Emergency Medicine Hub / HEENT & Ophthalmology • 3 min read • 2 sections

Ocular Trauma: Ruptured Globe & Retrobulbar Hematoma

Comprehensive emergency evaluation and protocolized surgical intervention for catastrophic ocular and orbital trauma: Open Globe/Ruptured Globe (full-thickness scleral/corneal laceration, 'teardrop' eccentric pupil pointing to wound, shallow anterior chamber, prolapsed uveal tissue, positive Seidel fluorescein test, strict eye protection with rigid Fox metal shield, avoiding IOP measurement, antiemetics to prevent valsalva extrusion); and Orbital Compartment Syndrome/Retrobulbar Hematoma (proptosis, rock-hard globe, IOP > 40 mmHg, afferent pupillary defect, bedside emergency surgical decompression via Lateral Canthotomy and Inferior Cantholysis).

Resuscitation Quick Actions • First 2 Minutes

High-Acuity

Ruptured Globe Cardinal Rule

DO NOT touch the eye, DO NOT check IOP, DO NOT instill eye drops; tape a rigid metal Fox shield resting ONLY on the bony orbital rim

Teardrop Pupil Sign

Peaked, eccentric pupil pointing toward the corneal laceration: iris has herniated into the wound to seal the perforation

Seidel Fluorescein Test

Under cobalt blue light: clear aqueous humor streams through yellow fluorescein stain, creating a flowing green river ('waterfall' sign)

Orbital Compartment Syndrome

Retrobulbar hematoma causing rock-hard globe + Proptosis + IOP > 40 mmHg + Afferent pupillary defect = STAT LATERAL CANTHOTOMY

Lateral Canthotomy Step 1

Inject 1–2 mL 1% lidocaine with epi; clamp lateral canthus with hemostat x 1 min; cut lateral canthal tendon horizontally 1–2 cm to orbital rim

Inferior Cantholysis Step 2

Retract lower lid; strum and SNIP THE INFERIOR CRUS of the lateral canthal tendon vertically; lower lid must become completely mobile

Ocular POCUS

High-frequency linear probe placed over closed eyelid with copious gel; rapidly identifies retinal detachment (thick undulating membrane tethered to optic disc), vitreous hemorrhage, and optic nerve sheath diameter (ONSD > 5.0 mm indicates elevated ICP).

Bottom-Line Clinical Pearl

Ocular emergencies require rapid branching into Open Globe vs. Retrobulbar Hematoma. (1) Ruptured/Open Globe: Full-thickness disruption of cornea/sclera. Clinical hallmarks: 'TEARDROP' PUPIL (peaked pupil pointing directly to the site of perforation), shallow anterior chamber, extrusion of pigmented uveal tissue (iris, ciliary body), and positive Seidel test. NEVER MEASURE INTRAOCULAR PRESSURE, NEVER REMOVE PENETRATING OBJECTS, AND NEVER PUT PRESSURE ON THE GLOBE. Place a rigid metal Fox shield resting on the bony orbital rim, administer IV Cefazolin (or Moxifloxacin) + IV antiemetics (Ondansetron to prevent vomiting/extrusion), and rush to the OR. (2) Retrobulbar Hematoma (Orbital Compartment Syndrome): Hemorrhage expands behind the rigid globe, compressing the central retinal artery and optic nerve (proptosis, rock-hard eye, IOP > 40 mmHg, RAPD). EMERGENCY BEDSIDE SURGICAL DECOMPRESSION VIA LATERAL CANTHOTOMY AND INFERIOR CANTHOLYSIS is mandatory within 60–120 minutes to prevent permanent, irreversible blindness.

1. Open Globe & Ruptured Globe Management Protocol

An open globe occurs from penetrating trauma (metal shrapnel, knives, glass) or blunt rupture across weak anatomic scleral zones (limbus, beneath extraocular muscle insertions). When the globe wall breaches, intraocular pressure drops instantly to zero, and intraocular contents (vitreous humor, iris, retina) herniate through the wound.

