Preoperative management

If surgical repair is required, the timing of the operation is crucial. Although studies have not documented any disadvantage in delaying the repair of an open globe for up to 36 hours, intervention ideally should occur as soon as possible. Prompt closure of the wound to restore the integrity of the globe helps minimize the risk of additional damage to intraocular contents, inflammation, microbial proliferation, and endophthalmitis.

The following should be done before proceeding to the operating room:

• apply a protective shield

• avoid interventions that require prying open the eyelids

• ensure that the patient has no food or liquids

• prescribe appropriate medications for sedation and pain control

• initiate intravenous antibiotics and antiemetics

• provide tetanus prophylaxis

• seek anesthesia consultation

Injuries associated with soil contamination and/or retained intraocular foreign bodies increase the risk of Bacillus endophthalmitis. Because this organism can destroy the eye within 24 hours, intravenous and/or intravitreal therapy with an antibiotic effective against Bacillus species may be necessary; fluoroquinolones (eg, levofloxacin, moxifloxacin, or gatifloxacin), clindamycin, or vancomycin should be considered. Surgical repair should be undertaken with minimal delay in cases at risk for contamination with this organism.

Anesthesia

General anesthesia is almost always preferred for repair of an open globe because retrobulbar or peribulbar anesthetic injection increases posterior orbital pressure, which may cause or exacerbate the extrusion of intraocular contents. Local or topical anesthesia may be considered for the repair in rare instances, such as a patient with a small, self-sealing laceration who is at medical risk from general anesthesia. After the surgical repair is complete, a periocular anesthetic injection may be used to control postoperative pain.

Surgical repair considerations

Management of a typical full-thickness corneoscleral laceration with uveal prolapse generally requires surgical repair in the operating room (Fig 14-28). The primary goal of the repair is to restore the integrity of the globe. The secondary goal at the time of the primary repair or during subsequent procedures is to restore vision.

Primary enucleation should be performed only for an injury so devastating that restoration of the anatomy is impossible, when it may spare the patient another procedure. If the prognosis for vision in the injured eye is hopeless and the patient is at risk for sympathetic ophthalmia, enucleation must be considered. In the overwhelming majority of cases, however, the advantages of delaying enucleation for a few days far outweigh any advantage of primary enucleation. This delay (which should not exceed the 12–14 days thought necessary for an injured eye to incite sympathetic ophthalmia) allows for assessment of postoperative visual function, consultation with a vitreoretinal or ophthalmic plastic surgeon, and stabilization of the patient’s medical condition. Most importantly, delay in enucleation following attempted repair and subsequent loss of light perception allow the patient time to acknowledge both loss of vision and accompanying disfigurement and to thoughtfully consider the benefits of enucleation in a nonemergency setting.

Agrawal R, Rao G, Naigaonkar R, Ou X, Desai S. Prognostic factors for vision outcome after surgical repair of open globe injuries. Indian J Ophthalmol. 2011;59(6):465–470.

Castiblanco CP, Adelman RA. Sympathetic ophthalmia. Graefes Arch Clin Exp Ophthalmol. 2009;247(3):289–302.

Galor A, Davis JL, Flynn HW Jr, et al. Sympathetic ophthalmia: incidence of ocular complications and vision loss in the sympathizing eye. Am J Ophthalmol. 2009;148(5):704–710.e2.

Repair of a corneoscleral laceration

Repair of a corneoscleral laceration in the operating room should take precedence over non-life-threatening surgical problems elsewhere on the body. Repair of an 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.

Figure 14-28 Scleral laceration with prolapse of uveal tissue secondary to blunt trauma.

The corneal component of the injury is approached first. If vitreous or lens fragments have prolapsed through the wound, the surgeon should cut these fragments flush with the surface of the globe (Fig 14-29), 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, the surgeon should reposit it using a gentle sweeping technique through a separate limbal incision, with the assistance of viscoelastic injection to keep the anterior chamber formed. If epithelium has obviously migrated onto a uveal surface or into the wound, an effort should be made to peel the epithelial layer off. Only in cases of frankly necrotic macerated tissue should uveal tissue be excised.

Figure 14-29 Restoring anatomical relationships in corneoscleral laceration repair. A, Prolapsed vitreous or lens fragments are excised. B, Iris is reposited by means of viscoelastic and a cannula inserted through a separate paracentesis. C, Landmarks such as limbus, laceration angles, or epithelial pigment lines are closed. Vertical lacerations are closed first to create a watertight globe more quickly, followed by shelved lacerations. D, The scleral part of the wound is exposed, prolapsed vitreous is severed, and the wound is closed from the limbus, working posteriorly.

