LWW/AENJ AENJ-08-00029R2.rev January 21, 2009 19:44 Char Count= 0 Advanced Emergency Nursing Journal Vol. 31, No. 1, pp. 27–33 Copyright c 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Cases OF NOTE Column Editor: Elda G. Ramirez, PhD, RN, FNP-BC, FAANP Patient With a Globe Rupture Carmen T. Paniagua, EdD, RN, CPC, ANP, ACNP-BC; Connie M. Gunter, BSN, MS; Jonathan D. Casciano, MD; Randy P. Maddox, MD Abstract Eye injuries are a leading cause of monocular blindness within the United States. The management of patients who have sustained eye injuries can be challenging for advanced practice nurses (APNs) who work in emergency care settings. APNs are required to have a thorough understanding of eye injuries in order to promptly and accurately assess and manage eye emergencies. This article presents a case of a patient with an open eye globe rupture and discusses the assessment, diagno- sis, and management for this patient. Key words: emergency eye trauma, eye globe rupture eye injury, globe rupture, traumatic globe rupture N the United States, nearly 2.4 million Witherspoon, & Mann, 2006). Emergency de- eye injuries occur each year (Centers partments (EDs) treat 0.3% of these injuries Ifor Disease Control and Prevention, Na- (McGwin and Owsley, 2005). Open eye globe tional Center for Health Statistics, 2008). injury is part of this small percentage of trau- Approximately 95% of all eye injuries are matic injury. reported to be minor, with the remain- ing 5% considered to have the potential of resulting in permanent vision loss and/or CASE REPORT permanent anatomic change (Kuhn, Morris, An 18-year-old Hispanic male presented the ED triage area. According to the patient, on From the College of Nursing & College of Medicine and the previous night he had consumed a large Emergency Department ACNP (Dr Paniagua), Emer- amount of alcohol. During this intoxicated gency Department Nurse III (Ms Gunter), Ophthalmol- ogy Resident PGY-3, Jones Eye Institute (Dr Casciano), state, he injured his right eye after running and Emergency Medicine (Dr Maddox), University of into a glass window. The patient then fell Arkansas for Medical Sciences, Little Rock. asleep and did not seek medical attention for The authors thank Carolyn Bloom, RN, for her contri- approximately 18 hr. bution. An acute care nurse practitioner (ACNP) Corresponding author: Carmen T. Paniagua, EdD, RN, working in the nonurgent side of the ED came CPC, ANP, ACNP-BC, College of Nursing & College of to assist with the interpretation in Spanish. Medicine, Emergency Department ACNP, University of Arkansas for Medical Sciences, Little Rock, AR 72205 The ACNP also performed the history and (e-mail: [email protected]) physical examination. 27 LWW/AENJ AENJ-08-00029R2.rev January 21, 2009 19:44 Char Count= 0 28 Advanced Emergency Nursing Journal Table 1. History of present illness for patient Skin: No rash or itching reported. Head/ with a right eye injurya Eyes/Ears/Nares/Throat (HEENT): No previ- ous blurred vision, pain, or eye trauma. Car- diovascular: No chest pain or palpitations. O = Onset: 18 hr ago L = Location: Right eye Pulmonary: No cough or shortness of breath. D = Duration: Progressive pain; now Gastrointestinal: No vomiting or diarrhea. constant Genitourinary: No frequency with urination C = Characteristics: Swollen, red, irritated, or discharge. Musculoskeletal: No pain in ex- right eye tremities or joints. Neurologic: No localizing A = Aggravating factors: Photophobia and weakness or trouble speaking. Hematopoi- bending forward etic: No easy bruising or prolonged bleed- R = Relieving factors: Unable to obtain ing. Immunologic: No frequent or recur- relief with closing the eye rent infections. Psychiatric: No depression or = T Treatment: Patient placed sunglasses anxiety. over eyes Physical examination—General. The pa- tient is a well-developed, well-nourished, con- aOLDCART mnemonic for history of present illness. scious, and coherent individual in moderate distress. Vital signs: Oral temperature 98.2◦F (36.7◦C), pulse 72 beats per minute, respi- Chief Complaint ratory rate 14 per minute, blood pressure The patient stated, “I have an irritation in my 132/74 mmHg, and pulse oximetry was 98% right eye.” on room air. Skin: Warm and dry. Normal History of present illness. The patient texture and turgor. HEENT: Head: Normo- stated that the onset of the injury was 18 hr cephalic, without evidence of trauma. Eyes: prior. The patient complained of progressive Gross external examination revealed a 1-cm pain and then stated, “It’s constant now.”The laceration of the right upper eyelid and a patient also described a swollen, red, irritated 0.5-cm laceration of the right upper eyelid right eye. He stated that his pain was aggra- skin crease. In addition, conjunctival