Corneal laceration - PowerPoint Presentation

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Corneal laceration

Alireza Peyman, MDSlide2

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

relieving

vitreous

incarceration

removing

any intraocular foreign

bodies

restoring

normal anatomic

relationshipsSlide3
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Partial-Thickness Corneal Lacerations

Must

be examined carefully to rule out any rupture of

Descemet

Seidel testing

Modified Seidel testingSlide11

If the wound edges are in good apposition with no wound gape, pressure patching with the use of prophylactic topical antibiotics is sufficient.Slide12

If the wound is unstable, a bandage soft contact lens may be used to support the

woundSlide13

Partial thickness laceration with gape

Sutures

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 topographySlide14

Full-Thickness Corneal LacerationsSlide15

BANDAGE SOFT CONTACT LENS

For 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 undertakenSlide16

In cases that respond satisfactorily, the contact lens should be kept in place until the wound has stabilized (usually 3–6 weeks).

A

protective shield should be worn at all times.

Topical

antibiotic prophylaxis and

cycloplegia

are recommended with the lens in place.Slide17

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.Slide18

SUTURE REPAIR OF SIMPLE CORNEAL LACERATIONS

The primary goal of corneal suturing is to achieve a watertight wound.

Secondary

goals include

minimizing scarring

restoring

normal anatomic

relationships

reconstructing

the normal corneal topographic

contoursSlide19

For 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

incisionSlide20

visco

through the wound

or

through

a

paracentesis

incision will helpSlide21

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 proceedsSlide22

Temporary sutures

Temporary 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 marginsSlide23

Technique and material

For 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.Slide24

Corneal sutures should be

90

% to 95% depth through the

stroma

1.5

mm in

length

of

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

.Slide25

D

eep

suture placement equidistant from the wound margins gives excellent wound approximationSlide26

Shallow sutures create internal wound gapeSlide27

Full-thickness sutures may create a conduit for microbial invasionSlide28

Sutures of unequal depth create wound override. Slide29

Sutures of unequal length create wound overrideSlide30

For shelved lacerations, sutures should be placed equidistant with respect to the

internal aspect

of the wound to achieve good wound appositionSlide31

Making

the suture bites close to the visual axis

shortSlide32

“no-touch” techniqueSlide33

When using a running suture for a nonlinear laceration, the suture should be placed with respect to a straight “regression” lineSlide34

Suture knot burialSlide35

STELLATE CORNEAL LACERATIONSSlide36

Bridging suturesSlide37

Purse-string sutureSlide38

multiple interrupted sutures and tissue

adhesive or patch graft Slide39

CORNEAL LACERATIONS WITH UVEAL PROLAPSE.Slide40

Iris incarceration

A peaked pupil signals tissue

incarceration

M

acerated

, 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 chamberSlide41

In 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.Slide42

Repositioning

Pharmacological

Midriatics

Myiotics

Mechanical

simply

deepening

Viscoelastics

through

the

paracentesis

or

the

wound

a

spatula or irrigating

canula

may be passed through the

paracentesis

site and used to directly sweep incarcerated tissueSlide43
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CORNEAL LACERATIONS WITH LENS OR VITREOUS INVOLVEMENTSlide46

Primary 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.Slide47
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Vitreous strands are swept into the anterior

chamberSlide49

CORNEOSCLERAL LACERATIONSSlide50

For

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.Slide51

it is important to clear the wound of any prolapsed or incarcerated vitreous

with dry cellulose sponges

and cutSlide52

options in selecting suture material for scleral closure

Some

surgeons prefer

nonabsorbable

sutures

Others

may use absorbable materials

For

larger defects,

nonabsorbable

sutures should be usedSlide53
Slide54

closing sclera over prolapsed uvea

Most

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.Slide55

Posterior extention

scleral 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

Slide56

The sclera is thinnest behind the muscle insertions; thus, careful exploration of these areas is crucialSlide57

ANTERIOR SEGMENT FOREIGN BODIESSlide58

FBs

Metalic

Vegetable matter

Glass

Plastic

Stones

Other

materials Slide59

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.Slide60

Imaging

Plain

graphies

CT

MRI

B-scan

sonography

UBMSlide61

Removal

Through

an incision directly

overlying

From

a limbal incision across the anterior chamberSlide62

Post-op managementSlide63

Medical therapy

To control infection

To

suppress

inflammation

To

stabilize the ocular surfaceSlide64

Antibiotics

Sub-conjunctival

Intra-op

Intra-

vitreal

Intra-op

IV

Vanco

or

cephalosporine+AG

Topical

Fortified, or 4

th

generation

flouroquinolones

Oral

After dischargeSlide65

Clindamycin

should be considered in cases involving vegetable matter to cover

Bacillus

species.

Top: 50mg/ml

Subconj

: 50mg/0.5ml

Intravitreal

: 1mg/0.1mlSlide66

Corticosteroids

To 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 periodSlide67

Others

Topical

β

-blockers

Carbonic

anhydrase

inhibitors

Lubricants

Bandage

contact

lenses

Patching

TarsorrhaphySlide68

Thank you for your attention