All attempts at repairing a corneoscleral laceration should be performed in the operating room with use of the operating microscope and trained ophthalmic personnel. Table 13-8 summarizes the basic steps in restoring the integrity of the globe with a corneoscleral laceration. No attempt should be made to fixate an open globe with rectus muscle sutures. Repair of adnexal injury should follow repair of the globe itself because eyelid surgery can put pressure on an open globe and certain eyelid lacerations may actually improve globe exposure.
The corneal component of the injury is approached first. If vitreous or lens fragments have prolapsed through the wound, these should be cut flush with the cornea, taking care not to exert traction on the vitreous or zonular fibers. If uvea or retina (seen as translucent, tan tissue with extremely fine vessels) protrudes, it should be reposited using a gentle sweeping technique through a separate limbal incision, with the assistance of viscoelastic injection to temporarily re-form the anterior chamber (Fig 13-15). If epithelium has obviously migrated onto a uveal surface or into the wound, an effort should be made to peel this tissue off. Only in cases of frankly necrotic uveal prolapse should uveal tissue be excised.
Points at which the laceration crosses landmarks such as the limbus are then closed with 9-0 or 10-0 nylon suture, followed by closure of the remaining corneal components of the laceration. It may be necessary to reposit iris tissue repeatedly after each suture is placed to avoid entrapment of iris in the wound. Despite these efforts, uvea may still remain apposed to the posterior corneal surface. Many surgeons place very shallow sutures at this stage of the closure to avoid impaling uvea with the suture needle. Then, after the closure is watertight, the uvea can be definitively separated from the cornea with viscoelastic injection, followed by replacement of shallow sutures with new ones of ideal, near-full-thickness depth. Suture knots should be buried in the corneal stroma, not in the wound.
If watertight closure of the wound proves difficult to achieve because of unusual laceration configuration or loss of tissue, X-shaped or “purse-string” sutures or other customized techniques may suffice. Cyanoacrylate glue or even primary lamellar keratoplasty may be required in extremely difficult cases. A conjunctival flap should not be used to treat a wound leak.
When the anatomy of the wound allows, a topographic closure is best for reducing long-term complications. Wider-spaced, longer sutures are used in the peripheral cornea to flatten locally and steepen centrally. Closer, shorter sutures are used centrally, avoiding the visual axis, to close the wound without excessive flattening (Fig 13-16); however, care should be taken that sutures are long enough to minimize their “cheese wiring” through the inflamed stroma.
The scleral component of the laceration is then approached with gentle peritomy and conjunctival separation only as necessary to expose the wound. Prolapsed vitreous is excised, and prolapsed nonnecrotic uvea and retina are reposited with a spatula or similar instrument (Fig 13-17). The scleral wound is closed with 9-0 nylon or 8-0 silk sutures. Often, dissection of Tenon capsule and management of prolapsed tissue must be repeated incrementally after each suture is placed.
Some posterior wounds are more easily approached with loupes and a headlight, because the open globe should not be rotated too far. If the laceration extends under an extraocular muscle, the muscle may be carefully removed at its insertion and reinserted following repair. Closure of the laceration should continue posteriorly only to the point at which it becomes technically difficult or requires undue pressure on the globe. Very posterior lacerations benefit from effective physiologic tamponade by orbital tissue and are best left alone.
Once the globe is watertight, a decision must be made whether intraocular surgery (if necessary) should be attempted immediately or postponed. Subconjunctival injections of antibiotics to cover both gram-positive and gram-negative organisms are given prophylactically at the conclusion of primary repair. Intravitreal antibiotics such as vancomycin 1 mg and ceftazidime 2.25 mg should be considered for contaminated wounds involving the vitreous.
, YiQ, CharlesPG, AllenPJ. Post-traumatic endophthalmitis.2004;111(11):2015–2022.