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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 25  |  Issue : 4  |  Page : 264-266

Spontaneous globe rupture in a blind glaucomatous eye: A report of three cases


1 Department of Ophthalmology, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
2 Department of Ophthalmology, College of Medical Sciences, University of Benin, Benin City, Edo State, Nigeria

Date of Web Publication21-Dec-2018

Correspondence Address:
Dr. Darlingtess Abies Oronsaye
Department of Ophthalmology, University of Benin Teaching Hospital, Benin City, Edo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/npmj.npmj_113_18

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  Abstract 

This paper aims to report cases of spontaneous globe rupture in the blind eyes of three elderly patients with end-stage glaucoma some of which were possibly structurally compromised with topical traditional eye medications and steroids. These patients presented to the ophthalmology department of the University of Benin Teaching Hospital with a history of bleeding from one of their eyes and no antecedent history of trauma. They were known glaucoma patients who were blind with previously recorded high intraocular pressures. Evisceration was performed for two of the cases while enucleation was performed for one shortly after presentation.

Keywords: Blind eye, enucleation, evisceration, glaucoma, globe rupture, suprachoroidal haemorrhage


How to cite this article:
Oronsaye DA, Kayoma DH. Spontaneous globe rupture in a blind glaucomatous eye: A report of three cases. Niger Postgrad Med J 2018;25:264-6

How to cite this URL:
Oronsaye DA, Kayoma DH. Spontaneous globe rupture in a blind glaucomatous eye: A report of three cases. Niger Postgrad Med J [serial online] 2018 [cited 2019 Jun 18];25:264-6. Available from: http://www.npmj.org/text.asp?2018/25/4/264/248206


  Introduction Top


Globe rupture occurs when the integrity of the outer coverings of the eye is disrupted (usually as a result of trauma-blunt or penetrating) from a full-thickness injury to the cornea and/or sclera. It usually occurs at sites where the sclera is thinnest: insertions of the extraocular muscles at the limbus and at previous sites of extraocular surgery.[1] Spontaneous globe rupture is relatively rare. Few cases have been reported in the literature in secondary glaucoma and angle-closure glaucoma.[2],[3],[4]

Evisceration and enucleation are destructive eye surgeries that involve removal of the intraocular contents and removal of the entire globe with part of the optic nerve, respectively. They are performed when the direct closure of the wound is impossible.

We present our experience of spontaneous globe rupture in the blind eyes of patients with end-stage glaucoma.


  Case Reports Top


Case 1

An 80-year-old male, retired farmer, who presented with bleeding from his right eye, 12 h prior to presentation. He reported an excruciating pain in his right eye, a day before the bleeding was noticed and this reduced remarkably after the bleeding started. He was a known glaucoma patient diagnosed 20 years ago who had a failed trabeculectomy in both eyes about 5 years before presentation. He also had defaulted on his topical, intraocular pressure-lowering medications. He was also hypertensive. On examination, his visual acuity was no light perception in his right eye and 6/12 in the left. On the right, there was mild lid oedema, generalised conjunctival injection, an encysted non-functional bleb on the superior limbus, an opaque cornea with a red mass (uveal tissue) protruding from the inferior limbus from 3 to 9'o clock [Figure 1] and no view of other structures. On the left anterior segment, there was a fibrotic bleb in the superior conjunctiva and peripheral iridectomy at 12'o clock, other findings were normal. Fundoscopy revealed a pale glaucomatous disc with a vertical cup to disc ratio of 0.9. The intraocular pressure in the left eye was 40 mmHg. He subsequently had evisceration with insertion of an orbital implant in the right eye. Topical intraocular pressure lowering medications were prescribed for his left eye and he was counselled on the importance of drug compliance.
Figure 1: Case 1: Showing ruptured right globe at the inferior limbus with protrusion of uveal tissue

Click here to view


Case 2

A 75-year-old female, retired farmer, who presented to the hospital with bleeding from her right eye, 6 h prior to presentation. There was no antecedent history of trauma. There was a history of long-term instillation of traditional eye medications (ground leaf extract) in both eyes. She was diagnosed with advanced glaucoma 8 years before presentation had stopped the prescribed topical intraocular pressure lowering medications and was lost to follow-up. She was also a known hypertensive and had lost vision in both eyes 6 years before presentation.

