25.1 Introduction

Ocular trauma is an important cause of vision loss worldwide, with an estimated 19 million people unilaterally blind and 1.6 million bilaterally blind from eye injuries. ¹ Moreover, eye injuries disproportionately affect young people, with the peak incidence occurring in young adult and adolescent males. ² While the prevention of ocular trauma should be the primary goal, optimizing post-traumatic surgical repair and reconstruction is of utmost importance. Injuries limited to the cornea and anterior segment generally have a better prognosis than those with posterior segment involvement. ³

The management of anterior segment trauma can be classified into three stages: the initial management of acute trauma, the intermediate care, and the definitive anterior segment reconstruction. ⁴ In cases of open-globe injuries, careful preoperative planning and attention to microsurgical suturing techniques during the primary repair may minimize the need for secondary surgeries. The primary goal of the initial repair is to restore globe integrity and achieve a watertight closure. Intermediate care should focus on the prevention of infection, control of inflammation, and stabilization of the ocular surface with medical therapy. Although certain situations may require early urgent surgical intervention, elective cases of anterior segment reconstruction are typically delayed to allow adequate time for inflammation control, wound healing, and assessment of the patient’s visual potential. In some cases, one or more reconstructive surgeries may be necessary to improve visual outcomes and prevent secondary complications. Just as with the primary repair, secondary reconstruction requires careful planning and meticulous anatomic restoration to achieve excellent outcomes.

This chapter will focus on the principles of primary repair and secondary reconstruction of corneal and anterior segment injuries.

25.2 Primary Repair

Ocular injuries are classified as either an open- or closed-globe injury.

The term open globe denotes a full-thickness wound of the eyewall due to either a laceration by a sharp object or a rupture due to a blunt object. The initial surgical repair of open-globe injuries is performed promptly after the initial injury, as delays may be associated with a worse visual prognosis. The primary surgical goal is to restore globe integrity with watertight wound closure. Secondary goals are to restore normal anatomical relationships, conserve viable tissue, minimize cornea scarring and astigmatism, and prevent future complications.

The sutures necessary for anterior segment repair and reconstruction are summarized in ▶Table 25.1. Spatulated microsurgical needles are ideal for corneal closure as they allow for passage of the suture with minimal tissue damage.

When suturing a laceration, the first step is to identify the edges of the wound. Tissue loss is rare, and it is imperative to avoid removal of any viable cornea or sclera, which can complicate wound closure. A paracentesis opposite the wound is used to inject the minimum amount of viscoelastic necessary and reposition any incarcerated iris. Iris tissue should be carefully preserved for future reconstruction and resected only if necrotic, infected, or epithelialized. Anatomic landmarks such as the limbus or an angle in the wound should be reapproximated first.

The following principles should be followed for corneal suturing: ⁵

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  Entry and exit with the needle should be perpendicular to the corneal surface.

  
  
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  Suture depth should be 90% deep in the stroma; full thickness also acceptable.

  
  
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  Suture length should be equal length and depth on both sides of the wound.

  
  
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  Sutures should be placed radial to the axis of the wound.

If the wound transects the entire cornea, it should be closed from the periphery to the center. Placing long, tighter sutures near the limbus and shorter bites near the central cornea will help maintain the natural prolate shape of the cornea. Suture placement in the center of the visual axis should be avoided. All suture knots should be buried into the cornea, away from the visual axis. Proper suturing is essential to minimize corneal astigmatism and achieve good closure (▶Fig. 25.1). Stepwise removal of sutures following the injury may help reduce astigmatism.

In a wound with multiple angles, each linear aspect is individually closed. Stellate lacerations can be difficult to repair and may require a combination of suture, tissue adhesive, and a bandage contact lens. A star-shaped technique described by Akkin can also be considered. ⁶

If an avulsed piece of viable corneal tissue is still present, it should be sutured back into place. Areas of large tissue loss are repaired with a full-thickness patch graft using donor tissue or a lamellar graft using gamma-irradiated corneas. ⁷ A full-thickness penetrating keratoplasty (PK) is rarely necessary for the primary repair of ocular trauma but may be necessary for secondary anterior segment reconstruction.

Corneal lacerations are frequently accompanied by trauma to the iris and lens. Iris incarcerated in the wound should be freed and repositioned in the eye. Excess iris manipulation during primary repair is avoided until the eye is less inflamed. If there is no anterior or posterior capsular violation, cataract surgery can be delayed until the cornea has healed and the initial traumaelated inflammation has subsided. Removal of the lens is indicated at the time of initial repair if there is violation of the anterior capsule with lens material in the anterior chamber. If the corneal laceration is large, it may be difficult to maintain a stable anterior chamber during removal of the lens. In these cases, the free lens material should be removed from the anterior chamber at the time of initial repair with plans for cataract removal when the corneal laceration is adequately stable, typically 5 or more days later. If there is a posterior capsular violation, an anterior or posterior approach can be used to the remove the cataract. The advantage of the posterior approach is that anterior chamber stability is improved. When possible, the sulcus should be salvaged for future intraocular lens (IOL) placement.

25.3 Anterior Segment Reconstruction

Definitive anterior segment reconstruction following ocular trauma is delayed until adequate healing from the initial trauma has occurred, the ocular inflammation has subsided, and treatment of the ocular surface is maximized. The patient’s visual potential is assessed to determine if the patient is a candidate for further surgery. If there is damage to the optic nerve or retina with limited vision potential, the decision to defer any further surgery may be appropriate.

