Open Globe Management

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

Disclosures

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

In This Article

Scleral Injuries

Scleral rupture sometimes can be occult, and careful assessment of the patient is essential in determining the need for globe exploration. Findings associated with occult scleral rupture include poor visual acuity, chemosis, 360-degree subconjunctival hemorrhage, hyphema, IOP < 10 mmHg, peaked pupil, and increased AC depth. In these settings, globe exploration should be considered (Figure 4).

Scleral wounds are closed from anterior to posterior, beginning at a recognizable landmark. Most of the scleral lacerations can be closed using 8.0 or 9.0 nylon, silk, or Dacron® (Invista, Wichita, KS), with interrupted sutures, passing through the deep sclera and avoiding damage to the underlying choroid. Prolapsed uveal tissue is gently reposited to avoid incarceration in the wound. If vitreous is present, it should be amputated at the scleral surface. Prolapsed retinal tissue is gently reposited if possible. If the scleral wound extends under the insertion of a rectus muscle, disinsertion of the muscle may be necessary. If the wound is extending posterior to the equator and cannot be safely visualized, the best treatment may be to leave the posterior portion unsutured. Sometimes, scleral defects cannot be closed primarily, especially in the setting of scleral thinning (infection, inflammation, or high myopia). Various types of graft material (sclera, dura, fascia lata, periosteum, etc.) can be used, and selecting the right material can be critical to the success of the scleral patch. Homologous sclera is usually used for large defects. Small and moderate defects, requiring minimal structural support, can be repaired with conjunctiva/Tenon capsule and tarsoconjunctival flap. Small to large defects requiring support can be repaired with autologous sclera, fascia lata, or periosteum. Split-thickness dermal graft can be employed for severe ocular surface disruption.

Open globe trauma involving the posterior segment can be associated with vitreous hemorrhage and/or retinal detachment. Rhegmatogenous retinal detachments rarely present acutely but tend to occur weeks to months following the injury; they are more often associated with progressive intraocular proliferation and traction. This series of events following open globe injury was eloquently described by Ryan and Cleary in their animal models.[31] The human situation appears to follow an analogous series of events in clinical and pathologic series.

Most ophthalmologists now agree that vitrectomy is indicated for traumatic open globe injuries with retinal detachment on presentation and for perforating ocular injuries (through-and-through injuries). Controversies still exist on the timing of vitrectomy and the role of vitrectomy in open globe injuries with vitreous hemorrhage but no retinal detachment.

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