At our busy UCLA-affiliated teaching hospital, Olive View-UCLA Medical Center, we frequently get severe ocular trauma including ruptured globes. We recently had a patient who sustained a full-thickness corneal laceration due to a construction accident. This is a step-by-step approach to repairing this injury.
There are three options for surgical repair:
(1) close the corneal laceration and defer the cataract removal for later
(2) close the corneal laceration, remove the cataract, and leave the eye aphakic
(3) close the corneal laceration, remove the cataract, and place the IOL.
The decision is left up to the surgeon’s judgment given the specific clinical situation. Note that implanting an IOL should be avoided in cases where there is a high likelihood of infection as it is difficult to clear an infection with any sort of hardware in the eye.
The patient presented three days after his initial trauma which occurred when a sharp object pierced his eye and was rapidly withdrawn. This resulted in a large corneal laceration of about 8mm in length and a punctured anterior lens capsule. Further testing demonstrated an intact posterior segment and orbit without foreign bodies. The patient presented with light perception vision due to a complete, white cataract due to rupture of the anterior lens capsule. The patient was taken to the operating room for surgical repair.
The primary goal in a ruptured globe repair is to close the eye and make it water-tight. In this regard, our first priority is to suture the corneal incision. But where do we start? Since this incision has a V shape, we should start at the apex. This is the most critical suture since it will align the two corneal edges and determine how well they fit together. Next we can bisect each leg of the laceration with another suture. Finally, we can place additional sutures along the laceration to ensure a water-tight closure.
Now it is time to address the traumatic cataract caused by the rupture of the anterior lens capsule. We first stain the capsule with trypan blue dye to see the extent of the damage. In this case it is a large irregular triangle of open lens capsule and there is no chance to turn it into a capsulorhexis or more stable opening.
Since the patient is young (in his 20s), the lens material is anticipated to be very soft and easily aspirated with just bimanual irrigation via two small 1 mm paracentesis incisions. Once this is complete, we inspect the posterior capsule and find it completely intact. We elect to implant a three-piece IOL in the suclus which will require about a 2.75 to 3mm wide incision. We avoid making this incision in the cornea and instead opt to make a temporal scleral tunnel which is then sutured shut after IOL insertion.
How do you do the IOL calculations? Our method is to measure the other eye which did not sustain trauma. The patient has a lifelong history of emmetropia bilaterally so we can assume that the IOL power for each eye will be similar. For good measure, we add 0.5 diopters to the IOL power that is calculated for the non-traumatized eye and then convert to the appropriate sulcus IOL power using this method.
If there is a suspicion of an infection, the eye should be left aphakic but with the posterior capsule intact. Some surgeons like to always leave these eyes aphakic with a plan to do a secondary IOL implant in the future. This is a good option as well. Ultimately it is the surgeon’s choice and clinical judgment.
At the end of the case, the corneal laceration and all incisions are checked with a fluorescein dye leakage test to ensure that the globe is water-tight. That is the yellowish color that is seen in the post-operative photos shown here.
The patient is healing well in the initial post-operative period. It will be a long road to recovery. Perhaps in the future once this corneal laceration has healed, the patient can be considered for a corneal transplant to help rehabilitate his vision. And certainly, we have stressed the importance of wearing safety goggles when performing his construction related activities.
Sir,Very well managed .
My approach will be slightly different.
I will not implant any IOL.will keep Aphakia.
Because there will be always chances of infective Endophthalmitis in such cases.
After corneal suture removal i will try RGP CL or secondary sulcus IOL.
Great case! As a third year resident currently, as I type, on globe call at Olive View, I wonder if this was done as a staged surgery. While on call, especially if the case is going in the middle of night, we may not have access to the IOL master and the ability to do phaco. My question is, is primary closure of the corneal laceration appropriate with a staged surgical approach and later completion of the cataract removal and IOL insertion?
Surgeon’s call. Three options: (1) just suture the K laceration closed and then come back later for cataract removal and IOL insertion, (2) remove cataract, leave aphakic, and suture K laceration, (3) suture K incision, remove cataract, place IOL. Option (1) is reasonable, but keep in mind that the patient will have a lot of inflammation due to the open lens capsule and you may need to remove the cataract within a week or two.