Scary- my eye is popping out!

Can your eye really pop out of your head? You see that in cartoons but can it happen to real people?

A group of our optometrist friends were chatting yesterday about this. One said that one of her patients told her about this history, and that she heard about this three times now from different sources. She did not see it herself but she was curious about it. 

I remember such an incident of one of my patients. It was an African American lady in her 30s in good health. I was holding her upper eyelid up in order to examine the lower part of her retina, when she suddenly screamed and screamed, ‘Oh my god, my eye pops out!’ she screamed repeatedly. I almost panicked by her screaming. But I looked at her and saw that her eyelid was retracted and got stuck behind the eyeball and the eyeball was fine. So I gently massaged her upper lid and asked her to blink. A few seconds later her eyelid came down and all was normal. At this time, my technician who was working in the next room came knocking on the door and asked if everything was OK. I told her that all was good. My patient was a little embarrassed about her reaction and calmed down. The rest of the exam was uneventful and the patient left with an essentially normal eye exam.

Having that experience made me cautious about manipulating patients’ eyelids thereafter. Some people’s eyelids are loose and you can easily flip them. If they also happen to have protruding eyeballs, then the lids can get stuck behind the eyeball, which further limits the eyeball from moving.

I thought that eyeball popping out was a misnomer, it’s rather the eyelid going behind. If you think about it, the eyeball is secured by 6 external eye muscles to the eye socket, and the optic nerve which is like a cable also connects the eyeball to the brain. How can you easily get the eyeball out of the socket? If you could, I imagine there would be a lot of damage, potentially to the optic nerve and can cause vision loss. Sure with strong force such as in trauma, eyeballs can fly out of the socket, even the brain can burst out of the skull. But for a person to have spontaneous eyeball popping out, that would require a very high pressure behind the eye, and it just does not happen that easily.

However, it turns out that I did not know this subject well enough. It truely can happen in a condition called globe subluxation. Yes the eyelid could be stuck behind, but the eyeball is really out of (maybe partially) the eye socket. This can be caused by trauma, but it can also happen from triggers such as eyelid rubbing or straining badly. 

Here is a photo from a real patient who suffered from globe subluxation. This is from a recent publication of a case report and all copyright belongs to the original authors and journal [1].

Figure 1. Spontaneous globe subluxation in a middle-aged woman [1]. Copyright in reference [1]

Quite a scene right? No doubt this is very unnerving to the patient as well as to the doctor!

According to this article, the most common risk factor associated with spontaneous globe luxation (SGL) is proptosis (that just means the eyeball is bulging) from having shallow orbits (eye sockets) or things growing in the back of the eyeball. The most common stuff growing behind the eyeball is actually from a condition called thyroid eye disease, in which excess fat and fibroblasts accumulate in the eye socket. Interestingly people with African descent tend to have shallow eye sockets and their eyes generally appear a little more bulging due to this reason. Other factors include loose tissues and muscles supporting the eye, loose eyelid, or having too much fat in the eye socket due to obesity. 

So what harm does globe subluxation do? Seems obvious that an eyeball hanging out is an eyeball not working well for its function, which is seeing. Indeed, if this is severe or goes on for a long time, the optic nerve may be damaged, resulting in vision loss, sometimes permanent. On the other hand, when the eyeball is out, it’s not covered by the lids, and the surface drys out quickly, which can cause pain, light sensitivity and blurry vision immediately. If you think about it, our eyelids really do a good job protecting the eyeball, you can simply close your eyes. With eye protruding out like in the photo above, the eyeball is left there to dry up and exposed to the outside world should something hit or scratch on it.

So how do you pop the eyeball back in? First, relax. Then ask the patient to lay down with face up (or recline on your exam chair). Ask the patient to look down while you gently apply pressure on the globe downward and inward. You can use a cotton swab to roll the eyelids back while applying pressure to the globe [2]. 

Lastly, after the eye goes back to normal, we should probably do some investigation as to why it’s out in the first place. As mentioned above, thyroid eye disease, floppy eyelid syndrome, or maybe even a tumor behind the eye can make a patient prone to developing globe subluxation. So these need to be ruled out.

When I think back about my patient, I wonder if that’s actually not the first time this happened to her. She could not see her eyes, how would she know her eye popped out if she had no prior experience? To me, that was not a true globe subluxation, but rather an eyelid retraction. But her eyelid being so loose and retracting easily should also raise some suspicion on my part to work up further for thyroid eye disease and floppy eyelid syndrome.

According to literature, this is a very rare condition. However it can happen when maneuvering eyelids including when rubbing or inserting/removing contact lenses. I feel lucky that so far I have not encountered this with numerous patients that I have worked with for contact lens I/R training. But the moral of the story is that don’t touch your eyes, cause they can pop out (just exaggerating). 

References

[1] Yadete, T., Isby, I., Patel, K. et al. Spontaneous globe subluxation: a case report and review of the literature. Int J Emerg Med 14, 74 (2021). https://doi.org/10.1186/s12245-021-00398-x

https://intjem.biomedcentral.com/articles/10.1186/s12245-021-00398-x

[2] https://www.reviewofoptometry.com/article/how-to-handle-globe-subluxation

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