Apologies for the lack of recent pearls. Now that the website is back up and running, we’ll be going back to our regularly scheduled programming.

“Hey doc, my eyeball popped out”.

It’s a chief complaint that we don’t hear too often in the ED but when it happens, it’s enough to make me sweat a little bit since we don’t see it very often. Spontaneous globe subluxation is a rare orbital complication and over the past century, fewer than 30 cases of spontaneous subluxation of the globe have been reported. When it does present, it does so dramatically as the patient’s eyeball is literally out of their eye socket.

Clinically, globe subluxation can present in a variety of ways from asymptomatic to blindness secondary to traumatic optic neuropathy. The most common presentation is spontaneous subluxation after a precipitating trigger, usually eyelid manipulation by the physician or caregiver. There have been cases of subluxation after manipulation from putting in a contact lens. Patients at risk of subluxation have underlying risk factors such as exophthalmos, severe lid retraction, floppy eyelid syndrome, thyroid orbitopathy or conditions that predispose patients to shallow orbits such as Crouzon’s syndrome.

In the acute event, immediate reduction of the globe is paramount. Topical anesthetic drops may be helpful, both with patient discomfort as well as breaking the exposure-dry eye cycle that makes reduction difficult. Two maneuvers have been described to reposition a subluxed globe. First, while the patient maintains downward gaze, the upper eyelid is pulled upward and the globe is simultaneously depressed with the index finger of the other hand. The second method utilizes a small Desmarres retractor or a paper clip, spread at a right angle; this is introduced between the upper lid margin and superior rectus. Once the tip is under the eyelid, digital manipulation downward of the globe is necessary to reposit the globe. Once the eyelid is over the equator, the patient is instructed to look up pulling the eyelid over the eye.

Thanks to Dr. Elaine Rabin for serving for the inspiration for today’s pearl. It was certainly eye-opening.