first 24–48 hours for pain relief in selected patients. However, these agents should be used with caution, as they can cause local toxicity. In addition, oral pain management for the first 24–48 hours can be helpful for many patients. Alternatively, a therapeutic contact lens in conjunction with antibiotic prophylaxis is also very effective, but this should be administered by eye-care professionals and reserved for patients being closely observed. Abrasions caused by organic material require close follow-up to monitor for infection.

Patients with contact lens–associated epithelial defects due to excessive wear or an improper fit should never be patched or have a therapeutic contact lens applied because of the chance of promoting or worsening a corneal infection. These patients should be treated with topical antibiotic drops or ointment. Patients with abrasions caused by contact with a fingernail or the edge of a piece of paper are more prone to developing recurrent erosions. Thus, antibiotic ointment should be used nightly for at least 1 month or longer after the abrasion has healed. See Chapter 3 for further discussion on recurrent erosions.

Perforating Trauma

It is important to differentiate a penetrating wound from a perforating wound. A penetrating wound passes into a structure; a perforating wound passes through a structure. For example, an object that passes through the cornea and lodges in the anterior chamber perforates the cornea but penetrates the eye.

Evaluation

History

If a patient presents with both eye and systemic trauma, diagnosis and treatment of any lifethreatening injury take precedence over evaluation and management of the ophthalmic injury. Once the patient is medically stable, the ophthalmologist should elicit a complete presurgical history. Even though the diagnosis of perforating injury in many cases may be obvious from casual eye examination, a detailed history of the nature of the injury should include questions about factors known to predispose to ocular penetration so that this diagnosis will not be overlooked in more subtle cases. Such factors include

metal-on-metal strike high-velocity projectile high-energy impact on globe sharp injuring object

lack of eye protection

Examination

Evaluation of a patient with suspected perforating injury to the eye should include a complete general and ophthalmic examination. As soon as possible, the examiner should determine visual acuity, which is the most reliable predictor of final visual outcome in traumatized eyes, and perform a pupillary examination to detect the presence of an afferent pupillary defect (including a reverse Marcus Gunn response). Busy emergency department staff may omit these “ocular vital signs”; therefore, it is incumbent on the ophthalmologist to check both visual acuity and pupils, as well as educate

nonophthalmologic practitioners about the importance of these assessments. The ophthalmologist should then look for key signs that are suggestive or diagnostic of penetrating/perforating ocular injury (Table 13-5).

Table 13-5

If a significant perforating injury is suspected, forced duction testing, gonioscopy, tonometry, and scleral depression should be avoided. Ancillary tests that may be useful in this setting are summarized in Table 13-6. Regardless of the results of laboratory tests, all cases should be managed with safeguards appropriate for patients known to have bloodborne infections.

Table 13-6

Management

Preoperative management

If surgical repair is required, the timing of the operation is crucial. Although studies have not documented any disadvantage in delaying the repair of an open globe for up to 36 hours, intervention ideally should occur as soon as possible. Prompt repair can help minimize numerous complications, including

pain

prolapse of intraocular structures suprachoroidal hemorrhage microbial contamination of the wound

proliferation of the microbes projected into the eye migration of epithelium into the wound intraocular inflammation

lens opacity

The following temporizing measures can be taken during the preoperative period:

Apply a protective shield.

Avoid administering topical medications or other interventions that require prying open the eyelids.

Keep the patient on NPO status.

Provide appropriate medications for sedation and pain control, as well as antiemetics. Initiate intravenous antibiotics.

Provide tetanus prophylaxis. Seek anesthesia consultation.

Injuries associated with soil contamination and/or retained intraocular foreign bodies require attention to the risk of Bacillus endophthalmitis. Because this organism can destroy the eye within 24 hours, intravenous and/or intravitreal therapy with an antibiotic effective against Bacillus species, usually fluoroquinolones (such as levofloxacin, moxifloxacin, gatifloxacin), clindamycin, or vancomycin, should be considered. Surgical repair should be undertaken with minimal delay in cases at risk for contamination with this organism.

