Surgical Techniques in the Management of Perforating Injuries of the Globe

Yoshihiro Yonekawa, MD; James Chodosh, MD, MPH; Dean Eliott, MD

Disclosures

Int Ophthalmol Clin. 2013;53(4):127-137. 

In This Article

Primary Repair

Goals

The goals of primary repair are to (1) repair the wound in a watertight manner to restore globe integrity and normal intraocular pressure, (2) remove contaminated and nonviable tissue, (3) remove foreign bodies, (4) reposit viable tissue to restore original anatomy, especially uvea and retina, and (5) avoid iatrogenic damage. Attempts at repairing the globe should always be made, unless there are clear indications for enucleation, which include eyes with insufficient tissue for repair and severely injured eyes without recognizable anatomy.[13]

Timing

The primary repair should be performed as soon as reasonably possible to increase the chances of anatomic and functional recovery, and to prevent endophthalmitis.[14,15] Perforating injuries always have a posterior segment component, but vitreoretinal intervention can be delayed and performed as a staged procedure. Vitreoretinal surgery during the primary repair may be considered in rare instances when the patient with a perforating ocular injury initially presents to a vitreoretinal surgeon. However, as discussed below, there are benefits in delaying posterior segment surgery for 1 to 2 weeks.

Surgical Techniques

The first step is to determine the full extent of the injury. A 360-degree peritomy and muscle isolation should be performed for any perforated globe. All foreign bodies are removed and obviously contaminated tissues excised. The wounds are then closed using nonabsorbable sutures. Interrupted 10–0 nylon sutures are used for corneal wounds, 9–0 for limbal wounds, and 7–0 or 8–0 for scleral wounds. Corneal wound suturing techniques are discussed in another review in this issue.

Uvea should be reposited unless it is obviously contaminated. For iris prolapse through the cornea, rather than directly pushing the tissue back into the wound, we recommend creating a paracentesis wound 90 degrees away to introduce a cyclodialysis spatula to sweep the iris back inside. This maneuver is best performed when the eye is pressurized after several sutures are placed. When iris has been prolapsed through the cornea for more than several hours, it may become covered in corneal epithelium. If present, this should be gently removed before repositing.

Scleral wounds are usually closed from anterior to posterior, because unlike corneal wounds, scleral wounds often begin anteriorly and extend posterior to an unknown extent.[16] Spatulated needles should be used with good wound apposition and removal of tissue incarceration to avoid subsequent fibrous ingrowth. Muscle hooks can be used to elevate the recti if wounds are located underneath extraocular muscles. In rare instances, the rectus muscle may be secured with 6–0 Vicryl and removed from the sclera. The muscle is reattached to its original location after the wound is repaired. Uvea is often prolapsed through scleral wounds, and the assistant can reposit the tissue while the sutures are being placed. Vitreous prolapse should be cut manually using sharp Wescott scissors flush to the sclera. Vitrectomy instruments should not be placed through the wound into the eye to avoid retinal damage. If retina is identified prolapsing from the wound, all efforts should be made to preserve its integrity, and to reposit it without incarceration.

Perforating injuries often have posterior exit wounds that are difficult to expose. Heroic measures to close these wounds are not necessary. Orbital contents are usually able to exert enough pressure for the wound to close spontaneously, as seen in Topping's animal model by day 7.[9] Blindly attempting to suture in the vicinities of the macula and optic nerve is not recommended. Furthermore, torquing and compressing the globe for exposure can result in intraocular hemorrhage, wound dehiscence, or prolapse of intraocular contents. The wound can be closed anteriorly, and then closed posteriorly for a reasonable distance until the benefits of further closure become negligible.

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