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
- procedures
- history
- 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 2nd 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:
