Trauma

63

518

63 Trauma

Table 63.1 The timing of surgery for the injured eye

Variablea

Comment

Child/elderly patient

In general, the earlier the better

Endophthalmitis,

Emergency surgery is needed: wound closure and PPV in the same

high risk

session. With certain organismsb, the time from Òno symptomÓ to

a fulminant, retina-destroying infection may be only a few hours

Endophthalmitis,

Emergency surgery is needed: wound closure and PPV in the same

present

session

General anesthesia,

If the patient ate or drank in the previous 6 hc, the surgeon should

availability

discuss the options with the anesthesiologist. If the

anesthesiologist, for whatever reason, will not be able use general

anesthesia and the surgery is otherwise urgent, some type of local

anesthesia (see Chap. 15) should be used. The surgeon himself

should administer the periocular injection

Hyphema

In adults, the primary factors are whether the retina can be visualized

and the IOP can be kept in the normal range. High IOP in the

presence of full hyphema is an urgent indication; the surgeon

should err on the side of early intervention

Hypotony

Early removal of vitreous, Þbrin, and any capsular remnantd from the

surface of the ciliary body can prevent scarring, which in turn is

irreversible

IOFB

Some of the mechanical damage has already been done, but there is an

immediate risk of infection (and chalcosis if the object is copper),

further mechanical injury due to the bodyÕs scar-producing reaction,

as well as the longer-term threat of chemical trauma (siderosis)

IOL implantation

In a child of the amblyopic age, this can be urgent (in those under

2 years, a contact lens may be a better optione). In virtually all

other cases, deferral of the implantation may be preferable

Iris, retraction

The sooner the better. Once the Þbrinous membrane turns into a scar

(Òmissing irisÓ)

tissue, the condition becomes irreversible

Lens, damage to either

In adults, there is no urgency

capsules

In children, the lens may swell in hours, leading to pupillary block

glaucoma with extremely high IOP: urgent lens removal is needed

Lens, cataract

In adults, the primary factor is whether the retina can be visualized;

otherwise there is no urgency

In children, amblyopia is the key factor: the younger the child, the

more urgent the visual rehabilitation is

Perforating injury

Immediate or early surgery is needed to prevent PVR and retinal

incarceration

PVR

Early surgery is recommended if the macula is involved or threatened;

otherwise it may be preferable to delay the PPV until the PVR

cycle is complete

RD

PPV is urgent but not necessarily an emergency

Rupture

Especially if the wound is posterior to the muscle insertions,

immediate or early surgery is needed to prevent PVR and retinal

incarceration

Subretinal hemorrhage

Usually, no action is needed unless the blood is under the macula. If it is,

removal or at least displacement should be done as soon as possible

(continued)

63.2 Contusion

519

Table 63.1 (continued)

Variablea

Comment

Suprachoroidal

If it occurs intraoperatively, the wound/s must be closed immediately

hemorrhage

and the IOP raised. Otherwise, surgery is urgent only if a kissing

choroidal is present, the blood is underneath the macula, or an RD

accompanies the bleeding

Surgery, secondary

In general, the earlier the better; if the infrastructuref is in place and

(reconstructive)

the surgeon is aware of the possibility and handling of ECH,

comprehensive primary reconstruction may be performed. If the

traditional staged (2-step) approach is chosen, it is best to apply

heavy topical steroid therapy and perform the PPV within 4 days

Systemic condition of

Hypertension and agitation in patientsg with open-globe injury make

the patient

the surgery more urgent

Anxious patients should be operated earlier, but this is not an absolute

requirement (antianxiety medications may be needed if the

surgery is delayed). Proper counseling may have a calming effect

VH, contusion

There is no urgency to remove the blood, but leaving it in the eye for

an extended period is unjustiÞable today (see the text for more

details)

VH, open-globe injury

The sooner the blood is removed, the better. The blood not only

prevents visualization of the retina but is a strong inciting factor in

PVR development

Wound, corneal

Close it as soon as possible, although it may be acceptable to

postpone it from the middle of the night till the morning hoursh if

the wound is small and the proper infrastructure (see above) is not

unavailable

The longer the wound, the more urgent the need for early closure

Wound, scleral

The longer the wound, the more urgent the need for early closure

The more anterior the wound, the more urgent the need for early

closure

520

63 Trauma

521

Surgical to-do

Mechanical cleaning with a Wechsel sponge, antibiotic jet spray, occasionally

forceps

Do not excise it; if it bulgesb, gentle diathermy will shrink it sufÞciently

Pull the iris back into the AC through a paracentesis (see Sect. 39.2). The iris

almost always can be saved; excision is restricted to cases when the iris is

severely macerated or soiled to the point that it cannot be cleaned

Try to prevent it from prolapsing; if it did prolapse, try to keep it back with a

blunt instrument, held by the assistant, while you are suturing. Address the

incarceration from the inside as soon as possible (see below)