On examination, visual acuity was no light perception in either eye. On the right, there was marked periorbital oedema, generalised injection of the conjunctiva, uveal tissue protruding from the superior limbus, an opaque cornea and poor view of other structures [Figure 2]. On the left, there were total afferent pupillary defect and lens opacities which precluded the view of the fundus. The intraocular pressure in her left eye was 35 mmHg.
Figure 2: Case 2: Showing an extruding red mass of haemorrhagic uveal tissue from the superior limbus. The cornea appears opaque

Click here to view


A diagnosis of a possible intraocular tumour was entertained. She subsequently had an enucleation with insertion of an orbital implant performed on her right eye. The histology report showed inflammatory infiltrates involving the corneoscleral, uveal and retinal layers. There were also large areas of haemorrhagic necrosis in the uveal and retinal layers and no sign of malignancy. Topical intraocular pressure-lowering medications were prescribed for her left eye.

Case 3

A 63-year-old female trader who presented to the eye clinic with complaints of gush of warm fluid and blood from her right eye of 1 week duration. There was also no antecedent history of trauma to the eye. There was a history of use of a topical steriod (Betamethasone) and traditional eye medications (ground leaf extract) in her right eye because of pain, intense redness and swelling of the right eye before the bleeding. She was a known glaucoma and hypertensive patient who had lost vision in both eyes 6 years before presentation and was not on any topical intraocular pressure-lowering medication. On examination, visual acuity was no light perception in either eye. On the right, there was periorbital oedema, generalised injection and chemosis of the conjunctiva, uveal tissue protruding through the temporal limbus from 6 to 12'o clock and an opaque cornea. The anterior segment of the left eye had a shallow anterior chamber depth, total afferent pupillary defect and early cortical lens opacities, and other findings were normal. Fundoscopy revealed a pale glaucomatous disc with a vertical cup to disc ratio of 0.95. The intraocular pressure in the left eye was 37 mmHg. She subsequently had evisceration with insertion of an orbital implant in the right eye. Topical intraocular pressure-lowering medications were prescribed for her left eye.


  Discussion Top


Spontaneous globe rupture is rare and is postulated to occur due to suprachoroidal haemorrhage in glaucoma.[4] Other ocular risk factors for suprachoroidal haemorrhage include chronic use of topical steroid, age-related macular degeneration and high myopia.[5],[6],[7] Systemic risk factors include old age,[8],[9] anticoagulant or thrombolytic therapy,[10],[11] atherosclerosis,[12] diabetes mellitus,[13] systemic hypertension,[14] blood dyscrasias[15] and chronic renal failure.[16]

Rutherford described a case of ruptured globe in a woman with secondary glaucoma due to ocular trauma.[2] Similarly, Ellett and Park et al. reported spontaneous globe rupture in two patients with angle-closure glaucoma.[3],[4] Our patients had multiple risk factors for spontaneous expulsive suprachoroidal haemorrhage including advanced age, systemic hypertension, chronic untreated glaucoma, use of topical steroids and traditional eye medications. The proposed mechanisms for spontaneous expulsive suprachoroidal haemorrhage in glaucoma patients include bullous keratopathy that may become secondarily infected and lead to corneal perforation, a greater decompressive force at the time of perforation with resultant anterior displacement of the retina and choroid and focal ischaemia of the posterior ciliary arteries at the point where they enter the globe.[6] Some studies agree with these mechanisms from microscopic examination of the intraocular contents of the eviscerated eye.[3],[4],[17],[18] Another mechanism that may have contributed to the globe rupture of one of our patients could have been trabeculectomy which can be considered as an iatrogenic penetrating trauma to the eye; however, surprisingly, the site of rupture was at the opposite side of the limbus. No other literature was found to have reported this particular finding.