(Reproduced from Hamill MB. Repair of the traumatized anterior segment. Focal Points: Clinical Modules for Ophthalmologists. San Francisco: American Academy of Ophthalmology; 1992, module 1. Illustrations by Christine Gralapp.)

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 remain apposed to the posterior corneal surface. Very shallow sutures may be helpful at this stage of closure to avoid impaling the 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 the shallow sutures with deeper ones of near-full-thickness depth. Suture knots should be buried in the corneal stroma with the knot on the side of firmest tissue support to facilitate eventual removal.

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, but a bandage contact lens over the glue is necessary for comfort. A conjunctival flap should not be used to treat a wound leak.

When the anatomy of the wound allows, specific suturing techniques may be helpful to restore the normal corneal contour. Longer, more widely spaced sutures create flattening in the area of the suture and are therefore placed in the peripheral cornea to re-create the aspheric curvature of the cornea—flatter in the periphery and steeper centrally. Shorter, more closely spaced sutures are then used centrally, when possible, in order to close the wound without excessive central flattening (Fig 14-30). When the sutures are being tied, it is important to have sufficient tension to create a watertight closure but not excessive tightness, which can induce corneal folds, astigmatism, or maceration of the inflamed stromal tissue. The knots should be buried for patient comfort. Very short sutures are harder to remove than longer sutures.

To evaluate the scleral component of the laceration, a gentle peritomy and conjunctival separation are performed to expose the wound. Prolapsed vitreous is excised, and prolapsed nonnecrotic uvea and retina are reposited, as in corneal repair, by use of a spatula or similar instrument (Fig 14-31). The scleral wound is closed with 9-0 nylon or 8-0 silk sutures. Often, resection of Tenon capsule and management of prolapsed tissue must be repeated incrementally after each suture is placed. The McCannel technique is a popular approach for repair of an iris defect (Fig 14-32).

Some posterior wounds may require visualization with a loupe and a headlight if the open globe cannot be rotated enough for visualization under the operating microscope. If the laceration extends under an extraocular muscle, the muscle may be carefully removed at its insertion and then reinserted following repair. The surgeon should exercise extreme care if fixation of an open globe with rectus muscle sutures is necessary for visualization, as is sometimes done in retinal surgery, because doing so would put undue pressure on the eye and could exacerbate the extrusion of intraocular structures. Closure of the laceration should continue posteriorly only to the point at which it becomes technically difficult or requires undue pressure on the globe to complete. Very posterior lacerations may be tamponaded effectively by orbital tissue and are best left alone.

Figure 14-30 Restoring functional architecture in corneal wound closure. A, Laceration has a flattening effect on the cornea. B, Long, compressive sutures are taken in the periphery to flatten the peripheral cornea and steepen the central cornea. Subsequently, short, minimally compressive sutures are taken in the steepened central cornea to preserve sphericity despite the flattening effect of the sutures.

(Reproduced from Hamill MB. Repair of the traumatized anterior segment. Focal Points: Clinical Modules for Ophthalmologists. San Francisco: American Academy of Ophthalmology; 1992, module 1.)

Figure 14-31 The zippering technique of scleral wound closure. Prolapsed uveal tissue is depressed while the scleral wound is progressively closed, moving in an anterior-to-posterior direction.

(Redrawn from Hersh PS, Shingleton BJ, Kenyon KR. Management of corneoscleral lacerations. In: Hersh PS, Shingleton BJ, Kenyon KR, eds. Eye Trauma. St Louis: Mosby Year Book; 1991.)

Once the globe is watertight, the surgeon must decide whether intraocular surgery (if necessary) should be attempted immediately or postponed. Deciding whether to pursue such intervention at the time of initial repair is a complex process. The expertise of the surgeon; the quality of the facility, technical equipment, and instruments; the adequacy of the view of anterior segment structures; and issues of informed consent should be considered. In general, it is recommended that, if there are concerns regarding any of these parameters, the surgeon complete the closure of the laceration to maintain globe integrity and postpone the secondary procedures until a later date. For example, the average anterior segment surgeon should not attempt automated vitrectomy with retina present in the anterior chamber, and the most expert cataract surgeon might not attempt a lens extraction with limited visualization.

