Ocular Trauma: Globe Rupture and the Retrobulbar Hematoma Clock

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Updated July 2026  |  More ICU clinical guides →

Eye injuries are easy to overlook in a multiply injured trauma patient — the eye is small, often swollen shut, and competing with more obviously life-threatening problems. But two eye emergencies can permanently take a patient's vision, one by mishandling and one by a ticking clock. A globe rupture can be worsened by any pressure on the eye, and a retrobulbar hematoma causing orbital compartment syndrome can blind the patient within an hour or two unless the orbit is decompressed. ICU nurses who know the signs and the "do not press on this eye" rule can protect vision that would otherwise be lost.

Globe rupture: protect, don't press

An open-globe injury means the wall of the eye has been breached, either by a laceration or a blunt burst. Signs include a pupil that is peaked, teardrop-shaped, or irregular; a shallow or collapsed-looking eye; dark uveal tissue prolapsing through the wound; a subconjunctival hemorrhage so severe it balloons; blood in the front chamber (hyphema); and marked vision loss. The single most important nursing principle is that anything that raises pressure on or in the eye can extrude the eye's contents and worsen the injury permanently.

Retrobulbar hematoma: a true time emergency

The orbit is a rigid bony cone closed at the back, so bleeding behind the eye has nowhere to go. A retrobulbar hematoma raises pressure inside that closed space — an orbital compartment syndrome — and pushes the eye forward while stretching and compressing the optic nerve and its blood supply. Just like compartment syndrome elsewhere in the body, the pressure chokes off perfusion; here the tissue at risk is the retina and optic nerve, which tolerate ischemia for only a short time. Untreated, it causes permanent blindness in as little as 60 to 120 minutes.

The clinical picture is a tense, bulging (proptotic) eye that is hard to the touch, severe and escalating pain, decreasing vision, an eye that cannot move well, and — a key exam finding — an afferent pupillary defect as the optic nerve fails. Rising eye pressure is objective evidence. Because the treatment window is so short, diagnosis is clinical: you do not wait for imaging when the eye is tense and vision is going.

Lateral canthotomy and cantholysis

The bedside procedure that saves the eye in orbital compartment syndrome is a lateral canthotomy with inferior cantholysis — a small incision at the outer corner of the eye that releases the lower lid's tendon and instantly relieves the pressure, the eye's version of a fasciotomy. It is performed by a trained provider, but the ICU nurse's role is to recognize the syndrome early, escalate loudly, gather the setup (local anesthetic, forceps, scissors, hemostat), and support the patient. Minutes matter, so the value of a nurse who says "this eye is tense and the vision is dropping — we need decompression now" is enormous.

ICU care and the sedated patient

In the ICU, the hard part is the patient who cannot report vision or pain — the sedated, intubated, or brain-injured patient. Facial and orbital fractures should raise your suspicion, and a tense, increasingly proptotic eye with a firm orbit is a red flag even without a complaint. Check pupils as part of your neuro assessment and note any new afferent defect or a pupil that changes shape. For a known open globe, maintain the shield, head elevation, and pressure-lowering measures around the clock, and coordinate antiemetics and cough/gag control during suctioning and turns. Because orbital injuries travel with maxillofacial fractures and with traumatic brain injury, keep the whole face and head in view, not just the obvious wound.

Where to go from here

Pair this with the maxillofacial and Le Fort trauma guide for the facial fractures that accompany eye injury, the traumatic brain injury guide for the head injury that shares the mechanism, and the compartment syndrome guide for the same closed-space physiology in the limb.