Corneal laceration Alireza Peyman, MD

Surgical repair  The primary goal is to achieve a watertight globe and maintain structural integrity.  Secondary goals include:  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  Must be examined carefully to rule out any rupture of Descemet  Seidel testing  Modified Seidel testing

 If the wound edges are in good apposition with no wound gape, pressure patching with the use of prophylactic topical antibiotics is sufficient.

 If the wound is unstable, a bandage soft contact lens may be used to support the wound

Partial thickness laceration with gape  Sutures may be used to re-approximate the wound margins.  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  For small, self-sealing corneal perforations, a bandage contact lens may be sufficient  Such lacerations include nondisplaced, beveled, self-sealing wounds.  If aqueous leakage persists for more than 24 hours or there is progressive shallowing of the anterior chamber, more definitive treatment should be undertaken

 In cases that respond satisfactorily, the contact lens should be kept in place until the wound has stabilized (usually 3–6 weeks).  A protective shield should be worn at all times.  Topical antibiotic prophylaxis and cycloplegia are recommended with the lens in place.

TISSUE ADHESIVE.  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  The primary goal of corneal suturing is to achieve a watertight wound.  Secondary goals include  minimizing scarring  restoring normal anatomic relationships  reconstructing the normal corneal topographic contours

 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:  Balanced salt solution or air may also be used to re-form the anterior chamber.  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  Temporary sutures may be used if the initial placement of deep definitive sutures would cause loss/flattening of the anterior chamber.  The number of temporary sutures should be minimized, however, to prevent undue trauma to the wound margins

Technique and material  For corneal suturing, 10-0 monofilament nylon on a fine spatula-design microsurgical needle is used.  The simplest method is to progressively halve the wound with simple interrupted sutures.

 Corneal sutures should be  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.

 Deep suture placement equidistant from the wound margins gives excellent wound approximation

 Shallow sutures create internal wound gape

 Full-thickness sutures may create a conduit for microbial invasion

 Sutures of unequal depth create wound override.

 Sutures of unequal length create wound override

 For shelved lacerations, sutures should be placed equidistant with respect to the internal aspect of the wound to achieve good wound apposition

 Making the suture bites close to the visual axis short

“no-touch” technique

 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  A peaked pupil signals tissue incarceration  Macerated, feathery, devitalized, or depigmented iris should be excised  The prolapsed tissue should be evaluated for any signs of surface epithelialization.  In this case, it should be excised to prevent any epithelial cells from proliferating in the anterior chamber

 In general, tissue that has been prolapsed for longer than 24 hours should be excised to avoid infection;  however, if the tissue appears healthy, it may be replaced with caution.

Repositioning  Pharmacological  Midriatics  Myiotics  Mechanical  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  Disrupted capsule and flocculent cortical material liberated into the anterior chamber.  In cases in which vitreous is involved with lens remnants, this may be best addressed in the initial surgery.  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

 For large lacerations with structural deformation, sutures should be placed to restore wound integrity before rigorous exploration of the globe  Initially, the limbus should be reapproximated with 8-0 or 9-0 nonabsorbable nylon or silk sutures.

 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  Some surgeons prefer nonabsorbable sutures  Others may use absorbable materials For larger defects, nonabsorbable sutures should be used

closing sclera over prolapsed uvea  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  scleral lacerations may extend far posteriorly, and may not be accessible.  In these situations, it is preferable to leave the most posterior portion of the wound unsutured

 The sclera is thinnest behind the muscle insertions; thus, careful exploration of these areas is crucial

ANTERIOR SEGMENT FOREIGN BODIES

FBs  Metalic  Vegetable matter  Glass  Plastic  Stones  Other materials

 Typically, the foreign body is small and the eye may not show obvious signs of trauma  Foreign bodies frequently lodge in the anterior chamber angle and may display overlying focal corneal edema.  Gonioscopy may be useful in detecting the foreign body  may also embed themselves in the lens and may create a focal cataract. Iris transillumination defects may signal an entry site.

Imaging  Plain graphies  CT  MRI  B-scan sonography  UBM

Removal  Through an incision directly overlying  From a limbal incision across the anterior chamber

Post-op management

Medical therapy  To control infection  To suppress inflammation  To stabilize the ocular surface

Antibiotics  Sub-conjunctival  Intra-op  Intra-vitreal  Intra-op  IV  Vanco or cephalosporine+AG  Topical  Fortified, or 4 th generation flouroquinolones  Oral  After discharge

 Clindamycin should be considered in cases involving vegetable matter to cover Bacillus species.  Top: 50mg/ml  Subconj: 50mg/0.5ml  Intravitreal: 1mg/0.1ml

Corticosteroids  To minimize scarring and new vessel ingrowth  The anti-inflammatory advantages against the risk of infection  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  Topical β -blockers  Carbonic anhydrase inhibitors  Lubricants  Bandage contact lenses  Patching  Tarsorrhaphy

Thank you for your attention