Spontaneous Globe Rupture following Prolonged Uncontrolled Elevated Intraocular Pressure

Abstract:

We report two glaucoma patients who experienced unusual instances of spontaneous globe rupture. The patients arrived at the Bowen University Teaching Hospital’s emergency ophthalmology unit with a history of bleeding from one eye without any history of ocular trauma. They were known glaucoma patients with poor control of their intraocular pressures (IOP). They eventually underwent evisceration shortly after presentation. Spontaneous eyeball rupture in glaucomatous eyes is extremely unusual and has a very poor prognosis for vision. Proper management and appropriate follow-up of glaucoma patients are very important to avert this dreaded complication of uncontrolled IOP.

Introduction

Spontaneous globe rupture is a term used to describe a full-thickness eyewall defect in the absence of significant external trauma. It is an open globe injury. Spontaneous globe ruptures are documented to have occurred in patients with secondary glaucoma, angle-closure glaucoma, cornea diseases, etc.[1] Spontaneous globe rupture following prolonged uncontrolled elevated intraocular pressure (IOP) was postulated to be due to suprachoroidal hemorrhage.[2] Other ocular risk factors include chronic use of topical steroids, age-related macular degeneration, and high myopia.[3] This case series is aimed at presenting spontaneous globe rupture as a possible complication following uncontrolled elevated IOP.

Case Reports

Case 1

A 60-year-old male presented to the emergency ophthalmology unit of our center with 2-day history of painful sudden gushing out of blood from his right eye (RE) when waking up. There was no history of ocular trauma, eye discharge, or swelling on the eye before this incident. The patient was a known patient of our eye clinic being managed for bilateral advanced open-angled glaucoma; right absolute since about 3 years ago but had since defaulted from the clinic. The initial visual acuity (VA) at the first visit was “no light perception” (NLP) in the RE with an IOP of 34 mmHg and a cup-disc ratio (CDR) of 1.0. He was then commenced on topical antiglaucoma medications and was asked to come back for follow-up, however defaulted since then.

Immediately after the incident 2 days earlier, he presented to a nearby health facility where the affected RE was padded and crepe bandage was tightly applied over it to tamponade the bleeding. At the presentation [Figure 1], VA was NLP in the RE. There was a ruptured globe on the RE with an abrasion over the right upper eyelid (due to too tight crepe bandage dressing over the eye). In the left eye (LE), VA was 6/24, had a nasal fleshy pterygium, clear cornea, normal pupil, immature cataract, CDR of 0.9, and IOP of 30 mmHg. He was occasionally using the antiglaucoma medications to the LE and had abandoned the RE since he had no expectation for vision in it. He had financial constraints in procuring the prescribed antiglaucoma medications. He was immediately worked up for emergency RE evisceration under local anesthesia.Examination of the eye under anesthesia in the operating room revealed a finding of a ragged full-thickness eyewall defect extending along the limbus circumferentially from 11 o’clock (clockwise) to 6 o’clock position with multiple radial extensions (about 2-3mm each) extending into the sclera oozing blood from the intraocular cavity.

Figure 1.

A 60-year-old male with right eye spontaneous globe rupture

Case 2

A 75-year-old male was rushed into the emergency ophthalmology unit of our center with 6 h history of sudden painful bleeding from the LE upon waking up. There was no antecedent trauma and no history of ocular surgery; however, he had lost vision in the eye since about 5 years ago. He had been on management for glaucoma in another facility where he had defaulted. He is no longer on any antiglaucoma medications. On presentation [Figure 2], the VA in the RE was 6/60, anterior segment was quiet, there was an immature cataract, and CD ratio was 1.0. The IOP on the RE was 25 mmHg. On the LE, the VA was NPL with ruptured globe and blood clot over the lid margin. He was immediately worked up for the LE evisceration under local anesthesia in the operating room. Examination under anesthesia revealed a ragged limbal full wall thickness defect with blood oozing out from within the intraocular cavity. The process of evisceration was then completed.

Figure 2.

A 75-year-old male with left eye spontaneous globe rupture

Discussion

Spontaneous globe rupture is a rare ophthalmologic emergency that requires prompt recognition and ophthalmologic intervention.[4] It is an unusual complication of prolonged uncontrolled elevated IOP, especially in a case of absolute glaucoma in which the patient has lost hope of visual recovery, hence has stopped applying medications to the eye such as just occurred in these two cases. Glaucoma patient requires adequate and appropriate counseling to have a better understanding of the disease, its course, and how to be part of the management.[5] Some patients including our patients in this case report still find it difficult to believe that they need to be instilling medications and presenting for follow-up continuously despite no improvement of their vision and a very poor prognosis for visual recovery. It has been reported that poor understanding of glaucoma[6] and the cost of drugs is part of the factors responsible for poor compliance in glaucoma patients on medical management[5] which are also present in these patients. Oronsaye and Kayoma[2] also noted uncontrolled glaucoma as part of the risk factor for spontaneous globe rupture in their patient and uncontrolled glaucoma usually results from noncompliance with glaucoma management, especially in a developing country like Nigeria where patients pay for health services out of pocket.[5] The full-thickness defects that usually occur in cases of globe rupture are usually ragged making repair of the laceration virtually impossible, hence the need to carry out evisceration as it occurred in these patients. Another reason why evisceration was carried out was to remove the uveal tissue of the damaged eye which can sensitize the body to develop an immune response (sympathetic ophthalmitis) against the other normal eye over a period of time.[7]

In conclusion, this case report describes the presentation and treatment of this rare complication of glaucoma. Although spontaneous globe rupture has a similar dismal prognosis as those of trauma-related cases, this unpalatable outcome is preventable if the patient has adequate knowledge about glaucoma management. Proper health education should be given to all glaucoma patients about the course and management of the disease. The scope of health insurance should be expanded to accommodate both the workers in the formal and informal sectors of the nation. When patients are on a health insurance scheme, financial constraints will not be part of the reason for not complying with treatment modalities as seen in these cases. This will go a long way in preventing this uncommon, cosmetically embarrassing, and disastrous complication of prolonged uncontrolled elevated IOP among glaucoma patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.