Figure 14-32 The McCannel technique for repairing iris lacerations. With large lacerations, multiple sutures may be used. A, A limbal paracentesis is made over the iris discontinuity. A long Drews needle with 10-0 polypropylene is then passed through the peripheral cornea, the edges of the iris, and the peripheral cornea opposite, and the suture is cut. B, A Sinskey hook, introduced through the paracentesis and around the suture peripherally, is drawn back out through the paracentesis. C, The suture is securely tied. D, After the suture is secure, it is cut, and the iris is allowed to retract.

(Reproduced from Hamill MB. Repair of the traumatized anterior segment. Focal Points: Clinical Modules for Ophthalmologists. San Francisco: American Academy of Ophthalmology; 1992, module 1. Illustrations by Christine Gralapp.)

As always, the welfare of the patient determines the proper course. In general, if a foreign body is visible in the anterior segment and can be grasped, it is reasonable to remove it, either through the wound or through a separate limbal incision. Metal fragments are difficult to remove through their entrance wounds because the rough metal edges usually require a surprisingly larger wound for extraction than would appear necessary. If removal of opacified lens material is attempted, it is helpful to know whether the posterior capsule has been violated and lens–vitreous admixture has occurred. The removal of a ruptured lens may be undertaken from a posterior approach with vitrectomy during a second procedure. BCSC Section 11, Lens and Cataract, also discusses the issues of cataract surgery and IOL placement following trauma to the eye.

Closure of iris lacerations helps keep the iris in its proper plane, decreasing the formation of anterior or posterior synechiae while reducing glare and polyopia from severe corectopia, but may be difficult to achieve during the primary procedure. Iridodialysis may cause monocular diplopia and an eccentric pupil if left untreated. In the event that corneal opacity prevents safe repair of internal ocular injury, repairs can be performed secondarily.

Subconjunctival injections of antibiotics to cover both gram-positive and gram-negative organisms may be given prophylactically at the conclusion of the repair. Intravitreal antibiotics such as vancomycin 1 mg and ceftazidime 2.25 mg should be considered for contaminated wounds involving the vitreous.

Postoperative management

Postoperatively, therapy is directed at preventing infection, suppressing inflammation, controlling IOP, and relieving pain. Patients may be given intravenous antibiotics (eg, a cephalosporin and an aminoglycoside) for 48 hours or an oral antibiotic such as moxifloxacin (400 mg per day) for 3–5 days. Topical antibiotics are generally instilled 4 times a day for 7 days or until epithelial closure of the ocular surface is complete. Topical corticosteroids may be given 4–8 times a day, depending on the amount of inflammation or the risk of infection. Corticosteroid drops and cycloplegics are slowly tapered as the inflammation subsides. A fibrinous response in the anterior chamber may respond well to a short course of systemic prednisone. IOP should be monitored; low pressure may suggest a wound leak, cyclodialysis, ciliary body shutdown, choroidal effusion, or intraocular hemorrhage. Elevated IOP should be controlled to minimize the risk of optic nerve damage.

Corneal sutures that do not loosen spontaneously are generally left in place for at least 3 months, depending on wound healing and patient age, and then removed incrementally over the next few months. Fibrosis and vascularization are indicators that enough healing has occurred to render suture removal safe. Applying fluorescein at each postoperative visit is mandatory to ensure that suture loosening or erosion through the epithelium has not occurred, as these eroded sutures can induce pain, infection, and inflammation.

Traumatized eyes are at increased risk of choroidal effusion or retinal detachment, so frequent examination of the posterior segment is mandatory. If media opacity precludes an adequate fundus examination, evaluation for an afferent pupillary defect and B-scan ultrasonography are useful in monitoring retinal status.

Refraction and vision correction with contact lenses or glasses can proceed when the ocular surface and media permit. Partial or complete suture removal should be performed when safe to facilitate improvement in vision. Because of the risk of amblyopia in a child or loss of fusion in an adult, vision correction should not be unnecessarily delayed.

For more information on wound repair, see BCSC Section 4, Ophthalmic Pathology and Intraocular Tumors.

Macsai MS, Rohr A. Surgical management and rehabilitation of anterior segment trauma. In: Mannis MJ, Holland EJ, eds. Cornea. Vol 2. 4th ed. Philadelphia: Elsevier; 2017:1588–1600.

Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.