Pediatric Open Globe Repair
Marina Roizenblatt, MD
Kim Jiramongkolchai, MD
PREOPERATIVE CONSIDERATIONS
Type:
Rupture: full-thickness wound of the eye, usually caused by a blunt object.
Penetrating: presence of a single entrance wound, usually caused by a sharp object.
Perforating: presence of both entrance and exit wounds, usually caused by a sharp object.
Intraocular foreign body (IOFB): a retained foreign object, responsible for the entrance laceration, found within the eye cavity.
Grade:
Defined by the VA at the presentation exam.
Baseline VA is a significant prognostic indicator for visual outcome.
Pupils:
Positive (presence of an afferent pupil defect).
Negative (absence of an afferent pupil defect).
Zones:
Zone I: cornea and limbus.
Zone II: 0-5 mm posterior to the limbus (excludes the retina).
Zone III: >5 mm posterior to limbus.
In cases involving a perforating injury, the most posterior defect, (usually the exit site) is used to classify the zone.
Examination
Signs that may indicate an occult open globe (see Chapter 22):
Significantly reduced vision (out of proportion to findings).
Afferent pupillary defect.
Blood at multiple layers: hemorrhagic chemosis, hyphema, and/or vitreous hemorrhage.
Corectopia.
Hypotony (intraocular pressure of 5 mm Hg or less).
An abnormally deep or shallow anterior chamber.
Avoid manipulating or applying pressure to the open globe.
Avoid intraocular pressure measurement, gonioscopy, forced duction testing, or scleral depression.
B-scan ultrasonography, if absolutely necessary, should be performed gently over a closed eyelid.
Children frequently need sedation or anesthesia for adequate examination.
Ketamine is typically avoided in patients with suspected ruptured globe injury as it has been reported to increase intraocular pressure.
If open globe is suspected, make the patient NPO, provide pain control and antiemetics if needed, and place an eye shield to protect the eye
Preoperative CT scanning indications:
Suspected occult open globe, IOFB, or facial fractures.
Lack of visualization of the posterior segment with funduscopic exam.
Assess for child abuse:
Consider consultation with child abuse specialist if there are inconsistencies in the caregiver’s history of the event, multiple associated and unexplained injuries, repeated trauma, or delay in presentation to the hospital. In most states, physicians are legally obligated to report any suspected abuse.
Check for tetanus immunization status, and update if necessary.
Consider the administration of IV antibiotics preoperatively and intravitreal antibiotics intraoperatively. While these decisions are based on surgeon’s discretion, below are some general guidelines:
Adults: cefazolin 1 g IV q8h or vancomycin 1 g IV q12h and moxifloxacin 400 mg IV daily.
Children <12 years old: cefazolin 25-50 mg/kg/d IV in 3 divided doses and gentamicin 2 mg/kg IV q8h.
Consider 48 hours of intravenous antibiotics to reduce the risk of posttraumatic endophthalmitis.
Open globe repair should be performed as soon as reasonably possible under general anesthesia. Do not put any pressure on the globe when prepping and try not to instill any iodine directly into the eye. Use an eyelid speculum that puts minimal pressure on the globe (ie, Jaffe eyelid retractor).
Anterior Segment Surgical Reconstruction
Corneal Laceration
Create an incision at the limbus with a keratome or a sideport blade.
Gently irrigate the anterior chamber with a blunt infusion cannula (avoid this if there is extensive prolapse of intraocular tissue).
Inject viscoelastic to reform the anterior chamber.
If lens fragments, necrotic iris, or vitreous are noted to prolapse through the corneal defect, they should be carefully excised so as not to cause traction on the vitreous body or zonular fibers. Gently sweep viable iris tissue back into the anterior chamber using a separate limbal incision.
Suture the corneal wound using interrupted 10-0 nylon sutures. Tips:
If the laceration involves the limbus, start suturing from this point with 9-0 or 10-0 nylon.
Suture passes should be partial thickness through the cornea.
Knots are buried within corneal stroma, not in the wound.
In case of difficulty in closing a complex corneal laceration, consider X-shaped sutures or even cyanoacrylate glue and a therapeutic bandage contact lens.
Sutures should be longer with increased interval spaces between sutures in the peripheral cornea, but shorter, and closer to adjacent sutures in the central cornea. This pattern of suture placement will help restore the normal cornea curvature.
In cases where the corneal wound edges are irregular, the sutures may need to be longer in order to incorporate healthy tissue.
Clot removal from the anterior chamber can be performed with a vitreous cutter or with an irrigation and aspiration unit after the corneal wound is closed. This should be done with care, as dislodging a clot can occasionally precipitate worse bleeding.
Lens Injuries
Penetrating or blunt trauma may result in traumatic cataract formation (see Chapter 7).
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