External prolapse: Do not use a Wechsel sponge because it may cause traction

on the anterior vitreous; the probe is the ideal instrument to deal with the

prolapse. If a Wechsel sponge must be used, at least do not lift it up from the

eye surface; keep it dipped into the vitreous and use the scissors to Þrst push

down on the eyewall and then cut the vitreous

Internal prolapse: Inject TA to identify the vitreous in the AC. If the eye is

phakic, use a paracentesis for probe entry; in the aphakic eye, the pars plana

approach is preferable since it gives better access to the vitreous. In the

pseudophakic eye an individual decision must be made. If the eye is phakic,

it may be impossible to completely remove the vitreous; at least sever the

connection between the remaining prolapsed vitreous and the gel proper

522

63 Trauma

Table 63.3 The basics in corneal wound closure

Variable

Rule

Comment

Timing

As early as

Delaying the wound closure is a crucially important risk

possible

factor in endophthalmitis development. Still, in certain

casesa it may be acceptable, after proper counseling, to

delay the closure for a few hoursb

Making the

Absolutely yes

A leaking wound has difÞculty healing, and there is an

wound

increased endophthalmitis risk

watertight

Excision of

Never

The suture must be placed so that the fragment is preserved;

loose

otherwise either a gap will be present or the suture

fragments

needs to be overtightened to close it

Type of suture

10-0 nylon

It is small enough not interfere with vision, does not cause

material

any reaction, and is nonabsorbable

Visco use

Avoid if

The only true indication is an AC so ßat that there is no

possible

space for needle entry (see Fig. 39.4), an extremely rare

occurrence

Forceps use

No

The needle is sufÞciently sharp so that counterforce

against needle movement is not needed (see Sect.

14.6). Grabbing the cornea with forceps further

traumatizes the tissue, increasing the time until the

tissue becomes clear again. In the rare cases with

difÞculty at the point of needle entry, the conjunctiva

may be grabbed behind the needle (see the concept

on Fig. 54.6)c; if the difÞculty is during the exit of the

needle, the jaws of the forceps can be placed over the

cornea so that the needle emerges between the

forceps jaws (see the concept under Sect. 59.2)

Depth of the

100%

The suture loop should encompass the entire thickness of

suture

the cornea (see Fig. 63.2)d. This instantly stops aqueous

supply to the stroma, which often clears up within

minutes, allowing excellent visibility of the posterior

structures. The only risk of the full-thickness suture is

endophthalmitis at the time of suture removal (see

below)

The needle should penetrate the cornea at a 90¡ angle and

then turned so that it can be advanced parallel to the

cornea. What convinces the surgeon that the needle is in

the AC is his ability to move the tip of the needle freely

Order of suture

Depends on the

If the wound crosses the limbus, the Þrst suture is at the

placement

location of

limbus, then the cornea, and Þnally the scleral part is

the wound

closed

An angled wound requires the initial suture to be placed at

the anglee

A small wound may be closed according to the 50% rule:

the wound is always split into 2 equal parts until it is

completely closed

For large, transcorneal wound, the Rowsey-Hays rule

applies: start from the 2 endpoints at the limbus and

gradually progress toward the center from both

directions (Fig. 63.3)

(continued)

63.4 Suturing the Cornea

523

Table 63.3 (continued)

Variable

Comment

Type of suture

All running sutures in a dome-shaped tissue result in

ßattening the arch, something that must be avoided in the

cornea so that the AC depth is maintained. Conversely,

when applied in the limbus, the running suture causes

elevation of the apex (i.e., increasing the AC depth), which

is beneÞcial

Length of bite

A wound that is closed with uniformly placed sutures may

appear aesthetic, but it causes ßattening of the dome shape

(see above). A longer bite involves a greater compression

zonef; therefore wider spacing will sufÞce (Figs. 63.1 and

63.3)

Knot

3-2-1: The initial throw is a triple one; the hands must be

construction

turned 180¡ to make the thread architecture smooth; it is

tightened parallel to the suture. The second throw is double;

it is tightened parallel to the woundg. The Þnal throw is

singular; it is tightened parallel to the suture

Slipknot: A single throw is used Þrst, followed by a

second singular one in the same direction. When this is

tightened, the short thread must be lifted to send the knot

toward the tissueh. The Þnal, third, also singular knot is

thrown in reverse; this locks the knoti

Burying of the

The knot with either technique above is small enough to

knot

allow easy burial of the suture in the corneal channel in

either direction. The process can be facilitated by using a

forceps with a ßat jaw to compress the knot

Timing of

Wound length: the shorter the wound, the earlier the suture

suture removalj

can be removed

Age of the person: In children, early removal

(~3 months) is recommended since the sutures become

loose, due to increased tissue elasticity. In adults 6 months

is the norm, but the sutures can be left behind for longer

periods if need be

Preparation for

The endophthalmitis risk (see above) is high since what was

suture removal

on the corneal surface (outside) may be turned inside

during suture removal, possibly introducing organisms into

the AC

526

a