This resident surgeon had a busy night on call with two ruptured globe cases presenting to the emergency department. The suture passes through the cornea must follow the basic rules that we previously covered. There are many great teaching points that are covered in this video.
- 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 you suspect IOFB
- Other injuries? Globe, lids, orbit, face
- Status 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 vitrectomy
- procedures
- risks
- severe, permanent vision loss
- need for more surgery
- ugly cosmetic deformity
- limited visual recovery
- sympathetic ophthalmia
- chronic pain, irritation
- risks
- 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
- Remove OVD and fill AC with BSS
- 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