hemor- vated by photophobia and bending forward; rhage (2+) and scleral buckling with extru- nothing relieved the pain. The patient put a sion of ocular contents was noted (Fig 1). Vi- pair of sunglasses over his eyes and came to sual acuity 20/200 right eye and 20/20 left the ED (Table 1). eye without correction. Visual fields showed Medical history. Noncontributory. Patient denied any past ocular conditions and denied ever wearing glasses or contact lens. Current medications: None. Allergies: No known al- lergies. Immunization status: Tetanus immu- nization was up-to-date. Surgical history/hospitalizations. None. Family history. Noncontributory. Social history. The patient worked as a landscaper and he denied tobacco use. Posi- tive for “occasional” alcohol consumption re- ported as 2–3 or 3–4 (as previously stated above) beers on weekends. He denied any recreational drug use, including intravenous drugs. Figure 1. Patient with right eye globe rupture Review of systems—Constitutional. The showing scleral buckling and extrusion of ocular patient denied any fever or chills or malaise. contents. LWW/AENJ AENJ-08-00029R2.rev January 21, 2009 19:44 Char Count= 0 r January–March 2009 Vol. 31, No. 1 Patient With a Globe Rupture 29 the six cardinal direction of gaze intact for Table 2. Differential diagnoses for a patient both eyes. Extraocular movements were in- with a globe rupture tact for both eyes. A teardrop-shaped pupil (i.e., pupil distortion suggestive of globe Conjunctival laceration rupture with iris prolapsed) was noted in Corneal laceration the right eye. The right eye was reactive Retinal detachment to light; accommodation was compromised Subconjunctival hemorrhage because of the teardrop-shaped pupil. The Vitreous hemorrhage left eye was equal, round, and reactive to light and accommodation. Intraocular pres- sure reading was deferred because of visible ized tomography scanning is the most sensi- prolapsed iris of the right eye. Relative af- tive, readily available imaging study to detect ferent pupillary response was performed as occult rupture, associated optic nerve injury, a reliable way to rule out optic nerve dis- and small foreign bodies. CT can also visualize ease. This response was normal for both eyes. the anatomy of the globe and orbit (Pokhrel & Ears: Both ear canals were patent. Tympanic Loftus, 2007). membranes were clear. Nares: Without rhi- norrhea. Mouth/throat: Mucous membranes DIAGNOSTIC TESTS were moist, without erythema or exudate. Neck: Supple, without adenopathy or Coagulation and complete blood cell count meningismus. Carotids equal. Trachea: were ordered. The results were within normal Midline. No bruits or jugular venous disten- limits. tion. Chest: Normal AP diameter. Adequate expansion without retractions. No chest DIFFERENTIAL DIAGNOSIS wall tenderness. Lungs are clear bilaterally The differential diagnosis for this patient with good tidal volume. Abdomen: Soft and included corneal laceration, retinal detach- nontender without masses, guarding or re- ment, and vitreous hemorrhage (Table 2). In bound tenderness. Bowel sounds active. No addition, other problems such as subconjunc- hepatosplenomegaly. Back: Without spinal or tival hemorrhage and conjunctival laceration costovertebral angle tenderness. Extremities: needed to be considered when considering all Upper extremities—full range of motion. of the differential diagnoses. Good strength bilaterally. No cyanosis, club- bing, or edema. Peripheral pulses intact. Sensation intact. Lower extremities—full ASSESSMENT/DIAGNOSIS/ICD-9 CODE range of motion. Good strength bilaterally. Right eye globe rupture/rupture eye with pro- No cyanosis, clubbing, or edema. Peripheral lapse of intraocular tissue 871.1. pulses intact. Sensation intact. Neurologic: Alert and oriented to person, place, time, and ED COURSE event. Cranial nerves II–XII grossly intact. Motor and sensory examination nonfocal. A protective rigid shield was applied to cover Reflexes symmetric. the patient’s right eye, while an emergent consult was placed to the ophthalmologist. The ACNP conferred with the ED collabo- IMAGING STUDIES rative physician, who agreed with the ex- Computerized tomography (CT) without con- amination and management of this patient. trast was performed to visualize the anatomy The ophthalmologist noted corneal edema of the globe and orbit and to note any in- and opacification with fluorescein under a traocular foreign body (i.e., glass). The CT re- portable slit lamp (Table 3). The left eye was sults were reported as negative. Computer- also dilated, which demonstrated a normal LWW/AENJ AENJ-08-00029R2.rev January 21, 2009 19:44 Char Count= 0 30 Advanced Emergency Nursing Journal Table 3. Examination findings: Slit lamp instructions