Chapter 163. Globe Luxation Reduction

Luxation of the globe is a rare event whereby the eyelids slip behind the midcoronal plane of the eye in an extremely proptosed eyeball (Figure 163-1). The orbicularis oculi muscle then goes into spasm, which maintains the luxation of the globe. Extraocular eye movements become severely limited. The optic nerve and retinal vasculature are subjected to an abnormal amount of traction, resulting in possible damage to these structures or the retina.1 The end result is partial or full blindness in the affected eye if it is not reduced before irreversible ischemic changes occur.

There are three major causes of globe luxation: spontaneous, voluntary, and traumatic. Spontaneous luxation tends to occur in individuals with shallow orbits.2 Structural abnormalities—such as laxity of the supporting muscles and fascia as well as anomalous extraocular muscles—can predispose to spontaneous luxation.2–4 Pathologic processes that cause proptosis can predispose to luxation. The literature documents cases of luxation associated with orbital tumors, Graves' disease, cerebral gummas, histiocytosis X, and craniofacial dysostosis.1,5,6 Voluntary luxation occurs in individuals who learn to cause globe propulsion by using a digit or use of their extraocular muscles. Some patients use a Valsalva maneuver to luxate their globe(s) voluntarily. Traumatic luxation results from trauma to the globe or the surrounding bony orbit. It can occur from motor vehicle accidents or even relatively minor trauma to the face.7,8 Traumatic luxation can also occur from intentional eye gouging or even during the forceps-assisted delivery of a neonate.9,10

The normal anatomic relationship of the globe to the surrounding structures is seen in Figure 163-2. The midcoronal plane of the eye is a transverse section through the eye in the coronal plane. It is through the widest portion of the eye and divides the eye into anterior and posterior halves. When the eyelids get behind the midcoronal plane, the orbicularis oculi muscle is pulled taut and begins to go into spasm. This spasm prevents spontaneous reduction of the globe.

Globe reduction is indicated to relieve traction on the optic nerve and retinal vessels. The patient's visual acuity has the potential of being compromised without prompt reduction. Sustained globe luxation is physically and psychologically uncomfortable for the patient, may result in permanent loss of vision, and is difficult to reduce without general anesthesia.

Obvious rupture of the globe and extensive orbital fractures that require immediate surgical intervention are relative contraindications to globe reduction. Edema and retrobulbar hemorrhage can make reduction outside the Operating Room impossible.1,6

• Topical ocular anesthetic agent (e.g., 0.5% proparacaine or tetracaine)
• Sterile gauze and gloves
• Sutures or eyelid retractors
• Local anesthetic solution (1% lidocaine), if eyelid retaining sutures need to be placed
• 3 mL syringe
• 27 gauge needle

Prior to any attempt at reduction, a directed eye exam addressing the integrity of the globe, visual acuity, pupillary reactivity, and range of ocular motion should be performed. Describe the procedure to the patient and/or their representative. Answer any questions about the procedure and obtain an informed consent for the procedure. Relaxation of the patient and the orbicularis muscles are essential for procedural success. The use of a parenteral anxiolytic and analgesic or procedural sedation (Chapter 129) is recommended if not contraindicated.11 Place the patient supine. Instill a topical ocular anesthetic agent onto the affected eye. Allow 1 to 2 minutes for the anesthetic to take full effect.

Reduction of a globe luxation ideally requires two people (Figure 163-3).11,12 Instruct an assistant to apply steady upward and outward traction on the upper eyelid and downward and outward traction on the lower eyelid by grasping and pulling on the eyelashes. Instruct the patient to maintain a constant downward gaze. The downward gaze posture negates the retracting action of the levator palpebrae superioris muscle and simultaneously relaxes the superior rectus muscle.12 While traction is being applied to the eyelids, apply steady and gentle pressure with a gloved thumb to the exposed superior sclera of the globe in a simultaneously downward and posterior direction. Physical contact over the sclera minimizes discomfort and avoids possible corneal abrasions.12 Continue to apply constant and gentle pressure until the globe is manipulated back into the orbit.1,6

Occasionally the patient's eyelashes are small or not accessible, or an assistant is not available. In these cases, an eyelid retractor may be placed behind the eyelids to provide countertraction. Other authorities have recommended the placement of a suture through the anesthetized skin of the eyelids to help retract them.1,4,6 Extreme care must be taken to prevent penetration of the globe by the anesthetic needle or the suture needle if retaining stitches are placed in the eyelids. If either of these techniques are used, the globe is then reduced in the same manner as described previously.

A repeat and complete eye examination must be performed after the procedure and documented in the medical record. Pay special attention to visual acuity, pupillary reflexes, and range of extraocular muscle movement.1,6,10 Full visual acuity may not return to baseline for several days or longer.4 A search for the possible causes of a nontraumatic luxation should be initiated in the Emergency Department.1 This includes but is not limited to thyroid function testing and orbital imaging to rule out a tumor. This evaluation should be performed after consultation with an Ophthalmologist. Conduct a search for associated injuries such as a bony periorbital fracture, globe rupture, retroorbital hematoma, or intracranial injury in the cases of traumatic luxation.

Patients with spontaneous luxations that reduce without difficulty and who are without visual impairment may be discharged home after consultation with an Ophthalmologist. These patients require follow-up with the Ophthalmologist within 24 hours.1,6 They should be instructed to avoid Valsalva maneuvers.1 All patients with traumatic luxation require emergent Ophthalmologic consultation and imaging of the orbits.1,6

It is not uncommon for eyelashes to be retained in the conjunctival fornices after this procedure.10 A thorough evaluation and removal of any free eyelashes is warranted to prevent corneal abrasions or injury.1,6,10 If one or two attempts at reduction are not successful, instill saline drops to the eye and apply an eye shield to prevent further injury while an emergent Ophthalmologic consult is obtained.1,6 Refer to Chapter 161 for the complete details regarding the application of an eye shield.

Globe luxation is a rare entity that can be effectively dealt with in the Emergency Department. Prompt intervention by an Emergency Physician can result in the preservation of visual acuity. After a brief initial eye examination, uncomplicated cases can be reduced by the Emergency Physician. Complicating factors—such as the presence of trauma, an open globe injury, or the inability to reduce the globe—warrant emergent Ophthalmologic consultation. Predisposing factors for a spontaneous luxation should be investigated.