Ruptured Globe: Key Teaching Points

Every ophthalmologist must know how to manage a ruptured globe. In this case it is a corneal laceration with a punctured anterior lens capsule. These are the key points and the video shows the technique:

• pre-op
  • history
    • nature of injury? IOFB? Clean? Metal vs plant matter, wood
    • timing of injury
  • exam
    • visual acuity
    • extent of injury, K, lens?
    • CT scan if suspect IOFB
    • Other injuries? Globe, lids, orbit, face
    • Status of other eye
    • IOL calcs of other eye
  • set patient expectations
    • will never have normal vision
    • will never be as good as other eye
    • will require years for recovery
    • will require more surgery in future
    • may be totally blind, irreversibly
    • may lose the eye
    • sympathetic ophthalmia may affect other eye
    • higher future chance of RG in same or other eye
    • need protective eyewear for life
  • consent
    • procedures
      • 1. Close globe
      • 2. Lensectomy
      • 3. Possible implants: IOL,CTR, sutures
      • 4. Possible vitrectomy
    • risks
      • severe, permanent vision loss
      • need for more surgery
      • ugly cosmetic deformity
      • limited visual recovery
      • sympathetic ophthalmia
      • chronic pain, irritation
• intra-operative
  • general anesthesia often preferred
  • take pics of eye pre-op, including with patient ID sticker near eye
  • surgeon may want to prep eye instead of nurse
  • give accurate time estimate to anesthesiologist – this case 1 hour
  • make sure draping is good and all eyelashes are sequestered
  • video record surgery, ensure good focus and white balance
  • steps:
    • take sample for culture
    • careful paracetesis with soft eye, flat AC
    • fill AC with OVD, dispersive will stay in place better, not too deep AC
    • identify extent of K laceration, find center or peak
    • suture peak first, at least 1 mm from each side of laceration, 80%+ depth
    • for cornea, 10-0 nylon preferred, make 2^nd throw 90 deg away, tension
    • once K is closed with sutures, check for reasonable level of watertight
    • for lensectomy: young vs older patients
      • young: very soft lens, use two paras for biman I/A
      • older: make a phaco incision in sclera (not K)
    • trypan blue dye to stain capsule, may need to remove OVD first
    • determine extent of anterior lens capsule rupture
    • placing an IOL is optional:
      • classic teaching: leave aphakic due to infection risk
      • benefit of placing an IOL: support for remaining capsule, can plug a hole in the posterior capsule, barrier effect
      • IOL is not for refractive purposes because the central K scar will still limit the vision to CF at best
      • Three-piece IOL preferred since more placement options and stability
    • Remove OVD and fill AC with BSS
    • Suture scleral phaco incision, suture conjunctiva
    • Seidel test with fluorescein to ensure 100% water tight at physiologic IOP
    • Re-throw any sutures as needed. Bury all knots.
    • Consider retrobulbar injection of small amount of Marcaine
    • Subconj and/or intra-cameral antibiotics
    • Patch and shield overnight
• Post-op
  • Temper patient expectations. Do not ask patient to read Snellen chart. HM is ok.
  • at slit-lamp: look at AC depth first, look at K laceration, any leakage? AC flat?
  • Now careful Seidel test with fluorescein, if no leaks then check IOP (tonopen)
  • Post-op regimen: steroids and antibiotics
  • Optional: NSAIDs (may slow K healing), cycloplegics
  • Look at posterior segment via indirect ophthalmoscope
  • Close follow-up care for first few months
  • Need continued follow-up for life
  • Future:
    • Give cornea at least 6-12 months to heal before removing sutures
    • Wait for topographic stability with monthly follow-up
    • Possible topo-guided excimer ablation (hopefully patient is myopic)
    • May need corneal transplant in future

click below to learn from this important video: