Primary repair

The principles of primary repair of open-globe injuries include careful, gentle microsurgical corneoscleral wound repair, during which incarcerated uvea is reposited or excised. If a laceration crosses the limbus, or if there is any suspicion of a scleral laceration or rupture, a gentle and generous peritomy, usually 360°, should be performed for best possible exposure. Corneal lacerations may be closed with 10-0 nylon interrupted sutures, and scleral wounds may be closed with stronger 7-0, 8-0, or 9-0 nonabsorbable sutures. Vitreous should be excised from the wound and the anterior chamber should be reformed. Any uvea or retina that protrudes should be amputated if contaminated or gently reposited into the eye. Chapter 4 of BCSC Section 4, Ophthalmic Pathology and Intraocular Tumors, discusses wound healing in detail.

Any scleral laceration must be explored until its posterior extent has been located. If no laceration or rupture can be seen, and a posterior rupture is suspected, a meticulous scleral exploration, including underneath the rectus muscles, should be performed. This may necessitate disinserting one or more extraocular muscles to achieve adequate exposure. If the wound is very posterior, the site should be left to heal without suturing; attempts to suture very posterior wounds may result in expulsion of intraocular content. Some ophthalmologists advocate for placing a prophylactic encircling scleral buckle at the time of primary repair to reduce the likelihood of a later retinal detachment.

Immediate vitrectomy

Immediate vitrectomy may be necessary or advisable in some circumstances—for example, if evaluation suggests the possibility of an IOFB or endophthalmitis.

Some surgeons favor immediate vitrectomy at the time of the primary repair, before cellular proliferation (proliferative vitreoretinopathy) begins. Inducing a posterior vitreous detachment and thorough dissection of the vitreous removes some of the scaffold on which contractile membranes grow. This may reduce the risk of late complications such as tractional retinal detachments, cyclitic membrane formation, and phthisis bulbi. Separating the posterior cortical vitreous from the retina may be difficult, especially in children, young adults, and in eyes with retinal breaks or retinal detachment. If the injury is perforating, the posterior wound may present challenges because it may leak infusate, making the maintenance of IOP during surgery difficult.

Delayed vitrectomy

Most practitioners in the United States prefer initially performing a primary repair of the wound(s) to restore the globe and IOP, followed by delayed vitrectomy, if needed. Reasons that support of delayed vitrectomy include

• decreasing the risk of intraoperative hemorrhage in eyes that are acutely inflamed and congested

• allowing the cornea to clear and improve intraoperative visualization

• permitting spontaneous separation of the vitreous from the retina, which facilitates a safer and more complete vitrectomy

• allowing posterior wounds in perforating injuries to heal, so there is ocular integrity during vitrectomy

The optimal timing of vitrectomy following primary repair remains controversial. It may be best to perform vitrectomy 2–14 days following primary repair. Many advocate waiting at least 5 days if there are unsutured (posterior) wounds. Vitrectomy that is delayed more than 2 weeks following the injury may contribute to substantial worsening of proliferative vitreoretinopathy and associated worse anatomic and visual outcomes.

Typical indications for vitrectomy may include the following:

• the presence of moderate to severe vitreous hemorrhage

• other tissue damage that requires repair

• phacoanaphylactic uveitis, which may occur if the lens is damaged

• signs of developing transvitreal traction

• retinal detachment

• Kuhn F. The timing of reconstruction in severe mechanical trauma. Ophthalmic Res. 2014;51(2):67–72.

• Mieler WF, Mittra RA. The role and timing of pars plana vitrectomy in penetrating ocular trauma. Arch Ophthalmol. 1997;115(9):1191–1192.

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.