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Corneoscleral Laceration Treatment & Management

  • Author: Guruswami Giri, MD, FRCS; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Jul 05, 2016
 

Medical Care

A corneoscleral laceration is surgically treated. Medications play a secondary role. Intravitreal, intracameral, topical, and systemic antibiotics are used for prophylaxis against infections. Topical steroids are used to reduce postoperative inflammation. Cycloplegics may be used to relieve ciliary muscle spasm. Elevated intraocular pressure is not uncommon as a result of the injury per se or due to associated inflammation. Under these circumstances, aqueous suppressants are indicated.

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Surgical Care

The patient is prepared for surgery as soon as possible and should be medically cleared.

The time of the last meal or drink determines when surgery is scheduled. To prevent aspiration, at least 6 hours should have elapsed since the last meal. Once the physician decides to repair the laceration, the patient should be restricted to nothing by mouth.

The primary aim of surgery is to restore the anatomical integrity of the globe.

Anesthesia

Repairing corneoscleral lacerations under general anesthesia is recommended.

Anesthesia should be achieved without any increase in intraocular pressure, which can occur during intubation or because of anesthetic agents.

Depolarizing agents (eg, succinyl choline) are not used. Although succinyl choline possesses several advantages, it contracts extraocular muscles and increases intraocular pressure.

External pressure from the mask can also increase intraocular pressure.

Local anesthesia is generally not used as an anesthetic agent because it may increase intraorbital and intraocular pressures. Injecting it is also difficult because the normal globe anatomy is lost as a result of the trauma. The patient may also squeeze the eye while the physician administers the injection.

Eye preparation

The eye should be prepared and draped with care. Pressure should not be applied to the globe. The eye is irrigated with a sterile balanced salt solution (BSS) to remove any superficial foreign bodies.

Eye examination

The eye is gently examined to evaluate the extent of damage. If the globe appears unstable, sutures are first applied prior to exploration of the wound.

First, a suture is applied to the limbus, and the wound is tightly secured. This suture helps to anatomically approximate the wound.

The author recommends the use of 9-0 or 10-0 nylon sutures.

After the first suture is applied, an iris prolapse or a vitreous prolapse is treated. In the presence of an iris prolapse, see Iris Prolapse for a description of the surgical procedure. In the presence of a vitreous prolapse, a vitrectomy is performed with cellulose sponges and scissors or an automated vitrector. During the vitrectomy, traction on the vitreous should be avoided. Any vitreous in the anterior segment may be removed using a vitrectomy machine.

To close the corneal wound, 10-0 nylon sutures are applied.

A traumatic cataract may be present. Unless lens material is fluffed up into the anterior chamber or the lens has become intumescent, the cataract is often not removed at this time. A more controlled cataract extraction with better visualization can be performed at a later date. Intraocular lens (IOL) calculations with keratometry and axial length measurements may not be available in an emergency situation.

If the cataract must be removed at the time of the corneoscleral laceration repair, it is typically performed through a limbal incision once the laceration has been repaired.

Scleral exploration and repair

After the corneal wound is repaired, the scleral wound is explored. This exploration is achieved by performing a limbal peritomy at the site of the limbal wound. The author recommends the placement of interrupted full-thickness scleral sutures using 9-0 nylon.

Segments of scleral laceration are explored and repaired. This method helps to stabilize the eye and to prevent uveal or vitreous prolapse. Scleral laceration should be repaired as far posteriorly as possible; far posterior scleral ruptures may be left unsutured. While repairing scleral lacerations, care must be taken to avoid exerting pressure on the globe.

In the presence of uveal prolapse, the prolapsed tissue is reposited. The author avoids excision of the prolapsed uveal tissue unless it is necrotic because it may cause excessive bleeding.

Vitreous prolapse is managed by performing a vitrectomy with cellulose sponges and scissors or by using an automated vitrector.[3] The sutures are placed closely together and tied to achieve a watertight closure.

Intravitreal antibiotics may be injected through the scleral laceration.

The conjunctiva is sutured using 7-0 Vicryl sutures. A patch and a shield are applied to the eye.

Postoperative monitoring

Postoperatively, patients should be monitored carefully for signs of infection.

Pain, photophobia, redness, tearing, or a deterioration of vision should alert the physician to look for signs of endophthalmitis.[4, 5]

Conjunctival injection, chemosis, corneal edema, and elevated intraocular pressure may be present but are not diagnostic of infection.

A more than expected anterior chamber reaction and cells in the vitreous suggest endophthalmitis.

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Consultations

Consultation is generally unnecessary unless other injuries are present or suspected.

Patients must also be cleared for general anesthesia.

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Diet

Postoperative fluids are administered and then advanced as tolerated.

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Activity

Patients should be instructed to wear polycarbonate (which is a shatterproof material) eyeglasses while working with mechanical tools or playing sports. Patients should be advised to avoid engaging in contact sports for several months after the laceration repair. If the patient has difficulty with depth perception because of poor vision in the injured eye, the patient should be advised not to work with sharp, cutting, or power tools and where depth perception is essential.

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Contributor Information and Disclosures
Author

Guruswami Giri, MD, FRCS Vitreo-Retinal Surgeon, Sacramento, CA

Guruswami Giri, MD, FRCS is a member of the following medical societies: American Academy of Ophthalmology, Royal College of Surgeons of Edinburgh, Royal College of Ophthalmologists

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Christopher J Rapuano, MD Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Director of the Cornea Service, Co-Director of Refractive Surgery Department, Wills Eye Hospital

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Ophthalmological Society, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, International Society of Refractive Surgery, Cornea Society, Eye Bank Association of America

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cornea Society, Allergan, Bausch & Lomb, Bio-Tissue, Shire, TearScience, TearLab<br/>Serve(d) as a speaker or a member of a speakers bureau for: Allergan, Bausch & Lomb, Bio-Tissue, TearScience.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Stephen D Plager, MD 

Stephen D Plager, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, California Medical Association

Disclosure: Nothing to disclose.

References
  1. McGwin G Jr, Hall TA, Xie A, et al. Trends in eye injury in the United States, 1992-2001. Invest Ophthalmol Vis Sci. 2006 Feb. 47(2):521-7. [Medline].

  2. McGwin G Jr, Xie A, Owsley C. Rate of eye injury in the United States. Arch Ophthalmol. 2005 Jul. 123(7):970-6. [Medline].

  3. Ryan SJ, Allen AW. Pars plana vitrectomy in ocular trauma. Am J Ophthalmol. 1979 Sep. 88(3 Pt 1):483-91. [Medline].

  4. Brinton GS, Topping TM, Hyndiuk RA, et al. Posttraumatic endophthalmitis. Arch Ophthalmol. 1984 Apr. 102(4):547-50. [Medline].

  5. Essex RW, Yi Q, Charles PG, et al. Post-traumatic endophthalmitis. Ophthalmology. 2004 Nov. 111(11):2015-22. [Medline].

  6. Schemmer GB, Driebe WT Jr. Posttraumatic Bacillus cereus endophthalmitis. Arch Ophthalmol. 1987 Mar. 105(3):342-4. [Medline].

  7. Barr CC. Prognostic factors in corneoscleral lacerations. Arch Ophthalmol. 1983 Jun. 101(6):919-24. [Medline].

  8. Albert DM, Jakobiec FA. Principles and Practice of Ophthalmology. WB Saunders Co; 2000. Vol 6: 5179-5217.

 
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