Corneoscleral Laceration 

Updated: Nov 19, 2018
Author: Guruswami Giri, MD, FRCS; Chief Editor: Hampton Roy, Sr, MD 

Overview

Background

A corneoscleral laceration is an injury involving the cornea and sclera and may occur following blunt, penetrating, or perforating ocular trauma. The injury may be sustained at work, during sports, following a motor vehicle accident, from airbag inflation, or in a brawl. The laceration may be the only injury; injuries to other structures in the eye such as the lens, uvea, retina, or vitreous may cause prolapse through the wound. A corneoscleral laceration is more likely to occur in an eye that has undergone a previous surgery, such as extracapsular cataract surgery.

Epidemiology

Frequency

United States

The exact incidence of corneoscleral laceration in the United States is unknown, but the overall estimated rate of all eye injuries ranges from 8.2-13 per 1000 population. Eye injury rates are highest among individuals in their 20s, males, and whites.[1, 2]

International

The incidence of corneoscleral laceration worldwide is unknown.

Mortality/Morbidity

Predicting the visual outcome in patients with corneoscleral lacerations is difficult. The outcome is generally poor in patients who have poor visual acuity at presentation, in patients with delayed presentation, and in patients who sustain agricultural-related injuries.

Sex

Corneoscleral lacerations are more common in young men than in young women.

Age

Corneoscleral lacerations are most common in young adults. Wound dehiscences after ocular surgery, such as cataract surgery and corneal transplantation, are most common in older patients.

Prognosis

Prognosis depends on several factors.[3]

Patients with a small corneoscleral laceration without any other intraocular injury have a better prognosis.

Patients with other intraocular injuries, intraocular foreign bodies, endophthalmitis, late presentation, or agricultural-related injuries tend to have a poor prognosis.

Patient Education

For excellent patient education resources, visit eMedicineHealth's Eye and Vision Center. Also, see eMedicineHealth's patient education article Eye Injuries.

 

Presentation

History

Obtaining a thorough history about the traumatic event is important. The place, the time, and the activity that caused the injury must be elicited. Events after the injury, including any first-aid measures, should also be noted. Patients should be asked about the use of safety glasses, especially in work-related eye injuries. Patients should be queried about other injuries, especially head injuries. Even if patients deny them, they must be carefully evaluated for such injuries. Life-threatening injuries must be managed first.

Medical and surgical history

Medical and surgical histories should be obtained. Immunization status for tetanus should be included.

Past ocular history

Past ocular history is required in patients with corneoscleral injuries. Dates and particulars of previous eye examinations or school vision screenings may help the physician in understanding the status of the eye prior to the trauma. History of amblyopia (lazy eye), eye patching, and muscle surgery for strabismus must be ascertained. Any previous trauma and/or eye surgery should also be included.

Other symptoms

Patients should be asked about other symptoms, such as headache, eye pain, nausea, or vomiting.

Physical

A good history helps the physician in performing an appropriate physical examination.

In conscious and cooperative patients, visual acuity should be obtained. Visual acuity at the bedside may be obtained with reading cards. In the presence of ecchymosis and lid swelling, a wire speculum may be used after instilling topical anesthetics, but no external pressure should be placed on the eye.

The anterior segment is ideally examined with a slit lamp. Pay particular attention to the corneoscleral laceration. The location and the length of the laceration should be noted. If the intraocular contents prolapse through the laceration, the rest of the eye examination should be deferred and performed in the operating room. Measurement of the intraocular pressure is also deferred because any pressure on the globe can result in extrusion of the intraocular contents.

The size and the shape of the pupil and its reaction should be checked. Whenever possible, the pupils should be checked for a relative afferent pupillary defect.

Confrontation visual fields must be assessed.

The fellow eye should be carefully evaluated, including a dilated fundus examination.

After a corneoscleral laceration is diagnosed, an eye shield is applied, and the head of the bed is elevated.

Pain, nausea, and vomiting must be appropriately managed.

Causes

A corneoscleral laceration may occur following blunt or penetrating ocular trauma. Patients who have undergone previous ocular surgery may develop a wound rupture with relatively mild trauma.

Complications

The following complications are associated with corneoscleral lacerations:

  • Endophthalmitis, which occurs in 2-7% of patients with ocular trauma

  • Cataract

  • Iris damage

  • Glaucoma, which can occur acutely or later, possibly related to angle recession

  • Hyphema

  • Vitreous hemorrhage

  • Retinal detachment

  • Epithelial downgrowth

  • Fibrous ingrowth

  • Uveitis

  • Cystoid macular edema

  • Sympathetic ophthalmia, which can occur anytime after the trauma (One case of sympathetic ophthalmia occurred 50 years after the initial trauma.)

 

DDx

 

Workup

Approach Considerations

Whenever possible, a thorough eye examination should be performed. This includes assessment of Snellen visual acuity, pupillary reaction, and confrontation visual fields, as well as noncontact intraocular pressure measurement, slit-lamp examination with fluorescein stain for Seidel test, and dilated fundus examination. Seidel test results may be negative if the corneal laceration is plugged or the intraocular pressure is very low.[4]

Laboratory Studies

If the wound appears infected, Gram stain and cultures for bacteria, anaerobes, and fungi should be performed in the operating room. Swabs from the wound should be obtained before the patient is prepared for surgery with betadine. Cultures can also be obtained from any intraocular foreign bodies or tissue resected during surgery.

Imaging Studies

Imaging should be considered when an intraocular foreign body is suspected. X-ray films and CT scans are quick and can be readily obtained. MRI should not be obtained if a metallic foreign body is suspected.

