Delhi Journal of Ophthalmology

Corneal Laceration Repair!

Prateek Jain, Anshuman Pattnaik
Department of Community Ophthalmology,Global Hospital Institute of Ophthalmology, Abu Road, Sirohi, Rajasthan, India

Corresponding Author:

Prateek Jain
(MS, DNB, MNAMS)
Department of  Community Ophthalmology,
Global Hospital Institute of Ophthalmology, 
Abu Road, Sirohi, Rajasthan India
Email: docprateekjain@gmail.com

Received: 29-OCT-2020

Accepted: 19-FEB-2022

Published Online: 03-APR-2022

DOI:http://dx.doi.org/10.7869/djo.747

Abstract
Ocular trauma is an emergency which should be addressed immediately. Injury to cornea is a preventable cause of blindness. A meticulous corneal tear repair is essential for optimal visual outcome. This photo essay aims to brief postgraduate residents with an insight on principles of full thickness corneal tear repair. Two cases of severe penetrating corneal injury are presented here who were operated with satisfactory restoration of ocular integrity

Keywords :Ocular Trauma, Full Thickness Corneal Tear, Corneal Laceration

Photo-essay 
Ocular trauma is an emergency which should be addressed immediately. Injury to cornea is a preventable cause of blindness. A meticulous corneal tear repair is essential for optimal outcome. Two cases of penetrating corneal injury are presented here who were operated with satisfactory restoration of ocular integrity. This photo essay aims to brief postgraduate residents with an insight on principles of full thickness corneal tear repair.

The first case involves a five year-old school-going girl. Her left eye was injured by goat’s horn while playing one day prior. On examination,a limbus-to-limbus full thickness corneal tear with 2mm extension into sclera (Figure 1) on either side was noted along with iris incarceration. Anterior chamber(AC) was shallow. Pupil was irregular, sluggishly reacting to light(No RAPD).Presence of posterior synechiae and traumatic cataract without vitreous herniation was noted. Self-sealed corneal wound by iris incarceration was noted. Visual acuity examination showed accurate Perception of light(PL) and projection of rays(PR)in all quadrants.


Figure 1 : (a)Pre-Op image of Case 1 -Limbus-to-limbus full thickness corneal tearwith scleral extension,iris incarceration and traumatic cataract; (b)Intra-Op image showing multiple interrupted 10-0 nylon corneal sutures after abscission of incarcerated iris tissue. Red pupillary reflex and intact posterior capsule visible after traumatic cataract extraction; (c) Intra-Op image showing optimally sutured corneal wound with buried suture knots; (d)POD1 image showing well formed AC with air bubble 

The second case involves a 27 year-old male whose left eye was injured by a sharp iron particle while working 2 days back. On examination, a limbus-to-limbus full-thickness corneal tear without iris incarceration was observed but with flat AC.(Figure 2) Traumatic mydriasis, sphincter tear and traumatic cataract were noted. Visual acuity was HMCF with accurate PL,PR in all quadrants.


Figure 2 : (a)Pre-Op image of Case 2 showing limbus-to-limbus full thickness corneal tear with flat AC and traumatic cataract; (b)Magnified view showing stellate shaped wound edges;
(c)POD1 image showing properly placed sutures with layer-to-layer apposition of wound edges,dilated pupil revealing traumatic cataract; (d)POD7 image showing healthy and intact sutures with buried knots. 

Orbital CT scan did not reveal any intraocular foreign body in either case. The mainstay of treatment involved assessment of wound extent followed by primary repair along with tackling traumatic cataract either in same sitting(in first case)or as staged procedure(in second case)under suitable anaesthesia. Post-op B-scan in the first case revealed vitreous haemorrhage with no retinal detachment while it was unremarkable in the second case.
Cornea forms the major refracting surface;any change in corneal contour, clarity, thickness can result in significant visual disturbance.1 Studies found that corneal injuries were more in most active period of life (15-50 years) and 15% of them were among children. This has a considerable socioeconomic impact since people of this age group form the bulwark of workforce.Literature search revealed full thickness corneal laceration asmost important cause of corneal blindness followed by infectious keratitis.2,3

Principles of corneal tear repair4,5
  1. Place the first suture at limbus when it is involved.It provides anatomic stability to wound edges.
  2. Place suture perpendicular and equidistant to the cut edge at 85-90% depth to ensure optimum tension for layer-to-layer approximation.Equal amount of tissue should be incorporated on each side of the wound.(Figure 3A)
  3. In shelved/oblique lacerations, sutures to be placed equidistant with respect to the internal aspect of the wound(Figure 3F).
  4. Apply long tight compressive suture at the periphery.Central sutures should be minimally compressive and short.This results in peripheral flattening and central steepening of the cornea.(Figure 4)
  5. Bury suture knots in corneal stroma to lessen post-op inflammation and infection.
  6. Revise any loose or too tight sutures to achieve regular corneal contour. Cornea flattens adjacent to tight sutures and steepens adjacent to loose sutures, hence affecting astigmatism significantly.


Figure 3 : Effects of suture placement for corneal lacerations. (a) For sharp perpendicular wounds, deep suture placement equidistant from the wound margins gives excellent wound approximation. (b) Shallow sutures create internal wound gape. (c) Full-thickness sutures may create a conduit for microbial invasion. (d) Sutures of unequal depth create wound override. (e) Sutures of unequal length create wound override. (f)For shelved lacerations, sutures should be placed equidistant with respect to the internal aspect of the wound to achieve good wound apposition.(Acknowledgement:Hersh P S et al.Surgical Management of Anterior Segment Trauma. In Duane's Clinical Ophthalmology 2006.Vol6 Chapter39).


Figure 4: Long, deep, and relatively tight peripheral sutures and shorter, shallower, appositional sutures near the central cornea may restore the normal corneal dome.(Acknowledgement:Hersh P S et al.Surgical Management of Anterior Segment Trauma. In Duane's Clinical Ophthalmology 2006.Vol6 Chapter39).

References
  1. Krachmer, Mannis and Holland: Book of Cornea; Second Edition 2005:Volume1; Section 8-Corneal Trauma; Chapter 100: Mechanical Injury. 1245. 
  2. Macewen CJ. Glasgow eye infirmary, eye injuries a prospective survey of 5671 cases. Br J Ophthalmol.1989; 73: 888-894. 
  3. Premchander A, Channabasappa S, Balakrishna N, Nargis N. An evaluation of visual outcome of corneal injuries in a tertiary care hospital. Int J Clin Exp Ophthalmol. 2019; 3: 020-029 
  4. John B, Raghavan C. Open Globe Injuries-Primary Repair of Corneoscleral Injuries. Kerala Journal of Ophthalmology. 2010;22(3):225-234

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Jain P, Pattnaik ACorneal Laceration Repair!.DJO 2022;32:69-70

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Jain P, Pattnaik ACorneal Laceration Repair!.DJO [serial online] 2022[cited 2022 May 19];32:69-70. Available from: https://www.djo.org.in/articles/32/3/Corneal-Laceration-Repair.html