Diagnostic/Clinical Feature	Physical Exam Findings	Critical Emergency Precautions & Actions
'Teardrop'/Peaked Pupil	The pupil loses its round shape and becomes pointed/eccentric, with the apex pointing directly toward the laceration	The iris has been drawn into the wound margin by escaping aqueous humor. Confirms open globe.
Extrusion of Uveal Tissue	Dark brown or pigmented black tissue visible at the corneal or scleral surface; flat/shallow anterior chamber	Uveal tissue (iris/ciliary body) is prolapsing. Do not attempt to wipe, touch, or culture this tissue.
Seidel Test	Instill concentrated fluorescein; view under cobalt blue light: leaking aqueous humor dilutes fluorescein, producing a bright green river flowing downward ('waterfall' sign)	Positive test confirms full-thickness laceration. (Avoid testing if gross rupture is already clinically obvious).
Rigid Fox Shield Placement	Metal or hard plastic perforated shield taped over the eye, resting entirely on the superior orbital rim and zygomatic arch	MANDATORY: Completely shields the eye from accidental touching, eye rubbing, or bandage pressure that would extrude the intraocular contents.
Medical Stabilization	IV Ondansetron 4 mg + IV Analgesia + IV Cefazolin (or Ciprofloxacin) + NPO	Prevent vomiting, coughing, or Valsalva maneuvers that spike intraocular pressure and expel the retina. Keep patient NPO for emergent OR surgical repair.

2. Orbital Compartment Syndrome & Lateral Canthotomy Protocol

The bony orbit is a rigid, non-compliant cone bounded anteriorly by the globes and the fibrous orbital septum. Bleeding behind the globe (retrobulbar hematoma from blunt facial trauma, retrobulbar injection, or orbital fractures) rapidly spikes intraorbital pressure above mean arterial pressure, compressing the posterior ciliary arteries and the central retinal artery. Retinal ganglion cells and optic nerve axons suffer irreversible ischemic death within 60 to 120 minutes.

Step Sequence	Surgical Action & Anatomy	Instruments & Technique Pearls
Indication Check	Triad: (1) Proptosis + 'Rock-hard' globe on palpation, (2) $IOP > 40\text{ mmHg}$ on tonometry, (3) Decreased visual acuity or Relative Afferent Pupillary Defect (RAPD)	DO NOT delay for a CT scan! If the patient has vision loss and a rock-hard eye after trauma, perform canthotomy immediately at the bedside.
Step 1: Anesthesia & Hemostasis	Inject 1 to 2 mL of 1% or 2% lidocaine with epinephrine into the lateral canthus toward the lateral orbital rim. Apply a straight hemostat horizontally across the lateral canthal angle for 60 seconds to crush tissue and minimize bleeding.	Local infiltration + crush hemostasis.
Step 2: Lateral Canthotomy	Use sterile iris scissors to make a 1 to 2 cm horizontal incision through the crushed skin and lateral canthal angle straight to the hard bony orbital rim.	Exposes the underlying bifurcated lateral canthal tendon.
Step 3: Inferior Cantholysis (THE CRITICAL STEP)	Grasp the lower eyelid with forceps, pull it anteriorly and down. Place scissors pointed inferiorly toward the patient's nose; palpate the strumming guitar-string tension of the INFERIOR CRUS of the lateral canthal tendon, then SNIP IT.	The lower eyelid must become completely loose, floppy, and mobile. If the lid does not fall away freely, the tendon was missed: re-strum and re-cut.
Confirmation of Decompression	Recheck IOP: intraocular pressure should immediately drop from $> 40\text{ mmHg}$ to $< 20\text{ mmHg}$; proptosis improves.	If IOP remains elevated $> 40\text{ mmHg}$, snip the superior crus of the tendon as well.

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