Blunt or penetrating trauma to the eye may result in a ruptured globe. The diagnosis is obvious when orbital contents spill from the globe itself. Occult presentations manifest as a tiny rent in the sclera. Ruptures at the limbus, the margin between the cornea and sclera, may cause a small amount of iris to herniate, resulting in an irregularly shaped “teardrop” or “peaked” pupil. Choroidal rupture may also occur. A coloboma of the iris may appear similar to a teardrop pupil.
Management and Disposition
Obtain urgent specialty consultation. Protect the eye with a rigid eye shield, and defer all further examination and manipulation of the eye. Administer antibiotics and adequate sedation (parenteral analgesics are appropriate). Address tetanus status. Since vomiting may result in further prolapse of intraocular contents, treat with antiemetics proactively. Consider CT scanning if the presence of a FB is suspected.
Suspect a rupture with severe conjunctival hemorrhage following trauma.
Rupture usually occurs where the sclera is thinnest, at the attachment of extraocular muscles and the limbus.
A teardrop pupil may easily be overlooked in the triage process or in the setting of multiple traumatic injuries.
Prolapsed Iris. A teardrop pupil is present, with a small amount of iris herniating from a rupture at 8-o’clock position on the limbus. (Photo contributor: Lawrence B. Stack, MD.)
Iris Coloboma. Iris coloboma is a congenital finding resulting from incomplete closure of the fetal ocular cleft. It appears as a teardrop pupil and may be mistaken for a sign of scleral rupture. (Photo contributor: R. Jason Thurman, MD.)
Choroidal Rupture. A traumatic choroidal rupture appears as a vertical linear line on the temporal aspect of the macula. There is pigmentation within the choroidal rupture and an adjacent traumatic macular hole. (Photo contributor: Lawrence Lee, MD.)