Mr. Santiago is a 32-year-old man who was working in the kitchen when a bungy cord snapped as he was trying to secure some boxes with it and he felt it strike his left eye. The kitchen supervisor sent him to the medical clinic for evaluation because he complained that there was something still in his eye. Prior to leaving the kitchen, they did flush the eye with the saline at the kitchen eye wash station, but the feeling that something was it the eye did not go away.
subjective
He reports the left eye pain as 10/10, stinging, sharp, throbbing, and very sensitive to light. He complains also of very blurry vision in the left eye, not being able to see much, including shapes. He denies double vision, denies any eye injury in the past, does not wear corrective lenses of any kind, has not had eye surgery, and cannot recall his last tetanus immunization. He denies any other injury to his face, mouth, or teeth.
The Review of Symptoms is positive for foreign body sensation in the left eye with severe pain, photosensitivity, excessive tearing, redness and extreme blurred vision in left eye, and throbbing headache behind left eye. His Review of Symptoms is negative for double vision, spots, specks, flashing lights, corrective lenses, facial lacerations, abrasions, or head injury. He has no medical or mental health chronic conditions.
Mr. Santiago reports an allergy to Sulfa medications, which causes itchiness and rash. He denies food allergies.
He currently denies taking any medication, including over the counter medications.
objective
Physical Assessment
Vitals: : T 99.0°F, P 114, R 16, BP 148/94 HT 6’ 1” WT 190 lbs, BMI 25.1.
General: Anxious male – worried about left eye vision. Alert and oriented x 4; answers all questions appropriately.
Skin, Hair, and Nails: Warm throughout; no lesions, lacerations, ecchymosis. No abnormal findings with hair or nails.
Head: Atraumatic, normocephalic, non-tender.
Eyes: No periorbital lacerations, lesions, ecchymosis, step offs, or tenderness bilaterally.
Left eye: Swollen and tender upper and lower lids, good position, unable to close fully. Injected sclera and hyperemic conjunctiva, subconjunctival hemorrhage at the medial canthus extending to the iris, excessive tearing, tear-drop-shaped pupil not reactive to light and no accommodation. Foreign body not visible to the naked eye. No fluid visualized as being emitted from the anterior or lateral portions of the globe. Extra Ocular Movements (EOMs) limited in movement. Difficult to assess retinal structures with funduscope due to patient’s pain level and difficulty with visualization.
Right eye: No lid edema, good position and closure, injected sclera, pink conjunctive. Pupil 4 mm, round, reactive to light and accommodation. EOMs intact, no disc edema or swelling, venous pulsations, or AV nicking.
ENT/Mouth: Hearing acuity intact bilaterally to whispered voice. No deformities, lacerations, lesions, or tenderness externally, bilaterally. TMs pearly gray, positive light reflex; no discharge or bleeding bilaterally. No maxillary or frontal sinus tenderness. Nares patent, septum midline, dark pink mucosa without drainage. Teeth and gums in good repair; no bleeding. Oral mucosa and tongue without lesions or lacerations, oropharynx patent, tonsils 1+ and symmetric, uvula midline.
Neck: Full Range of Motion, supple, no adenopathy.Neurologic: Cranial nerve II grossly intact OD; unable to assess cranial nerve II OS due to extreme blurred vision. Cranial nerves III to XII grossly intact.
Lungs clear to auscultation, no adventitious sounds
Heart S1S2, RRR without murmurs, rubs or gallops
Staff ACtions
Correctional Nurse Actions
Conduct the initial assessment for Mr. Santiago, including a Snellen eye exam. Due to the abnormal vision and complaint of continued pain and history of trauma, the Correctional Nurse contacted the provider, who immediately came and evaluated Mr. Santiago.
Provider Actions
Differential Diagnoses for MR. Santiago
Corneal abrasion or laceration may be possible given the patient’s injury. He complains of feeling as though he has a foreign body in his eye, but none visualized. We cannot test for corneal abrasion until we have ruled out a globe rupture because fluorescein stain should not be applied to the eye in the presence of a rupture.