Nonsurgical options

Some penetrating injuries are so minimal that they spontaneously seal before ophthalmic examination, with no intraocular damage, prolapse, or adherence. These cases may require only systemic and/or topical antibiotic therapy along with close observation. If a corneal wound is leaking (see Chapter 2, Fig 2-6), but the chamber remains formed, the clinician can attempt to stop the leak with the following interventions, used in combination or alone: pharmacologic suppression of aqueous production (topical [eg, β-blocker] or systemic), patching, a therapeutic contact lens, or tissue adhesive. Generally, if these measures fail to seal the wound in 2 days, surgical closure with sutures is recommended.

Surgical repair

The management of a typical corneoscleral laceration with uveal prolapse generally requires surgery (Fig 13-14). The primary goal of initial surgical repair of a corneoscleral laceration is to restore the integrity of the globe. The secondary goal, which may be accomplished at the time of the primary repair or during subsequent procedures, is to restore vision through repair of both external and internal damage to the eye.

Figure 13-14 Scleral laceration with prolapse of uveal tissue secondary to blunt trauma.

If the prognosis for vision in the injured eye is hopeless and the patient is at risk for sympathetic ophthalmia, enucleation must be considered. Primary enucleation should be performed only for an injury so devastating that restoration of the anatomy is impossible, when it may spare the patient another procedure. In the overwhelming majority of cases, however, the advantages of delaying enucleation for a few days far outweigh any advantage of primary enucleation. This delay (which should not exceed the 12–14 days thought necessary for an injured eye to incite sympathetic ophthalmia) allows for assessment of postoperative visual function, vitreoretinal or ophthalmic plastic consultation, and stabilization of the patient’s medical condition. Most important, delay in enucleation following unsuccessful repair and loss of light perception allows the patient time to acknowledge that loss and accompanying disfigurement and to consider enucleation in a nonemergency setting.

Castiblanco CP, Adelman RA. Sympathetic ophthalmia. Graefes Arch Clin Exp Ophthalmol. 2009;247(3):289–302.

Anesthesia General anesthesia is almost always required for repair of an open globe because retrobulbar or peribulbar anesthetic injection increases orbital pressure, which may cause or exacerbate the extrusion of intraocular contents. Local or topical anesthesia may be considered for the repair in rare instances, such as for a patient who is at medical risk from general anesthesia and has a small, self-sealing laceration. After the surgical repair is complete, a periocular anesthetic injection may be used to control postoperative pain.

Steps in the repair of a corneoscleral laceration All attempts at repairing a corneoscleral laceration should be performed in the operating room. Repair of adnexal injury should follow repair of the globe itself because eyelid surgery can put pressure on an open globe and certain eyelid lacerations may actually improve globe exposure.

The corneal component of the injury is approached first. If vitreous or lens fragments have prolapsed through the wound, these should be cut flush with the cornea, taking care not to exert traction on the vitreous or zonular fibers. If uvea or retina (seen as translucent, tan tissue with extremely fine vessels) protrudes, the surgeon should reposit it using a gentle sweeping technique through a separate limbal incision, with the assistance of viscoelastic injection to temporarily re-form the anterior chamber (Fig 13-15). If epithelium has obviously migrated onto a uveal surface or into the wound, an effort should be made to peel this tissue off. Only in cases of frankly necrotic uveal prolapse should uveal tissue be excised.

the wound. Despite these efforts, uvea may still remain apposed to the posterior corneal surface. Many surgeons place very shallow sutures at this stage of the closure to avoid impaling uvea with the suture needle. Then, after the closure is watertight, the uvea can be definitively separated from the cornea with viscoelastic injection, followed by replacement of shallow sutures with new ones of ideal, near-full-thickness depth. Suture knots should be buried in the corneal stroma, not in the wound.

If watertight closure of the wound proves difficult to achieve because of unusual laceration configuration or loss of tissue, X-shaped or “purse-string” sutures or other customized techniques may suffice. Cyanoacrylate glue or even primary lamellar keratoplasty may be required in extremely difficult cases. A conjunctival flap should not be used to treat a wound leak.