The secondary complications of severe ocular trauma can be as devastating as the initial injury and include: ⁸

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  Disruption of eyelid anatomy.

  
  
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  Conjunctival scarring with ocular surface damage and symblepharon.

  
  
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  Corneal scarring and neovascularization.

  
  
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  Intraocular fibrosis.

  
  
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  Epithelial downgrowth.

  
  
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  Pupillary or cyclitic membranes.

  
  
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  Lens-related injuries such as traumatic cataract, lens particle glaucoma, or lens subluxation.

  
  
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  Glaucoma secondary to peripheral anterior synechiae (PAS) or angle recession.

  
  
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  Vitreous incarceration within ocular wounds leading to chronic inflammation, cystoid macular edema, or retinal detachment.

  
  
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  Infections such as corneal ulceration or endophthalmitis.

The sequelae of ocular trauma that may be amenable to reconstruction are summarized in ▶Table 25.2. A rigid gas permeable (RGP) contact lens may be useful in the management of decreased vision from irregular corneal astigmatism or aphakia, which can coexist in a patient following anterior segment trauma. If medical management alone is not able to restore vision, additional anterior segment reconstruction may be warranted and include any combination of the following procedures:

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  PK.

  
  
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  Removal of anterior segment membranes.

  
  
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  Cataract extraction.

  
  
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  IOL implantation.

  
  
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  Goniosynechialysis.

  
  
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  Iris reconstruction.

  
  
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  Cyclodialysis cleft repair.

  
  
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  Anterior vitrectomy.

25.3.1 Penetrating Keratoplasty

Although lamellar techniques are being performed more frequently, full-thickness PK remains integral in the management of anterior segment trauma. Irregular astigmatism can generally be managed with an RGP. If an RPG fails to improve vision because of significant corneal scarring or persistent corneal edema, corneal transplantation is considered. If the injury was full thickness and the scarring involves the central visual axis, PK will be necessary. Partial-thickness injuries may be amenable to deep anterior lamellar keratoplasty. To optimize graft survival, corneal transplantation should be delayed until there is no intraocular or extraocular inflammation and the IOP is well controlled.

The size of the corneal button should be large enough to remove any central corneal scarring, and a size of about 7.5 mm is often sufficient. ⁸ The donor corneal button should be oversized 0.5 mm more than the host bed to help preserve anterior chamber depth and prevent the development of PAS and glaucoma postoperatively. ^{9 , 10} In eyes with shallow anterior chambers or broad PAS, trephination should be performed with great care. Dry cellulose sponges and smooth forceps should be used to gently separate the cornea from posterior adhesions. Vannas scissors should be used sparingly, taking great care not to excise or damage tissue that may be utilized for subsequent iris reconstruction. ⁴

It is often necessary to perform other anterior segment reconstructive techniques in conjunction with PK. ▶Fig. 25.2 illustrates a case of iris and anterior chamber reconstruction in conjunction with a PK in a patient with a remote history of trauma. The health of the ocular surface should be maximized prior to PK. In cases where there is still neovascularization in the host, cautery is sometimes used to ablate vessels in hopes of decreasing the risk of rejection. If the host cornea is vascularized, 16 or more interrupted sutures should be used to suture the graft instead of running sutures.

Open sky goniosynechialysis can be performed if significant PAS is present. Organized fibrovascular or cellophane-like hyaline membranes can form over the anterior surface of the iris, angle, and posterior cornea. ⁴ Dry cellulose sponges or 0.12 forceps can be used to identify the edge and peel the membranes away from the iris and angle to avoid synechiae and compromise of the angle. Any vitreous should be removed manually with Westcott scissors and a dry cellulose sponge or with automated vitrectomy.

If cataract extraction with posterior chamber IOL (PCIOL) implantation is planned in combination with PK, intravenous mannitol and a Honan balloon may be used to decrease posterior pressure. A Flieringa ring can also be used to maintain scleral rigidity and prevent an expulsive hemorrhage. If there is a view through the cornea at the beginning of the case, the capsulorhexis can be created under a closed system to minimize the chance of radialization and the cataract removed with an open sky technique. For IOL calculations, an average keratometry of 45 can be used to estimate the post-PK corneal curvature.

In aphakic patients without capsular support in whom PK is planned, suturing of a PCIOL to the iris or sclera at the time of transplantation can be considered, when appropriate.

In cases with severe anterior and posterior segment trauma, vitreoretinal surgery can be performed with the use of a temporary keratoprosthesis. ¹¹ The decision to suture a donor cornea versus the patient’s trephined corneal button after the vitrectomy should be based on the expected prognosis given the posterior segment findings. ¹²

In a review of 39 patients who underwent PK and anterior segment reconstruction after severe ocular trauma, 49% achieved a visual acuity of 20/100 or better compared with 10% preoperatively and 80% of grafts remained clear at a mean follow-up of 23 months. ⁸ It is important to note that chronically elevated IOP occurred in 46% patients postoperatively and was more common in eyes with preoperative glaucoma and persistent PAS. Thus, glaucoma management before and after reconstructive surgery is imperative.

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