Corneal laceration
Alireza Peyman, MD
Surgical repair
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The primary goal is to achieve a watertight globe and
maintain structural integrity.
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Secondary goals include:
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removing any disrupted lens fragments and vitreous
repositioning any uveal tissue
relieving vitreous incarceration
removing any intraocular foreign bodies
restoring normal anatomic relationships
Partial-Thickness Corneal Lacerations
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Must be examined carefully to rule out any rupture of
Descemet
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Seidel testing
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Modified Seidel testing
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If the wound edges are in good apposition with no wound
gape, pressure patching with the use of prophylactic
topical antibiotics is sufficient.
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If the wound is unstable, a bandage soft contact lens may
be used to support the wound
Partial thickness laceration with gape
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Sutures may be used to re-approximate the wound
margins.
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In these settings, properly placed sutures will minimize
scarring and perturbation of the ultimate surface corneal
topography
Full-Thickness Corneal
Lacerations
BANDAGE SOFT CONTACT LENS
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For small, self-sealing corneal perforations, a bandage
contact lens may be sufficient
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Such lacerations include nondisplaced, beveled, self-sealing
wounds.
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If aqueous leakage persists for more than 24 hours or
there is progressive shallowing of the anterior chamber,
more definitive treatment should be undertaken
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In cases that respond satisfactorily, the contact lens
should be kept in place until the wound has stabilized
(usually 3–6 weeks).
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A protective shield should be worn at all times.
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Topical antibiotic prophylaxis and cycloplegia are
recommended with the lens in place.
TISSUE ADHESIVE.
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Tissue adhesive may be useful for puncture wounds with
small amounts of central tissue loss and selected small
lacerations. It is not routinely utilized.
SUTURE REPAIR OF SIMPLE CORNEAL
LACERATIONS
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The primary goal of corneal suturing is to achieve a
watertight wound.
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Secondary goals include
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minimizing scarring
restoring normal anatomic relationships
reconstructing the normal corneal topographic contours
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For a wound that is less stable, a viscoelastic may be
irrigated into the anterior chamber either directly
through the wound itself or through a separate limbal
paracentesis incision
visco through the wound or through a
paracentesis incision will help
To form the chamber:
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Balanced salt solution or air may also be used to re-form
the anterior chamber.
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In most cases, a limbal paracentesis with a A 15-degree
sharp microsurgical knife is preferred because it will
minimize disruption of the wound edges and permit
better access as the case proceeds
Temporary sutures
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Temporary sutures may be used if the initial placement of
deep definitive sutures would cause loss/flattening of the
anterior chamber.
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The number of temporary sutures should be minimized,
however, to prevent undue trauma to the wound margins
Technique and material
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For corneal suturing, 10-0 monofilament nylon on a fine
spatula-design microsurgical needle is used.
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The simplest method is to progressively halve the
wound with simple interrupted sutures.
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Corneal sutures should be
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90% to 95% depth through the stroma
1.5 mm in length
of equal depth on each side
Shallow sutures create internal wound gape, whereas
sutures of unequal length and depth on each side of the
wound result in wound override.
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Deep suture placement equidistant from the wound
margins gives excellent wound approximation
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Shallow sutures create internal wound gape
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Full-thickness sutures may create a conduit for microbial
invasion
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Sutures of unequal depth create wound override.
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Sutures of unequal length create wound override
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For shelved lacerations, sutures should be placed
equidistant with respect to the internal aspect of the
wound to achieve good wound apposition
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Making the suture bites close to the visual axis short
“no-touch” technique
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When using a running suture for a nonlinear laceration,
the suture should be placed with respect to a straight
“regression” line
Suture knot burial
STELLATE CORNEAL
LACERATIONS
Bridging sutures
Purse-string suture
multiple interrupted sutures and tissue
adhesive or patch graft
CORNEAL LACERATIONS WITH
UVEAL PROLAPSE.