  Conclusion Top


In elderly patients with uncontrolled glaucoma, a combination of factors could lead to structural compromise of the integrity of the globe. These include high intraocular pressures from glaucoma, use of traditional eye medications, a thin limbus, infection, intraocular tumours, etc., These have been postulated to cause massive suprachoroidal haemorrhage with subsequent globe rupture.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sharma R, Brunette DD. Ophthalmology. In: Marx JA, Hockberger RS, Walls RM, editors. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed., Ch. 69. Philadelphia, Pa: Mosby Elsevier; 2009.  Back to cited text no. 1
    
2.
Rutherford WJ. Spontaneous rupture of the glaucomatous eye: An illustrative case. Br J Ophthalmol 1920;4:282-4.  Back to cited text no. 2
    
3.
Ellett EC. Spontaneous rupture of the eyeball a phenomenon of glaucoma. JAMA 1910;55:200-5.  Back to cited text no. 3
    
4.
Park D, Park JS, Kang HY, Lew H. Spontaneous eyeball rupture in a 94-year-old patient. J Korean Ophthalmol Soc 2011;52:734-7.  Back to cited text no. 4
    
5.
Goldsmith C, Rene C. Massive spontaneous expulsive suprachoroidal haemorrhage in a blind glaucomatous eye treated with chronic topical steroid. Eye (Lond) 2003;17:439-40.  Back to cited text no. 5
    
6.
Knox FA, Johnston PB. Spontaneous suprachoroidal haemorrhage in a patient with age-related macular degeneration on excessive anticoagulation therapy. Eye (Lond) 2002;16:669-70.  Back to cited text no. 6
    
7.
Chak M, Williamson TH. Spontaneous suprachoroidal haemorrhage associated with high myopia and aspirin. Eye (Lond) 2003;17:525-7.  Back to cited text no. 7
    
8.
Winslow RL, Stevenson W 3rd, Yanoff M. Spontaneous expulsive choroidal hemorrhage. Arch Ophthalmol 1974;92:33-6.  Back to cited text no. 8
    
9.
Ophir A, Pikkel J, Groisman G. Spontaneous expulsive suprachoroidal hemorrhage. Cornea 2001;20:893-6.  Back to cited text no. 9
    
10.
Chen YY, Chen YY, Sheu SJ. Spontaneous suprachoroidal hemorrhage associated with age-related macular degeneration and anticoagulation therapy. J Chin Med Assoc 2009;72:385-7.  Back to cited text no. 10
    
11.
Barsam A, Heatley CJ, Herbert L. Spontaneous suprachoroidal hemorrhage secondary to thrombolysis for the treatment of myocardial infarction. Clin Exp Ophthalmol 2006;34:177-9.  Back to cited text no. 11
    
12.
Chu TG, Green RL. Suprachoroidal hemorrhage. Surv Ophthalmol 1999;43:471-86.  Back to cited text no. 12
    
13.
Nguyen HN, Nork TM. Massive spontaneous suprachoroidal haemorrhage in a young woman with cystic fibrosis and diabetes mellitus on anticoagulants. Retin Cases Brief Rep 2012;6:216-8.  Back to cited text no. 13
    
14.
Oyakawa RT, Michels RG, Blase WP. Vitrectomy for nondiabetic vitreous hemorrhage. Am J Ophthalmol 1983;96:517-25.  Back to cited text no. 14
    
15.
Lim LT, Agarwal PK, Rotchford A. Angle-closure glaucoma due to suprachoroidal hemorrhage secondary to disseminated intravascular coagulation. Semin Ophthalmol 2011;26:59-60.  Back to cited text no. 15
    
16.
De Marco R, Aurilia P, Mele A. Massive spontaneous choroidal hemorrhage in a patient with chronic renal failure and coronary artery disease treated with Plavix. Eur J Ophthalmol 2009;19:883-6.  Back to cited text no. 16
    
17.
Williams DK, Rentiers PK. Spontaneous expulsive choroidal hemorrhage. A clinicopathologic report of two cases. Arch Ophthalmol 1970;83:191-4.  Back to cited text no. 17
    
18.
Pe'er J, Weiner A, Vidaurri L. Clinicopathologic report of spontaneous expulsive hemorrhage. Ann Ophthalmol 1987;19:139-41.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2]



 

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