A CT scan is also useful in assessing any injury to the orbital bone in patients who have sustained blunt trauma.

A B-scan ultrasound examination that is gently performed by an expert may be helpful in identifying an intraocular foreign body.

Other Tests

Consider other associated diseases such as connective-tissue disease in patients with minor trauma presenting with corneoscleral laceration.[5]

 

Treatment

Medical Care

A corneoscleral laceration is surgically treated. Corneal lacerations alone may be self-sealing and may not require repair.

Medications play a secondary role. Topical, systemic,, intravitreal, and intracameral 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.

Surgical Care

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

The time of the last meal or drink determines when surgery is scheduled. To prevent aspiration, at least 4-6 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.

Avoid external pressure from the mask, as this can 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 without applying any pressure 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.

Corneal laceration repair

First, a suture is applied to the limbus using 10-0 nylon sutures, and the wound is tightly secured. This suture helps to anatomically approximate the wound.

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. Then, close the corneal with 10-0 nylon sutures.

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.[6] 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.[7, 8]

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.

Consultations

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

Patients must also be cleared for general anesthesia.

Diet

Postoperative fluids are administered and then advanced as tolerated.

Activity

Patients should be instructed to wear polycarbonate 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.

Prevention

Eye protection with safety glasses should be considered while working with mechanical tools or playing sports. Contact sports may need to be deferred for months or permanently.

Long-Term Monitoring

Patients should be monitored long-term for the development of complications such as refractive errors, cataract, glaucoma, retinal tears, and retinal detachments. Children may develop amblyopia in the involved eye. Children may need glasses or contact lenses. Contact lenses have been shown to be effective for visual rehabilitation aid in children.[9]

Further Outpatient Care

Most patients with corneoscleral laceration are discharged home and are seen as outpatients at appropriate times as determined by the status of the eye.

Inpatient & Outpatient Medications

The author recommends oral antibiotics for 7-10 days, although no established controlled study supports this recommendation.

The author uses topical steroids, antibiotics, and cycloplegics for a few weeks. Depending on the intraocular pressure, topical antiglaucoma medication may be needed.

 

Medication

Medication Summary

Systemic antibiotics are routinely used for prophylaxis against infection. Endophthalmitis is uncommon but has a poor prognosis in the setting of ocular trauma. In one study, delayed repair, ruptured lens capsule, and dirty wound were each independently associated with the development of posttraumatic endophthalmitis. Antibiotics should cover both gram-positive and gram-negative organisms, including Bacillus, which is the most common cause of posttraumatic endophthalmitis.[10]

No controlled studies are available that show any benefits of systemic antibiotics.

Antibiotics

Class Summary

Therapy must cover all likely pathogens in the context of this clinical setting. Any of the fluoroquinolones may be used safely as ophthalmic drops.

Vancomycin (Vancoled, Vancocin, Lyphocin)

Provides excellent gram-positive coverage, including Bacillus. To avoid toxicity, current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dose. Use creatinine clearance to adjust dose in patients with renal impairment.

Ceftazidime (Tazidime, Fortaz, Ceptaz, Tazicef)

Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin binding proteins.

Gatifloxacin ophthalmic (Zymar)

Fourth-generation fluoroquinolone ophthalmic indicated for bacterial conjunctivitis. Elicits a dual mechanism of action by possessing an 8-methoxy group; thereby, inhibiting the enzymes DNA-gyrase and topoisomerase IV. DNA gyrase is involved in bacterial DNA replication, transcription, and repair. Topoisomerase IV is essential in chromosomal DNA partitioning during bacterial cell division.

Moxifloxacin ophthalmic (Vigamox)

Indicated to treat bacterial conjunctivitis. Elicits antimicrobial effects. Inhibits topoisomerase II (DNA gyrase) and IV enzymes. DNA gyrase is essential in bacterial DNA replication, transcription and repair. Topoisomerase IV plays a key role in chromosomal DNA portioning during bacterial cell division.

Carbonic anhydrase inhibitors

Class Summary

These agents are used to treat elevation of intraocular pressure associated with ocular injuries or inflammation. By slowing the formation of bicarbonate ions with subsequent reduction in sodium and fluid transport, it may inhibit the enzyme carbonic anhydrase in the ciliary processes of the eye. This effect decreases aqueous humor secretion, reducing intraocular pressure.

Acetazolamide (Diamox)

Inhibits enzyme carbonic anhydrase, reducing rate of aqueous humor formation, which, in turn, reduces intraocular pressure. Used for adjunctive treatment of chronic simple (open-angle) glaucoma and secondary glaucoma and preoperatively in acute angle-closure glaucoma when delay of surgery desired to lower intraocular pressure.

Anticholinergic agents

Class Summary

These are thought to work centrally by suppressing conduction in the vestibular cerebellar pathways. They may have an inhibitory effect on the parasympathetic nervous system.

Homatropine (AK-Homatropine, Isopto Homatropine)

Blocks responses of sphincter muscle of iris and muscle of ciliary body to cholinergic stimulation, producing pupillary dilation (mydriasis) and paralysis of accommodation (cycloplegia). Induces mydriasis in 10-30 min and cycloplegia in 30-90 min. These effects last up to 48 h.

Corticosteroids

Class Summary

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli. Corticosteroids may be used to reduce postoperative inflammation.

Dexamethasone ophthalmic (Ocu-Dex, AK-Dex, Alba-Dex, Baldex, Decadron)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.