Christopher J. Rapuano
BASICS
DESCRIPTION
• A tear or cut in the conjunctiva and/or cornea
• Corneal lacerations can be full or with partial thickness
EPIDEMIOLOGY
Incidence
• Exact incidence is unknown
• It is more common in young males
RISK FACTORS
Hazardous occupations, sports, or hobbies without the use of protective eyewear
GENERAL PREVENTION
Use of protective eyewear
ETIOLOGY
Can occur following blunt or sharp penetrating trauma
COMMONLY ASSOCIATED CONDITIONS
There should always be a high index of suspicion for an intraocular foreign body (IOFB) and/or occult scleral lacerations.
DIAGNOSIS
HISTORY
Details of the traumatic event and mechanism of injury
ALERT
Be highly suspicious for IOFB or ruptured globe with high-velocity injuries (e.g., metal on metal; BB gun injuries):
• Symptoms include pain, foreign body (FB) sensation, redness, and photophobia.
• Determine the last time the patient ate; this may influence time of surgical repair if required.
• Obtain complete history of previous ocular surgeries.
PHYSICAL EXAM
• Avoid pressure to the eye.
• Check visual acuity (VA); do not check intraocular pressure if you suspect there is a full thickness laceration.
• Diligent slit lamp examination is performed to learn the size and extent of the laceration and any entrapment or loss of intraocular contents; it is done without applying any pressure to the globe.
• Fluorescein staining may highlight subtle conjunctival or corneal defects.
• Clues for full thickness lacerations include:
– Chemosis
– Subconjunctival or anterior chamber hemorrhage
– Poor VA
– Afferent pupillary defect
– Irregular pupil
– Abnormally deep or shallow anterior chamber
– Hypotony
– Vitreous hemorrhage
– Traumatic cataract
• A positive Seidel test confirms full thickness laceration. Apply concentrated fluorescein to site of interest and watch for green (dye diluted by aqueous) stream of dye under the blue light.
• Always examine both eyes carefully.
• For conjunctival lacerations, perform a gentle but thorough examination using topical anesthesia and a sterile cotton tip applicator to rule out scleral laceration and/or subconjunctival FB.
• If possible perform a dilated fundus exam to look for the possibility of IOFB.
Pediatric Considerations
Pediatric patients often give a poor history and are difficult to examine and may require examination under anesthesia.
DIAGNOSTIC TESTS & INTERPRETATION
Imaging
• An orbital CT scan (1 mm axial and coronal cuts) may be helpful to rule out IOFB. MRI should be avoided if there is a possibility that the FB contains metal.
• An expert may be able to perform a gentle B-scan ultrasound to identify an IOFB.
ALERT
A normal CT scan does not rule out an occult laceration/ruptured globe; therefore, if there is clinical suspicion, a high standard of care mandates surgical exploration.
DIFFERENTIAL DIAGNOSIS
• Corneal abrasion
• Corneal or conjunctival FB
• Ruptured globe/scleral laceration
• IOFB
TREATMENT
MEDICATION
First Line
Conjunctival lacerations:
• Conjunctival lacerations without scleral involvement can be treated with topical antibiotic ointments.
– Consider polysporin, bacitracin, or erythromycin ointment q.i.d.
Corneal lacerations:
• Partial thickness corneal lacerations can be treated with an ophthalmic ointment and fluoroquinolones drops.
• Full thickness corneal lacerations should be treated with a 7- to 10-day course of systemic antibiotics perioperatively:
– For example, moxifloxacin 400 mg per day or cefazolin 1 g IV per 8 h or vancomycin 1 g IV per 12 h (pediatric patients: cefazolin 25–50 mg/kg per day is divided into t.i.d. dosing and gentamicin 2 mg/kg IV per 8 h)
• Subconjunctival, intravitreal, or intracameral antibiotics can also be considered at the time of surgery.
– Subconjunctival: 0.05 mL of cefazolin (25–50 mg/mL) or vancomycin (25 mg/mL) and gentamicin (40 mg/mL)
– Intraocular: 0.1 m of ceftazidime (2 mg/0.1 mL) or amikacin (0.4 mg/0.1 mL) and vancomycin (1 mg/0.1 mL)
• Topical antibiotics can be initiated once the wound is closed (fluoroquinolones or fortified antibiotics).
• Antiemetics and pain medications should be given before and after surgical repair to prevent vomiting or straining that can raise intraocular pressure and prolapse intraocular contents.
Second Line
• Cycloplegics can be added for inflammation and/or iris damage.
• Topical steroids should be used cautiously on a case-by-case basis.
ADDITIONAL TREATMENT
General Measures
Conjunctival lacerations:
• Conjunctival lacerations <1 cm and those in the fornix can often be observed without repair.
• Large lacerations can be closed using interrupted or running 8–0 Vicryl sutures and using caution not to incorporate folds of conjunctiva or Tenon’s capsule.
• Exploration is warranted if there is concern for an underlying scleral laceration or muscle involvement.
Corneal lacerations:
• Small self-sealing or slowly leaking lacerations may be treated with a combination of aqueous suppressants, cyanoacrylate tissue adhesive, a bandage soft contact lens and topical fluoroquinolones.
• Partial thickness corneal lacerations with associated wound gape should be surgically approximated to prevent excessive scarring and irregularity especially when in the visual axis.
• Large full thickness corneal lacerations require urgent repair in the OR.
• While waiting for repair, keep the eye covered with a firm shield to prevent eye rubbing.
• Administer a tetanus shot if appropriate.
• Nothing to eat or drink 6–8 h prior to surgical repair
Issues for Referral
Full thickness corneal lacerations need urgent repair by a qualified ophthalmologist.
SURGERY/OTHER PROCEDURES
• Full thickness corneal lacerations should be repaired in the operating room preferably under general anesthesia.
• A comprehensive informed consent should be signed prior to surgery.
ALERT
The anesthesiologist should be made aware of the open globe status which may influence which medications they use for induction.
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