Another patient presented to our resident ophthalmology clinic with a 1 day history of doing construction work on a roof of a house and having a nail pierce his left eye. Fortunately the trauma was not high speed and the damage was limited to the anterior segment of the eye. There is a central corneal laceration and the anterior lens capsule has been ruptured. The posterior lens capsule is intact and there is no posterior segment trauma. No retained foreign bodies were found.
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.
Just like the previous article posted here on CataractCoach, we used a step-wise approach to repair this traumatic ocular injury.
- The full extent of the trauma is determined while the patient is under anesthesia. The eye is dilated with a mixture of 1:6000 epinephrine in BSS and the anterior lens capsule is stained with trypan blue dye.
- The anterior chamber is formed with dispersive viscoleastic until a normal corneal contour is achieved.
- Using 10-0 nylon sutures, the corneal laceration is closed until it is mostly water-tight. At this step, a little leakage is tolerable.
- If possible, convert a small rupture into a capsulorhexis. In this case, the rupture is large and we use a cystotome to perform a can-opener style capsular opening.
- Since the patient is young and the lens is soft, it can be easily aspirated using bimanual irrigation-aspiration.Using two slightly enlarged paracentesis incisions (about 1.2 mm each), remove the entire lens being careful not to grab the capsule or cause a posterior capsular extension of the tears. Use a high vacuum (500 mmHg), low flow (30 cc/min), and moderate bottle height / infusion pressure (50 mmHg infusion pressure or 75 cm bottle height).
- Fill the capsular bag and anterior chamber with cohesive viscoelastic and create a scleral tunnel incision for IOL placement. We avoid using a corneal incision for IOL placement since the cornea has sustained trauma and we want to avoid stressing it further.
- Here we used a three-piece IOL based on calculations of the contra-lateral eye and then conversion to sulcus power using this method. The IOL is placed into the sulcus and then the scleral tunnel is sutured closed. Note that we still have viscoelastic in the eye.
- Now we can do further suturing of the corneal incision which is easier with the viscoelastic in the eye. When you think that the cornea is completely closed, we can remove the viscoelastic.
- Remove the viscoelastic using the bimanual instrumentation, this time with a higher flow rate (40 cc/min), higher infusion pressure (70 mmHg or 100 cm bottle height), and the same high vacuum level (500 mHg).
- Now check the cornea again, this time using a fluorescein dye leakage test. Any leaking should be addressed with careful suturing. Also make sure you bury the knots so that the corneal surface is smooth. Be careful with corneal suturing since each pass will tend to macerate the delicate tissue. You cannot attempt the same suture multiple times in the same location without destroying valuable corneal tissue.
- Close the conjunctiva over the scleral tunnel. Inject subconctival antibiotics and steroids. For post-op pain control, you may want to consider giving a retro-bulbar injection of a long-acting local anesthetic such as bupivicaine (Marcaine). Patch and shield the eye. Consider giving systemic acetazolamide (Diamox) for intra-ocular pressure control, particularly if you feel that you may have left some viscoelastic in the eye.
- Watch the patient closely in the post-op period and be sure to set reasonable expectations. Though the post-op result below looks great, those central corneal sutures are inducing irregular astigmatism and limiting the vision to 20/200.
What if you don’t have bimanual I/A instrumentation? In this case, we used the aspiration tip from the Alcon Transformer I/A Probe for outflow and then we used the plastic 22ga IV tip for the inflow. (Get the 22ga Angiocath IV and discard the metal needle since we just need the plastic tip that would be inserted into the vein.) With a slightly larger inflow (22ga) compared to outflow (23ga), we will have favorable fluidics and a more stable anterior chamber.
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.