Open Globe Management

Alessandro A. Castellarin, MD; Dante J. Pieramici, MD

Disclosures

Compr Ophthalmol Update. 2007;8(5):111-124. 

In This Article

Injuries Involving the Cornea

The most important questions in determining the management options of injuries involving the cornea are: Is there partial- or full-thickness corneal wound? Is the corneal laceration/discontinuity self-sealing with a reasonably normal IOP, or is it actively leaking? Are there other conditions present that would require surgical repair of an otherwise selfsealed wound?

For a small (< 2 mm) self-sealing laceration of the cornea, only topical antibiotics and close observation are required. For larger self-sealing lacerations, a bandage contact lens can be employed. Suturing may be appropriate in the presence of larger self-sealing wounds, particularly in cases with significant refractive implications. Full-thickness, non-selfsealing corneal lacerations require repair in the operating room with 10- 0 or 11-0 nylon sutures. Saline, viscoelastics, and air may all be used to maintain the AC during the repair. A separate paracentesis or the wound itself can be used as a port. A spatulashaped cutting needle should be employed, and the sutures should be perpendicular to the line of the laceration. The depth of the sutures should be 90% of full thickness, and the needle should pass over Descemet’s membrane. Sutures should not be placed on the visual axis if possible. Stellate lacerations are the most difficult to close; they may require a combination of sutures and tissue adhesive, and sometimes, a patch graft may be required. A pursestring technique has been proposed by Eisner.[22] In some cases, the additional use of cyanoacrylic glue can be helpful. Tissue adhesive may be applied at the slit lamp or in the operating room. Gluing should be avoided in cases of flat chamber, and when the laceration involves the sclera. Before applying the cyanoacrylate, 1 or 2 mm of surrounding epithelium should be removed to prevent sloughing of the glue.[23]

Areas of tissue loss, if > 5 mm in diameter, are usually repaired with corneal patch grafts. Full-thickness patch graft is technically easier to perform but requires a donor cornea. A lamellar patch graft is effective and may be performed with a corneal autograft or donor sclera. These grafts are often located outside of the visual axis; therefore, graft clarity may not be essential for good postoperative vision.

Widespread use of refractive surgery and laser-assisted in situ keratomileusis (LASIK) procedures has created new types of corneal injuries following ocular trauma. Laser-assisted in situ keratomileusis corneal flaps are vulnerable to traumatic dehiscence and dislocation, which can occur more than 2 years after the LASIK procedure. Partially displaced flaps following corneal injuries should be managed with a bandage soft contact lens, as sutures will induce astigmatism. A completely displaced flap can be repositioned and secured with sutures. Laserassisted in situ keratomileusis flaps may experience mechanical dislocation as late as 7 years postoperatively. Diffuse lamellar keratitis and epithelial ingrowth are associated with flap dislodgment.[24] The use of fibrin glue in conjunction with thorough debridement intensive steroid regimen may be helpful in preventing the recurrence of epithelial ingrowth.[24,25] Management of these injuries often requires the consultation of a refractive surgeon.

The incidence of tissue prolapse has been estimated to occur in approximately 42% of open globe injuries.[26] Tissue incarceration can plug the wound, re-establishing the IOP, tamponading the bleeding, and preserving the normal anatomy. Prolapsed iris is usually excised if necrotic, or contaminated. It is repositioned if viable, free from epithelial overgrowth and free from bacterial contamination. Prior to repositioning, topical antibiotics should be employed to prevent infection. The repositioning technique entails gentle sweeping with a spatula through a paracentesis and the use of viscoelastic, miotics (if the peripheral iris is entrapped), or mydriatics (if the central iris is involved). Sometimes, careful dissection using forceps may be necessary if there is presence of fibrin or scar tissue.

Plastic and glass foreign bodies tend to be well-tolerated and can be left in the AC if they are immobile, long-standing, and not associated with intraocular infection. Intralenticular foreign bodies can also be observed; however, metallic foreign bodies rarely can cause siderosis.[27] Intraocular cilia can also be welltolerated. Iron and copper foreign bodies should be removed from the AC to prevent toxicity.

Lens extraction is usually delayed until anterior segment inflammation is under control and until there is adequate visualization of the lens. Simultaneous lens removal combined with laceration repair may be advisable in case of anterior capsule disruption with liberation of lens material. There are certain advantages to primary cataract removal, such as the elimination of the source of inflammation and IOP elevation. In addition, it allows visualization of the posterior pole and early rehabilitation of the patient.

In the case of an intact posterior lens capsule and no vitreous prolapse, or in the case of a small posterior capsule lesion and no vitreous prolapse, careful phacoemulsification can be employed with the help of viscoelastics. In the case of a large posterior lens capsule lesion and no prolapse or with vitreous prolapse, vitrectomy should be considered with pars plana lens removal.

Following closure of the cornea laceration, cataract extraction may be performed with an anterior or posterior approach. When phacoemulsification is chosen, predominant aspiration and low power may be used, because traumatic cataracts tend to occur in young patients who have soft lenses. Every effort should be made to preserve the posterior capsule, the anterior capsule in case of lensectomy, and the capsule’s zonular support. If there is a high risk of developing anterior PVR, both anterior and posterior capsule removal is considered but is not always necessary.

Primary intraocular lens (IOL) implantation remains controversial. Several authors have shown that combined cataract extraction, vitrectomy, and IOL implantation with either pars plana lensectomy or anterior segment techniques can result in good visual outcomes for patients with a variety of trauma-induced conditions. It is preferable to use a posterior chamber IOL in the bag, or in the sulcus or sulcus-fixated. Irisfixated or anterior chamber IOLs can also be used. Intraocular lens calculations in the acute traumatic settings are usually derived from the contralateral eye.[28,29] However, there are numerous potential risks associated with primary IOL implantation, such as fibrinoid uveitis, papillary capture, synechia, lens subluxation, and the placement of an inaccurately measured IOL. It can also affect the visualization of the posterior pole if vitrectomy is needed in the future. Concurrent irregular corneal astigmatism resulting from the corneal wound and repair may necessitate the use of a hard contact lens postoperatively, bringing to question the need for an IOL in such situations.[30] Primary IOLs should be considered in patients under 8 years of age for amblyopia prevention. In such cases, aggressive postoperative amblyopia management is undertaken with patching as necessary.

Corneal lacerations may extend beyond the limbus and into the sclera (Figure 3). Careful exploration under the operating microscope to delineate the lacerations’ full extent is necessary. When possible, the limbus is approximated first to restore normal anatomic relationships using 8-0 or 9-0 nylon sutures.

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