Corneal foreign body is also possible. The patient complains of the painful sensation of a foreign body in his eye. Before inspection of the cornea with fluorescein stain, globe rupture must first be ruled out as fluorescein stain should not be applied to the eye if this is the case. Also, foreign body was not visible to the naked eye.
Globe rupture is suspected because of the patient’s misshapen left pupil. Caused by a corneal laceration, aqueous humor may be visualized as seeping from the globe. A misshapen pupil confirms the diagnosis of globe rupture, and orbital trauma must also be ruled out.
Hyphema is blood pooling, or red blood cell layering, in the anterior chamber secondary to blunt force trauma to the globe. It is best seen with the patient in a sitting position, not laying supine, as gravity pulls blood inferiorly. Blood in the anterior chamber would likely not be seen if the patient was laying supine.
Glaucoma as a diagnosis would be secondary to hyphema, as blood pooling in the anterior chamber would cause an elevated intraocular pressure, hence a secondary glaucoma. Tonometry would need to be performed, but not before globe trauma is ruled out.
Most Likely Diagnosis
The patient has a probable a full-thickness injury penetrating completely through the cornea, causing a ruptured globe from the high-velocity, blunt force trauma of the metal hook on the bungy cord. The misshapen pupil and the patient’s inability to perceive anything other than light with his left eye upon examination makes this the most likely diagnosis. He must be sent to the emergency department emergently.
Pathophysiology of Globe Rupture
When a sharp object or small foreign body hits the eye at a high velocity, it may perforate the globe directly. Small objects may be retained in the globe without the patient’s knowledge. When a blunt object makes impact with the surrounding orbit, the globe becomes compressed, causing the intraocular pressure to immediately elevate to the point where the sclera tears. The rupture site is typically where the sclera is the thinnest and weakest, just posterior to rectus muscle insertion points.
Diagnostic Tests/Imaging
Snellen eye chart for visual acuity – 20/30 OD Light perception only OS
CT scan of orbit is needed, which means Mr. Santiago must go to the emergency department. In addition, he may need surgery, and that can be arranged most quickly if he goes directly to the emergency department.
Next Steps
The prognosis depends on the mechanism of injury, extent of injury, and time from injury to appropriate surgical intervention.
Providers should always check visual acuity first before performing the physical examination. Try to assess which structures are injured. If globe rupture is suspected, do not apply a pressure patch; do not apply fluorescein stain to the eye; do not attempt tonometry; and do not press on the globe any more than necessary. Doing any of these increases the risk of extruding the inner contents of the eye outward.
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Outcome
Once in the ED, Mr. Santiago had a confirming non-contrast CT scan of the orbits and he went right to surgery. Although the vision in his left eye is far from perfect, he is able to engage in most of his typical activities, after an approximate 6-month recovery.
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Patient Education
Because of the trauma, there is an increased risk for developing angle-closure or chronic glaucoma, retinal tears, and cataracts. Mr. Santiago must have periodic eye check-ups, even after discharge and must be counseled about the importance of these monitoring visits.
Staff must review the importance of using protective eyewear to decrease the risk of another eye injury. Mr. Santiago must also be educated about the importance of always wearing appropriate UV-protective sunglasses when outside.
Comments
The time it takes for ophthalmologic intervention has significant consequences if not taken as an emergency. If the patient was laying supine for the entire examination, the tear-drop-shaped pupil might not have been noticed on examination and the diagnosis may have been missed. Gravity pulls on the pupil and the contents of the injured globe, changing the pupil’s shape. The pupil may have appeared round if he were to be examined laying supine. If there was a delay getting Mr. Santiago to the emergency department and operating room, the outcome could have included permanent vision loss of his right eye.
References
Acerra, J.R., Gilman, S.L., Golden, D.J. (2019). Globe rupture. Medscape. https://emedicine.medscape.com/article/798223-clinical.
Cydulka, R.K., Cline, D.M.(2017). Tintinalli’s Emergency Medicine Manual, 8th ed. McGraw-Hill; 820–822. ISBN-13: 978-0071837026
Kent C. (2008). Managing serious cases of ocular trauma. Review of Ophthalmology.
Wijesinghe, Sampath. (2021). 101 Primary Care Case Studies: A workbook for clinical and bedside skills. Springer Publishing Company. Kindle edition.
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