1. General anesthesia or bust!
The best situation is a controlled one under general anesthesia. If you practice in an area where open globe trauma is less common, confer with your anesthesiologist beforehand to ensure that the patient will be deeply sedated for the duration of the procedure (i.e., no bucking please), and that non-depolarizing induction agents are used.
One may be tempted to repair smaller lacerations under MAC (monitored anesthesia care). However, the injury may be more extensive than originally thought and the repair can become more tedious and difficult with a poorly cooperative patient.
2. Be careful when prepping and dressing the eye for surgery
. If you are working with unfamiliar nursing circulators, gently remind them to not apply any pressure on the globe during the prepping process and to not instill any povidine iodine directly onto the eye. You can also offer to prep the patient yourself if you are inclined to do so. If available, use a lid speculum that will not apply undue pressure on the globe. Loose Jaffe lid retractors are great options.
3. No matter the condition of the globe, always close the globe (if possible)
. Although some eyes will have a very poor postoperative prognosis, all open globes should be closed initially, unless an expulsive hemorrhage has already occurred. The idea of potentially losing an eye via enucleation or evisceration is devastating and difficult to come to terms with, and patients need time to adjust to such a situation.
4. Examine and stabilize the globe
. Realign the tissues and form a chamber with sutures and viscoelastic before further exploration of the globe. Your initial stabilization sutures will likely end up being removed and replaced before the end of the case. However, it is essential to gain control early on in the case with strategically placed sutures to close the eye first.
5. Cut the vitreous, but not the iris!
Weck and manually cut any prolapsed vitreous that may be present outside of the eye. If possible, scrape and reposit any iris tissue that has prolapsed. Patients may be able to have further anterior segment reconstruction and iris repair in the future. Iris reconstruction is much easier to perform when there is a sufficient amount of iris tissue.
6. Identify the extent of the laceration or perforation
. This one is fairly self-explanatory. Lacerations will commonly track posteriorly behind a rectus muscle, requiring further exploration after disinsertion.
7. If possible, be kind to the cornea
. Oftentimes, patients have very good postoperative visual potential. Try to realign and reapproximate the corneal tissue properly. This can seem almost impossible in a complex laceration such as a stellate one, but try to take suture bites at even depths on both sides of the laceration. The sutures within the central cornea should be shorter than those aligning the periphery.
8. You may need more than just sutures to repair the globe
. In the setting of a larger perforation, order emergency corneal tissue for a potential tectonic graft. Complex corneal lacerations may continue to leak with suture closure alone. Corneal cyanoacrylate and/or fibrin glue(s) can help seal such problematic wounds.
Bandage contact lenses are also very helpful to help tamponade and stabilize any slower leaks, such as suture track leaks. Additionally, aqueous suppressants can be helpful in sealing a slow leak in the post-operative period.
9. Irrigate out the hyphema, but leave the clot alone
. Dislodging the clot can lead to another vigorous hemorrhage. If a hyphema does occur intraoperatively, viscoelastic and an increased intraocular pressure can help halt the bleeding.
10. Leave the violated lens alone!
It is tempting to remove the lens material in the setting of a violated lens capsule. But the true extent of the lens violation and the status of the posterior capsule at the time of the original injury are very difficult to assess. It is best to leave this alone during the open globe repair. Such traumatic cataracts are best dealt with at a later time, under a controlled situation, after the capsule has fibrosed and stabilized.
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About the author: Elizabeth Yeu, MD, is an assistant professor at the Cullen Eye Institute, Baylor College of Medicine in Houston, Texas. She currently serves as an examiner for the American Board of Ophthalmology and serves as an editor for the Academy’s Ophthalmic News and Education (ONE®) Network refractive surgery subcommittee. She is also an appointed member of the Academy’s refractive surgery Annual Meeting subcommittee.