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Surgeon offers pointers for repairing anterior segment ruptured globes
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In the field of ophthalmic surgery, ocular trauma is inevitable. The surgeon should follow sound, time-tested principles in surgical repair to obtain the optimal outcome and offer possible sight-saving surgical procedures for the patient.
Globally, it has been estimated that there are about 55 million eye injuries each year; of these, about 750,000 cases require hospitalization, including about 200,000 open globe injuries. Secondary to trauma, about 19 million have unilateral blindness or low vision, 2.3 million have bilateral low vision, and 1.6 million are blind. Common product-related injuries vary with age. These include chemicals in children up to age 4 years, household items in children age 5 to 9 years, sports products in children and young adults age 10 to 24 years, cutting and construction tools in adults age 25 to 64 years, and chemicals in adults older than age 65 years.
In the U.S., work-related injuries contribute to accidental ocular trauma. Every day, more than 2,000 U.S. workers receive some type of medical treatment for work-related eye injuries. On a yearly basis, more than 800,000 such injuries occur in the U.S. Eighty percent of these workers are men. In 70% of cases, the trauma is secondary to equipment or an object, while about 30% of injuries are due to exposure to harmful substances or environments.
In this column, Dr. Rapuano describes his surgical approach to the management of ocular traumatic injuries and offers surgical pearls that can be useful for all ophthalmic surgeons.
Thomas “TJ” John, MD
OSN Surgical Maneuvers Editor
Christopher J.
Rapuano
When first examining a patient with a possible ruptured globe, make sure to obtain a history of the accident, including the mechanism of injury and whether eye protection was being used, especially to determine the likelihood of an intraocular foreign body (Figure 1). If an intraocular foreign body is suspected, there should be a low threshold for obtaining imaging, typically a CT scan with 1- to 2-mm axial and coronal cuts.
Once in the operating room, the eye should not be manipulated during the surgery prep because pressure on the globe increases the risk of extrusion of intraocular contents. Oftentimes, at the beginning of the surgery, fibrin or iris has plugged the rupture and the anterior chamber is formed, at least partially. I often find it helpful at this point to create a “useful” limbal paracentesis. Useful means it is located so the surgeon has comfortable access to it and it is angled toward abnormalities in the anterior chamber, such as iris to the wound. The paracentesis should be made before manipulating the wound because that often causes the anterior chamber to flatten, making formation of a paracentesis riskier. A paracentesis is helpful in reforming the anterior chamber without going through the laceration, which often causes iris prolapse. Additionally, a paracentesis allows the use of a cyclodialysis spatula to release peripheral anterior synechiae and remove iris from the wound.
Figure 1a. A full-thickness corneal laceration with some residual foreign body material was noted just superotemporally in this left eye.
Figure 1b. On retroillumination, an iris transillumination defect became much more apparent than in Figure 1a, indicating the possibility of an intraocular foreign body. There should be a low threshold to obtain appropriate imaging to rule out an intraocular foreign body. In this case, a CT scan revealed a small metallic foreign body in the vitreous, which was removed. Remarkably, it missed the lens, which remained clear postoperatively.
Images: Rapuano CJ
Figure 2a. A partial-thickness laceration was noted at the inferior limbus. It was Seidel negative with pressure; however, it was gaping. It is typically best to close these gaping lacerations because closure facilitates healing, decreases the risk of infection, decreases the degree of scarring and minimizes induced astigmatism.
Figure 2b. One day postoperatively, the wound was nicely closed with no gape using five 10-0 nylon sutures. As the laceration reached the limbus, a small conjunctival peritomy was performed to make sure it did not proceed under the conjunctiva and into the sclera, which it did not. The peritomy was closed with one 8-0 Vicryl suture.
Once the wound is explored to determine its configuration and extent, there is a tendency not to suture partial-thickness lacerations. I believe that if a partial-thickness laceration is approximating perfectly, then it is often fine to let it heal without suturing. However, if there is any gaping of the wound, which is almost always present with large partial-thickness lacerations, it is best to suture it closed. I feel this reduces the risk of infection, speeds healing and decreases the chances of significant postoperative irregular astigmatism (Figure 2).
If a corneal wound reaches the limbus and you cannot be certain it stops there, you should perform a conjunctival peritomy and explore the wound to make sure there is no posterior extension.
Wound closure and viscoelastic
When I work with residents and fellows repairing ruptured globes, I am frequently asked where to start the wound closure. I am not sure it matters a huge amount as long as the anatomy lines up as best as possible at the end of the case. Having said that, I find there are a few logical places to start. If the wound crosses the limbus, the first suture should be at the limbus, where there is a nice anatomical landmark to follow. If there is a “V” shape or shapes in the laceration, then sutures should first be placed at the apices of the “Vs” because here, too, the anatomy lines up nicely (Figure 3). If there are no good anatomical landmarks to follow, then I feel it is best to place the first suture in the middle of the laceration and then continue suturing by bisecting the largest unsutured areas until the laceration is sealed. I try to avoid placing sutures in the center of the visual axis. I also try to rotate knots away from the visual axis (Figure 4).