When the anatomy of the wound allows, specific suturing techniques are used to promote restoration of the normal corneal contour. Wider-spaced, longer sutures are used in the peripheral cornea to flatten locally and steepen centrally. Closer, shorter sutures are used centrally, avoiding the visual axis, to close the wound without excessive flattening (Fig 13-16); however, care should be taken that sutures are long enough to minimize their “cheese wiring” through the inflamed stroma.

Figure 13-16 Restoring functional architecture in corneal wound closure. A, Laceration has a flattening effect on the cornea. B, Long, compressive sutures are taken in the periphery to flatten the peripheral cornea and steepen the central cornea. Subsequently, short, minimally compressive sutures are taken in the steepened central cornea to preserve sphericity despite

the flattening effect of the sutures. (Reproduced with permission from Hamill MB. Repair of the traumatized anterior segment. Focal Points: Clinical Modules for Ophthalmologists. San Francisco: American Academy of Ophthalmology; 1992, module 1.)

The scleral component of the laceration is then approached with gentle peritomy and conjunctival separation only as necessary to expose the wound. Prolapsed vitreous is excised, and prolapsed nonnecrotic uvea and retina are reposited with a spatula or similar instrument (Fig 13-17). The scleral wound is closed with 9-0 nylon or 8-0 silk sutures. Often, dissection of Tenon capsule and management of prolapsed tissue must be repeated incrementally after each suture is placed.

Figure 13-17 Zippering technique of scleral wound closure. Assistant depresses prolapsed uveal tissue while the scleral wound is progressively closed, moving in an anterior to posterior direction.

Management of corneoscleral lacerations. In: Hersh PS, Shingleton BJ, Kenyon KR, eds. Eye Trauma. St Louis: Mosby Year Book; 1991.)

Some posterior wounds are more easily approached with loupes and a headlight, because the open globe should not be rotated too far. If the laceration extends under an extraocular muscle, the muscle may be carefully removed at its insertion and reinserted following repair. No attempt should be made to fixate an open globe with rectus muscle sutures, as is sometimes done in retinal surgery, because doing so would put undue pressure on the eye and could exacerbate the extrusion of intraocular structures. Closure of the laceration should continue posteriorly only to the point at which it becomes technically difficult or requires undue pressure on the globe. Very posterior lacerations benefit from effective physiologic tamponade by orbital tissue and are best left alone.

Once the globe is watertight, a decision must be made whether intraocular surgery (if necessary) should be attempted immediately or postponed.

Deciding whether to pursue such intervention at the time of initial repair is a complex process. The expertise of the surgeon; the quality of the facility, technical equipment, and instruments; the adequacy of the view of the anterior segment structures; and issues of informed consent should be considered. In general, it is recommended that if there are concerns regarding any of these parameters, the surgeon complete the closure of the laceration to maintain globe integrity, and postpone the secondary procedures until a later date. For example, the average anterior segment surgeon should not attempt automated vitrectomy with retina present in the anterior chamber, and even the most expert cataract surgeon might not attempt a lens extraction with limited visualization of the lens. However, intraocular inflammation may worsen, opportunity for placement of an IOL in the capsular bag may be lost, vitreoretinal complications may worsen, and the patient may experience increased pain and expense if these procedures are delayed.

As always, the welfare of the patient should determine the proper course. In general, if a foreign body is visible in the anterior segment and can be grasped, it is reasonable to remove it, either through the wound or through a separate limbal incision. If removal of opacified lens material is attempted, it is helpful to know whether the posterior capsule has been violated and lens–vitreous admixture has occurred. BCSC Section 11, Lens and Cataract, also discusses the issues of cataract surgery and IOL placement following trauma to the eye.

Iris repair can be undertaken either primarily or secondarily. Closure of iris lacerations may keep the iris in its proper plane, decreasing the formation of anterior or posterior synechiae. The McCannel technique, using 10-0 polypropylene suture with long needles that may be passed transcamerally, requires only a small additional limbal incision (Fig 13-18). Iridodialysis, usually resulting from blunt trauma, may cause monocular diplopia and an eccentric pupil if left untreated. The McCannel technique can also be used to repair an iridodialysis (Fig 13-19). In the event that corneal opacity prevents safe repair of internal ocular injury, repairs can be combined later with penetrating keratoplasty or with placement of a temporary keratoprosthesis, if posterior segment repair is planned.