Iris incarceration
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A peaked pupil signals tissue incarceration
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Macerated, feathery, devitalized, or depigmented iris
should be excised
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The prolapsed tissue should be evaluated for any signs of
surface epithelialization.
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In this case, it should be excised to prevent any epithelial cells
from proliferating in the anterior chamber
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In general, tissue that has been prolapsed for longer than
24 hours should be excised to avoid infection;
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however, if the tissue appears healthy, it may be replaced with
caution.
Repositioning
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Pharmacological
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Midriatics
Myiotics
Mechanical
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simply deepening
Viscoelastics through the paracentesis or the wound
a spatula or irrigating canula may be passed through the
paracentesis site and used to directly sweep incarcerated tissue
CORNEAL LACERATIONS WITH
LENS OR VITREOUS
INVOLVEMENT
Primary removal of the lens
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Disrupted capsule and flocculent cortical material
liberated into the anterior chamber.
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In cases in which vitreous is involved with lens remnants,
this may be best addressed in the initial surgery.
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When it is clear that a lens is cataractous and surgical
visualization is good, the lens may be removed in the
primary operation.
Vitreous strands are swept into the anterior
chamber
CORNEOSCLERAL
LACERATIONS
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For large lacerations with structural deformation, sutures
should be placed to restore wound integrity before
rigorous exploration of the globe
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Initially, the limbus should be reapproximated with 8-0
or 9-0 nonabsorbable nylon or silk sutures.
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it is important to clear the wound of any prolapsed or
incarcerated vitreous with dry cellulose sponges and
cut
options in selecting suture material for
scleral closure
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Some surgeons prefer nonabsorbable sutures
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Others may use absorbable materials
For larger defects, nonabsorbable sutures should be used
closing sclera over prolapsed uvea
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Most easily closed from the anterior (limbal) end
“
zippering” or “close-as-you-go” technique.
sutures are placed in close proximity to one another in
an attempt to achieve oversewing of the uveal tissue with
the sclera.
Posterior extention
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scleral lacerations may extend far posteriorly, and may
not be accessible.
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In these situations, it is preferable to leave the most
posterior portion of the wound unsutured
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The sclera is thinnest behind the muscle insertions; thus,
careful exploration of these areas is crucial
ANTERIOR SEGMENT FOREIGN
BODIES
FBs
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Metalic
Vegetable matter
Glass
Plastic
Stones
Other materials
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Typically, the foreign body is small and the eye may not
show obvious signs of trauma
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Foreign bodies frequently lodge in the anterior chamber
angle and may display overlying focal corneal edema.
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Gonioscopy may be useful in detecting the foreign body
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may also embed themselves in the lens and may create a
focal cataract. Iris transillumination defects may signal an
entry site.
Imaging
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Plain graphies
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CT
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MRI
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B-scan sonography
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UBM
Removal
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Through an incision directly overlying
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From a limbal incision across the anterior chamber
Post-op management
Medical therapy
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To control infection
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To suppress inflammation
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To stabilize the ocular surface
Antibiotics
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Sub-conjunctival
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Intra-vitreal
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Vanco or cephalosporine+AG
Topical
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Intra-op
IV
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Intra-op
Fortified, or 4th generation flouroquinolones
Oral
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After discharge
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Clindamycin should be considered in cases involving
vegetable matter to cover Bacillus species.
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Top: 50mg/ml
Subconj: 50mg/0.5ml
Intravitreal: 1mg/0.1ml
Corticosteroids
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To minimize scarring and new vessel ingrowth
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The anti-inflammatory advantages against the risk of
infection
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May also diminish the rate of stromal healing as well as
the tensile strength of the wound
Corticosteroid use should be kept at a minimum in the
early postoperative period
Others
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Topical β-blockers
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Carbonic anhydrase inhibitors
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Lubricants
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Bandage contact lenses
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Patching
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Tarsorrhaphy
Thank you for your attention