corneal laceration

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Corneal laceration. Alireza Peyman, MD. Surgical repair. The primary goal is to achieve a watertight globe and maintain structural integrity . Secondary goals include: removing any disrupted lens fragments and vitreous repositioning any uveal tissue - PowerPoint PPT Presentation

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Corneal laceration

Corneal lacerationAlireza Peyman, MDSurgical repairThe primary goal is to achieve a watertight globe and maintain structural integrity.

Secondary goals include: removing any disrupted lens fragments and vitreousrepositioning any uveal tissuerelieving vitreous incarcerationremoving any intraocular foreign bodiesrestoring normal anatomic relationships

Partial-Thickness Corneal LacerationsMust be examined carefully to rule out any rupture of Descemet

Seidel testing

Modified Seidel testing

If the wound edges are in good apposition with no wound gape, pressure patching with the use of prophylactic topical antibiotics is sufficient.If the wound is unstable, a bandage soft contact lens may be used to support the wound

Partial thickness laceration with gapeSutures may be used to re-approximate the wound margins.

In these settings, properly placed sutures will minimize scarring and perturbation of the ultimate surface corneal topographyFull-Thickness Corneal LacerationsBANDAGE SOFT CONTACT LENSFor small, self-sealing corneal perforations, a bandage contact lens may be sufficient

Such lacerations include nondisplaced, beveled, self-sealing wounds.

If aqueous leakage persists for more than 24 hours or there is progressive shallowing of the anterior chamber, more definitive treatment should be undertakenIn cases that respond satisfactorily, the contact lens should be kept in place until the wound has stabilized (usually 36 weeks).

A protective shield should be worn at all times.

Topical antibiotic prophylaxis and cycloplegia are recommended with the lens in place.

TISSUE ADHESIVE.Tissue adhesive may be useful for puncture wounds with small amounts of central tissue loss and selected small lacerations. It is not routinely utilized.

SUTURE REPAIR OF SIMPLE CORNEAL LACERATIONSThe primary goal of corneal suturing is to achieve a watertight wound.

Secondary goals include minimizing scarringrestoring normal anatomic relationshipsreconstructing the normal corneal topographic contoursFor a wound that is less stable, a viscoelastic may be irrigated into the anterior chamber either directly through the wound itself or through a separate limbal paracentesis incisionvisco through the wound or through a paracentesis incision will help

To form the chamber:Balanced salt solution or air may also be used to re-form the anterior chamber.

In most cases, a limbal paracentesis with a A 15-degree sharp microsurgical knife is preferred because it will minimize disruption of the wound edges and permit better access as the case proceedsTemporary suturesTemporary sutures may be used if the initial placement of deep definitive sutures would cause loss/flattening of the anterior chamber.

The number of temporary sutures should be minimized, however, to prevent undue trauma to the wound marginsTechnique and materialFor corneal suturing, 10-0 monofilament nylon on a fine spatula-design microsurgical needle is used.

The simplest method is to progressively halve the wound with simple interrupted sutures.Corneal sutures should be 90% to 95% depth through the stroma 1.5 mm in lengthof equal depth on each side

Shallow sutures create internal wound gape, whereas sutures of unequal length and depth on each side of the wound result in wound override.Deep suture placement equidistant from the wound margins gives excellent wound approximation

Shallow sutures create internal wound gape

Full-thickness sutures may create a conduit for microbial invasion

Sutures of unequal depth create wound override.

Sutures of unequal length create wound override

For shelved lacerations, sutures should be placed equidistant with respect to the internal aspect of the wound to achieve good wound apposition

Making the suture bites close to the visual axis short

no-touch technique

When using a running suture for a nonlinear laceration, the suture should be placed with respect to a straight regression line

Suture knot burial

STELLATE CORNEAL LACERATIONSBridging sutures

Purse-string suture

multiple interrupted sutures and tissue adhesive or patch graft

CORNEAL LACERATIONS WITH UVEAL PROLAPSE.Iris incarceration A peaked pupil signals tissue incarceration

Macerated, feathery, devitalized, or depigmented iris should be excised

The prolapsed tissue should be evaluated for any signs of surface epithelialization. In this case, it should be excised to prevent any epithelial cells from proliferating in the anterior chamberIn general, tissue that has been prolapsed for longer than 24 hours should be excised to avoid infection;

however, if the tissue appears healthy, it may be replaced with caution.RepositioningPharmacologicalMidriaticsMyiotics

Mechanicalsimply deepeningViscoelastics through the paracentesis or the wounda spatula or irrigating canula may be passed through the paracentesis site and used to directly sweep incarcerated tissue

CORNEAL LACERATIONS WITH LENS OR VITREOUS INVOLVEMENTPrimary removal of the lens Disrupted capsule and flocculent cortical material liberated into the anterior chamber.

In cases in which vitreous is involved with lens remnants, this may be best addressed in the initial surgery.

When it is clear that a lens is cataractous and surgical visualization is good, the lens may be removed in the primary operation.

Vitreous strands are swept into the anterior chamber

CORNEOSCLERAL LACERATIONSFor large lacerations with structural deformation, sutures should be placed to restore wound integrity before rigorous exploration of the globe

Initially, the limbus should be reapproximated with 8-0 or 9-0 nonabsorbable nylon or silk sutures.it is important to clear the wound of any prolapsed or incarcerated vitreous with dry cellulose sponges and cutoptions in selecting suture material for scleral closureSome surgeons prefer nonabsorbable sutures

Others may use absorbable materials

For larger defects, nonabsorbable sutures should be used

closing sclera over prolapsed uveaMost easily closed from the anterior (limbal) end zippering or close-as-you-go technique.

sutures are placed in close proximity to one another in an attempt to achieve oversewing of the uveal tissue with the sclera.Posterior extentionscleral lacerations may extend far posteriorly, and may not be accessible.

In these situations, it is preferable to leave the most posterior portion of the wound unsutured The sclera is thinnest behind the muscle insertions; thus, careful exploration of these areas is crucial

ANTERIOR SEGMENT FOREIGN BODIESFBsMetalicVegetable matterGlassPlasticStonesOther materials Typically, the foreign body is small and the eye may not show obvious signs of trauma

Foreign bodies frequently lodge in the anterior chamber angle and may display overlying focal corneal edema.

Gonioscopy may be useful in detecting the foreign body

may also embed themselves in the lens and may create a focal cataract. Iris transillumination defects may signal an entry site.ImagingPlain graphies

CT

MRI

B-scan sonography

UBMRemovalThrough an incision directly overlying

From a limbal incision across the anterior chamber

Post-op managementMedical therapyTo control infection

To suppress inflammation

To stabilize the ocular surfaceAntibioticsSub-conjunctivalIntra-opIntra-vitrealIntra-opIVVanco or cephalosporine+AGTopicalFortified, or 4th generation flouroquinolonesOralAfter dischargeClindamycin should be considered in cases involving vegetable matter to cover Bacillus species.

Top: 50mg/mlSubconj: 50mg/0.5mlIntravitreal: 1mg/0.1mlCorticosteroidsTo minimize scarring and new vessel ingrowth

The anti-inflammatory advantages against the risk of infection

May also diminish the rate of stromal healing as well as the tensile strength of the wound

Corticosteroid use should be kept at a minimum in the early postoperative periodOthers Topical -blockers

Carbonic anhydrase inhibitors

Lubricants

Bandage contact lenses

Patching

TarsorrhaphyThank you for your attention