases the likelihood of a full-thickness corneal rupture following ocular or orbital impact.¹

When full-thickness corneal or globe rupture is encountered, the only solution is surgical repair. In the non-surgical setting, once a cursory evaluation is completed (which might include gross inspection and visual acuity), no further attempts at examination should be made. For the sake of comfort, the patient may be medicated with topical or local anesthesia.

No matter the circumstance, the nearest eye hospital or properly prepared institution should be contacted and briefed about the patient’s situation. The eye should be covered with a Fox Eye Shield or similar protective shell. The cover should vault over the eye, guarding it from further contact.

This will minimize the risk for extrusion of intraocular contents.

In the event something has impaled the eye, no attempt should be made to remove it. In these instances, the vaulting protective cover should be modified to either encompass the object or allow it to pass through it. Moving impaled objects may have to be carefully stabilized using tape. If the situation is precarious, it is better to do nothing than risk further trauma through intervention. Furthermore, if any intraocular tissue has been exposed or has luxated through the wound, no attempt should be made to reposition or replace it.

If the perforation is small or the location where the injury occurred permits immediate or expedient transport to a suitable surgical facility, corneal patching with cyanoacrylate glue offers an emergent alternative. This can stabilize the injury until it heals or until the patient receives surgical treatment.²

Endophthalmitis is a severe complication of globe perforation secondary to ocular trauma. If the managing clinician believes that there is the potential for microbial contaminants, he or she should initiate antibiotic therapy.³

One prospective study of 50 consecutive open-globe injuries over a two-year period, where samples were taken from the inferior conjunctival sac and anterior chamber at the beginning and end of the open-globe repair, found positive microbial cultures in 13 eyes (26%).3 The microbial spectrum included Aspergillus in 45.6% of cases, Alternaria in 15.2%, Curvularia in 15.2%, Staphylococcus aureus in 7.6 %, Bacillus in 7.6% and Streptococcus pneumoniae in 7.6%.³ Of these 13 eyes, nine developed clinically evident, frank endophthalmitis during follow-up.³

Overall, endophthalmitis developed in 20 eyes (40%).³ Fifty-three percent of culture-positive cases achieved ambulatory vision compared to 73% of culture-negative cases, underscoring the potential hazard of the complication. While not all cases should require immediate prophylactic treatment, the authors recommended close follow-up of cases that demonstrated contamination following open-globe injury to rule out the need for intervention.³

As for our patient, the literature recognizes that most individuals with phacoemulsification-site dehiscence regain the majority of their vision after open globe repair.⁴ We sent her back to the eye hospital where her IOL implantation was performed. There, her surgeon removed the old IOL, repositioned a new one in the posterior segment and repaired the cornea-to-corneal-graft laceration. The patient recovered over the course of 10 weeks, and achieved a final visual outcome of 20/30 O.S.

1. Vinger PF, Mieler WF, Oestreicher JH, et al. Ruptured globes following radial and hexagonal keratotomy surgery. Arch Ophthalmol. 1996 Feb;114(2):129-34.
2. Vote BJ, Elder MJ. Cyanoacrylate glue for corneal perforations: a description of a surgical technique and a review of the literature. Clin Experiment Ophthalmol. 2000 Dec;28(6):437-42.
3.Bhala S, Narang S, Sood S, et al. Microbial contamination in open globe injury. Nepal J Ophthalmol. 2012 Jan;4(7):84-9.
4. Kloek CE, Andreoli MT, Andreoli CM. Characteristics of traumatic cataract wound dehiscence. Am J Ophthalmol. 2011 Feb;152(2):229-33.