Figure 3. Five days after a triangular corneal laceration repair and lensectomy/vitrectomy. The laceration was so large and gaped, the cataract was removed through the laceration. Then the wound was sutured, starting with the two sutures at the apex of the wound and then proceeding with bisecting the sides in a numbered fashion, as illustrated.
Figure 4a. A large metallic foreign body was noted to be embedded deep in this cornea. Due to its size and depth, it was elected to remove it in the operating room. When it was removed, there was a significant amount of residual rust. As much rust as possible was removed in the operating room. While it was not a full-thickness laceration, there was significant wound gape centrally, so it was thought best to suture the laceration closed.
Figure 4b. One week postoperatively, the wound was nicely opposed with two 10-0 nylon sutures. Note the knots are buried away from the visual axis.
Figure 4c. Ten years postoperatively, a mild central scar with essentially no residual rust remained with minimal corneal irregularity. The patient’s vision was 20/25 with a mild hyperopic astigmatism correction (similar to the fellow eye).
While viscoelastic material is extremely useful in the majority of anterior segment surgeries we perform, I do not think that is the case in most anterior segment ruptured globe repairs. I rarely use it when repairing ruptured globes because it does not help close the wound, and once the wound is closed, it is not needed to reform the anterior chamber. If it gets behind the iris, it actually causes more iris prolapse than it was intended to help. It can also make a leaking wound appear to be closed, leading to a false sense of security, only to leak 1 to 2 days postoperatively. And lastly, it is very difficult to remove at the end of surgery, resulting in a high risk of extremely elevated IOP on postop day 1.
A damaged lens
The lens can be damaged from ocular trauma. The question often arises as to whether to remove the opacified lens at the time of ruptured globe repair or leave it alone and remove it at a later date. My rule of thumb is, if you are not certain there is a cataract, then leave it alone. Frequently, fibrin over the lens makes it appear to be a white cataract, only to resolve postoperatively, leaving a clear lens. If there is a rent in the anterior capsule but the lens is in good position, there is no cortex fluffing up into the anterior chamber, and the anterior chamber is deep, consider leaving the lens alone for now (Figure 5). If the lens is severely damaged, the cortex is fluffing up into the anterior chamber, or the anterior chamber remains shallow after the laceration is repaired, it should probably be removed at the time of laceration repair.
Figure 5a. A small full-thickness corneal laceration with iris prolapse was noted inferotemporally in this right eye. A small rent was seen in the anterior lens capsule with a sector cataract. Because there was no cortical material coming through the rent and the lens was not bulging the iris forward, it was decided to leave the lens at the time of laceration repair.
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Reasons to delay cataract removal when appropriate include the difficulty in removing cataract at the time of ruptured globe repair due to poor visualization from corneal edema and irregular astigmatism, which increases the risk of untoward events during lens removal. Other reasons include the challenges of placing an IOL at the time of lens removal, such as the difficulty in obtaining accurate IOL calculations and the theoretical increased risk of endophthalmitis. If the cataract needs to be removed at the time of ruptured globe repair, then the corneal/corneoscleral laceration should be repaired first, a separate limbal incision made and the cataract removed in a standard fashion. Be prepared to perform an anterior vitrectomy.
Repairing a ruptured globe may not be what you want to do at 11 p.m. on a Friday, but these cases can be very interesting for the surgeon and vision saving for the patient. They are challenging in that they require the surgeon to use a variety of surgical maneuvers and techniques and to think on his/her feet because no two cases are identical. They can also be quite rewarding, taking an eye that looks like a jigsaw puzzle and putting it back together.
References:
Bi H, et al. Curr Ther Res Clin Exp. 2013;doi:10.1016/j.curtheres.2012.10.002. Chen AJ, et al. R I Med J. 2014;97(1)44-48.Négrel AD, et al. Ophthalmic Epidemiol. 1998;5(3):143-169.
For more information:
Christopher J. Rapuano, MD, can be reached at Wills Eye Hospital, 840 Walnut St., Suite 920, Philadelphia, PA 19107; 215-928-3180; email: cjrapuano@willseye.org.Edited by Thomas “TJ” John, MD, a clinical associate professor at Loyola University at Chicago and in private practice in Oak Brook, Tinley Park and Oak Lawn, Ill. He can be reached at 708-429-2223; fax: 708-429-2226; email: tjcornea@gmail.com.
Disclosure: No products or companies that would require financial disclosure are mentioned in this article.