Annals of B Pod: Acute Globe Subluxation
/HISTORY OF PRESENT ILLNESS
A middle aged male presented with right eye pain. Patient stated that upon waking up from a nap his right eye spontaneously “popped out.” He was able to self-reduce the eye via relaxation and gentle pressure. He reported residual redness and soreness of the right eye. He denied any visual changes or difficulty with eye movements. He reported a similar event involving the right eye approximately five years ago, in which he was evaluated with no identifiable causes found, including thyroid pathologies. He is blind in his left eye secondary to a prior retinal detachment and resultant glaucoma.
PAST MEDICAL HISTORY: Left Retinal Detachment
PAST SURGICAL HISTORY: Repair of Left Retinal Detachment
MEDICATIONS: None
ALLERGIES: Peanuts
SOCIAL HISTORY: No alcohol, tobacco or drug use
PHYSICAL EXAM
Vitals: HR 77, BP 175/108, RR 20, SpO2 100% on room air, T 98.4 F
The patient was a well-appearing male who was awake, alert and oriented. Cardiopulmonary, abdominal and neurologic examinations were normal. The head was atraumatic. The right eye appeared proptotic, with mild conjunctival injection. Extra-ocular eye movements were intact without pain. The left eye was noted to have exotropia, which the patient stated was chronic. The visual acuity was 20/30 in the right eye. The patient was chronically blind in the left eye, with no light perception. While performing tonometry of the right eye (23 mmHg), the eye briefly subluxed out of the orbit.
CT of orbits
NOTABLE DIAGNOSTICS
BMP: unremarkable, CBC: unremarkable
TSH: 0.95, Free T4: 0.69
Computed Tomography (CT) of Orbit: Bilateral radiographic ocular proptosis, right greater than left. No mass or vascular malformation (Figure 1).
HOSPITAL COURSE
Ophthalmology was consulted and attributed the patient's globe subluxation to a shallow orbit. The patient was educated on avoiding potential triggers such as eye rubbing or eyelid manipulation. Ophthalmology recommended oculoplastic referral for tarsorrhaphy if subluxation continued to recur at greater frequency.
DISCUSSION
illustration of globe subluxation
Spontaneous globe subluxation (SGS) is characterized by spontaneous anterior displacement of the eye (Figure 2). This is a dramatic and rare phenomenon, with fewer than 30 cases reported over the last century. SGS occurs without conscious effort or without a precipitant factor. There have also been reported cases of both voluntary and traumatic globe subluxation, with voluntary subluxation occurring at the will of the patient and traumatic typically occurring following direct trauma to the eye.[1,2]
Subluxation of the globe occurs when the globe’s equator bulges anteriorly past the eyelid, which causes contraction of the orbicularis muscle, further displacing the globe anteriorly. The eye then becomes trapped outside of the eyelid aperture, which limits spontaneous reduction and extraocular movements. The most common risk factor associated with SGS is proptosis, most commonly secondary to shallow orbits or space-invading retrobulbar lesions, such as Graves’ ophthalmopathy.[3] Cases of SGS have also been described in obese patients, women with hyperemesis gravidarum, and patients with chronic obstructive pulmonary disease (Table 1). [3,4,5]
Any patient presenting with globe subluxation should receive a thorough ocular exam including visual acuity, pupillary reflex, and extraocular movements. SGS is associated with both immediate and long-term complications. In the acute setting, patients are at risk of pain, vision changes, exposure keratitis, corneal abrasions and blepharospasm. Most urgently, SGS may cause traction on the optic nerve and retinal vasculature, threatening the patient’s long-term vision.[4] To improve chances at successful reduction, patients should be treated with anxiolytics or analgesics. If the patients’ eyelids are retracted behind the globe, the patient should be instructed to look down while a continuous amount of moderate pressure is placed posteriorly and inferiorly, while lifting the upper eyelid.[6] A Desmarres retractor or paper clip spread at a right angle can be introduced between the upper eyelid and superior rectus for this purpose, or the lid can be pinched between the provider’s fingers. Once the tip is under the eyelid, apply downward pressure until the eyelid is over the equator, then instruct the patient to look up, which should pull the upper eyelid over the eye (Figure 3).[7] If attempts to reduce the globe are unsuccessful, emergent ophthalmology consultation is necessary.
photo illustration of reduction technique for globe subluxation. A) Patient keeps downward gaze while eyelid is manually retracted. Downward and backward pressure is applied gently to the globe. B) The superior eyelid continues to be manually retracted while the patient looks upward to complete reduction.
Following successful reduction, diagnostics should be obtained to evaluate for potential etiologies, including thyroid studies and CT imaging of the orbits. If reduction is successful and there are no residual vision changes or other complications identified, emergent ophthalmology consultation may not be required, but all patients with globe subluxation should be referred for ophthalmology follow-up. Patients with recurrent subluxations may be candidates for surgical procedures such as lateral tarsorrhaphy, lid retraction repair, or orbit reconstruction.[8]
AUTHORED BY CASEY GLENN, MD
Dr. Glenn is a PGY-3 in Emergency Medicine at the University of Cincinnati
EDITING BY Dr. Courtney Kein and THE ANNALS OF B POD EDITORS
REFERENCES
1. Tucker B. Two cases of dislocation of the eyeball through the palpebral fissure. J Nerv Ment Dis 1907;34:391-7.
2. Roka N, Roka YB. Traumatic luxation of the eye ball with optic nerve transection following road traffic accident: report of two cases and brief review of literature. Nep J Ophthalmol. 2018;10(2)
3. Zeller J, Murray SB, Fisher J. Spontaneous globe subluxation in a patient with hyperemesis gravidarum: a case report and review of the literature. J Emer Med. 2007;32(3):285–7.
4. Zeller J, Murray SB, Fisher J. Spontaneous globe subluxation in a patient with hyperemesis gravidarum: a case report and review of the literature. J Emer Med. 2007;32(3):285–7.
5. Kumar MA, Srikanth K, Pandurangan R. Spontaneous globe luxation associated with chronic obstructive pulmonary disease. Indian J Ophthalmol. 2012;60(4):324–5.
6. Gupta H, Natarajan S, Vaidya S, et al. Traumatic eye ball luxation: a stepwise approach to globe salvage. Saudi J Ophthalmol. 2017;31(4)
7. Tse DT. A simple maneuver to reposit a subluxed globe. Arch Ophthalmol. 2000;118(3).
8. Lumbreras-Fernández B, Sales-Sanz M, Contreras I, Albandea AR. Orbital decompression for the treatment of spontaneous globe luxations. Orbit. 2015;34(4):2015.
