Ocular Trauma Principles
This is a case shared by Dr. Diego Ruiz Casas from Madrid – Spain
In this video we discuss important principles guiding the repair of complex corneoscleral lacerations in ocular traumas.
This is a case of a patient with severe ocular trauma and visual acuity of no light perception. The first important message in surgery for ocular trauma is: Don’t perform primary enucleation or evisceration. Try always to close the eye and restore as much as possible the structural integrity of the globe.
Close the eye as soon as possible to avoid choroidal detachment and infection.
The goal of the first procedure is to close the eye. If possible, you can try to fix some intraocular injuries, but if not possible, leave it to another surgical intervention.
Start the sutures at the limbus and the wound apex with interrupted 10-0 Nylon sutures.
Tissues bites should initially be placed full thickness deep into cornea to close the endothelium gaps and avoid further edema during the surgery. However, the first sutures are difficult, due to hypotony and if they are too or little thighted they can be changed at the end of the surgery.
In this procedure, the surgeon used a vitreous probe to remove the prolapsed vitreous from the wound and anterior chamber. Avoid always to pull the vitreous and to cut with scissors so you can avoid further traction. Pay special attention suturing the limbal gaps trying the most linear apposition.
We can see that the eye acquires an anatomical aspect closer to normal with the sutures.
After finishing corneal sutures, it’s critical to determine the extent of the injury. So, perform a gently conjunctival dissection to explore the sclera from anterior to posterior. It may be necessary to remove prolapsed vitreous also, but be careful about prolapsed uveal or retinal tissue. In this case the surgeon 8-0 non-absorbable Nylon sutures for the repair of posterior sclera.
A Scleral laceration may either be located under the rectus muscles or it may extend under the muscles. In these cases the area can be exposed, lifting it out gently with a muscle hook, or sometimes, you may need to isolate the muscle with a 6-0 Vycril suture and cut it from the globe. After repair of the laceration, the muscle is resutured to its original insertion.
In this case the surgeon placed an anterior chamber infusion to restore the normal IOP and perform sutures review. In this moment you can change possible irregular sutures to keep watertight closure of all wounds. Iris hooks were placed and lens material was removed with a 25-G pars plana vitrector.
After checking the position of the trocar, the infusion line was placed in the pars plana and the surgeon was able to perform PPV in the same procedure.
Despite the severity of the trauma, the patient didn´t have any retinal breaks. Even so, PFCL was injected to stabilize a peripheral choroidal detachment and so the surgeon was able to perform the vitreous shaving safely.
In the end of the surgery iris sutures were performed, and after Fluid air exchange the silicone oil was implanted.
Diego Ruiz Casas MD
Filipe Lucatto MD
Juliana Prazeres MD