Ординатура / Офтальмология / Учебные материалы / Ocular Traumatology Springer
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Fig. 2.2.8 Closure of the star-shaped wound. a The corneal wound from the surgeon’s view. b The initial suture is an intrastromal one in the center (top: surgeon’s view; bottom: cross-sec- tional view). The intrastromal suture is placed roughly at mid-depth. It is a permanent suture (i.e., never to be removed). c Enlarged view of b, top. d The intrastromal suture brought all wound edges together, and have created several individual wounds, which are now dealt with one at a time. This is done in a way determined by the location and length of the individual wounds (see earlier). These sutures are full thickness. Top: surgeon’s view; bottom: cross-sec- tional view
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Fig. 2.2.9 Closure of perpendicular vs oblique (shelved) wounds. a If the wound’s plane is close to vertical as it relates to the surface1, the needle’s entry and exit points should be at equal distance from the wound on both the epithelial and endothelial corneal surfaces (x1=y1) and (x2=y2). b If the wound’s plane is oblique, use of full-thickness sutures becomes especially crucial. The distances as measured for needle entry and exit relative to the edge of the wound need to be modified so as to create the same compression on either side. As shown, the epithelial distance on one side is matched up with the endothelial distance on the other side (x1=y2) and (x1=y2). This technique prevents tissue override, which is a permanent2 abnormality
1 Which is the majority of the cases
2 i.e., it does not disappear with suture removal
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Fig. 2.2.10 Closure of a complex, angled corneal wound. The wound that has two angles should be considered as three separate wounds. To achieve this, the single wound is first divided into three by placing the first two sutures at the angles (as in Fig. 2.2.5c). The two peri pheral wounds are closed then, and the central part last. The numbers represent the order of suture placement
Fig. 2.2.11 Closure of a small corneal wound. Closure is correct here in terms of suture length (longer in the periphery and shorter in the center); however, the knots still need to be buried, and leaving the tags too long makes this difficult. The tags may also cause additional problems once turned into the AC
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Fig. 2.2.12 Closure of a long corneal wound. A properly closed wound., note that the sutures are longer in the periphery and that scar formation is minimal (Courtesy of B. Hamill)
Fig. 2.2.13 Closure of a long corneal wound. A similarly long wound as in Fig. 2.2.11; however, the suture bites are arbitrary in terms of length, and introduction sequence is also presumed to have been haphazard. Suture placement was obviously not based on a carefully designed plan. Furthermore, the sutures are too tight, making the surface uneven (bulging wound edges). It will take a long time for this cornea to clear, and permanent visual impairment is inevitable
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Fig. 2.2.14 Corneal blood staining. This wound was closed with evenly spaced sutures, which appears esthetical but causes flattening. Nonetheless, closure technique in this case has relatively little significance. The cornea has become nontransparent due to blood staining; posterior segment surgery is impossible without using the TKP (see Chap. 2.15), making PK unavoidable1
1 Endoscopy is also an option (see Chap. 2.20), but it is doubtful that this cornea will escape the need for a PK.
Fig. 2.2.15 Scar formation following closure of a corneal wound. Although scarring cannot be avoided once the wound is deeper than the epithelium, it can be minimized by proper suturing techniques and the judicious use of corticosteroids postoperatively
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2.2.3.7Scar Management
If the scar is in the visual axis or causes major distortion of the cornea’s curvature, surgical intervention may be necessary to alleviate the undesirable consequences. Even deep scars may be treated with PTK [10]; otherwise, surgical excision, including PK, may be employed.
2.2.3.8Suture Removal
If full-thickness sutures have been used (Fig. 2.2.6b), certain precautions must be taken to prevent endophthalmitis development following suture removal.
Z
DO:
•master the techniques of examining the cornea at the slit lamp
•have increased concern for injuries with little or no pain
•be careful not to push a deep corneal FB into the AC by inappropriate removal techniques
•plan all aspects of wound closure before introducing any suture into the cornea
•make use of the benefits of full-thickness sutures
DON’T:
•hesitate to start a new therapy if on current management the corneal erosion keeps recurring
•neglect to consider all posttreatment eventualities (such as rubbing of the eye) when deciding whether to suture an apparently self-sealing partial-thickness laceration
•forget the need to prepare the eye as if it were undergoing an intraocular procedure when a full-thickness suture is to be removed
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Summary
The cornea is the most commonly injured ocular tissue. In most cases, pain is inversely proportional to significance. Full-thickness wounds are of major concern since they represent increased endophthalmitis and ECH risk. Improper treatment of the corneal injury can result in visual
impairment because of several factors ranging from an unnecessarily prominent scar to vitrectomy delayed too long because of undue corneal edema. Scleral and corneal wounds have very different implications; this is discussed in Chap. 2.11.
References
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2.3 Sclera and Limbus
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2.3.1Introduction
While playing only limited and indirect role in vision, the sclera is responsible for much of the globe’s strength and integrity. The proximity of the scleral “shell” to vital tissues such as the choroid, ciliary body, and the retina gives it significant clinical implications. Compared with most ocular tissues, the sclera has few pathologies. The limbus is one of the loci minoris resistantiae of the globe , which is further excerbated by the fact that it is often the site of elective surgical incisions.
2.3.2Evaluation
Through the usually transparent conjunctiva, it is typically possible to directly inspect the limbus and the anterior sclera with the naked eye, but especially at the slit lamp. Subconjunctival hemorrhage, among other pathologies, however, can interfere with direct inspection of the sclera, making it necessary to use radiological tests (most importantly, CT), ultrasonography, or even exploratory surgery (see Chap. 1.9).
e.g., an improperly sutured anterior scleral or limbal wound can cause significant astigmia
As is the area at the insertion of the extraocular muscles (see Chap. 2.12)