As one of the most severe forms of ocular trauma, open-globe injury (OGI) causes significant vision loss. Timely and meticulous repair of these injuries can improve patient outcomes. This video-based educational curriculum is intended to serve as an efficient, yet comprehensive reference for OGI repair. We hope that these video-based articles help surgeons and trainees from around the world find answers to specific surgical questions in OGI management. The curriculum has been divided into six separate review articles, each authored by a different set of authors, to facilitate a systematic and practical approach to the subject of wound types and repair techniques. This fourth article highlights special considerations in the repair of open-globe injuries affecting the anterior chamber and cornea.
Curriculum Editors
Paracentesis Creation in the Hypotonic Open Globe
Paracentesis creation is often an early step in the repair of an anterior open-globe injury (OGI). Due to the loss of integrity of the eye wall, however, open globes tend to be hypotonic, with unstable anterior chambers, making paracentesis creation difficult.
Our recommended technique is to use toothed 0.12 Colibri forceps to grasp the episcleral tissue immediately adjacent to the location of the desired paracentesis wound.1 The Colibri forceps stabilize the eye and the anterior chamber, allowing for a “lifting” technique to ensure that creation of the wound does not depress the eye and extrude intraocular contents. A paracentesis blade is then used to incise the cornea near the limbus just anterior to the teeth of the forceps. If the anterior chamber is flat and the iris is abutting the corneal endothelium, the blade cannot be fully inserted, because it would otherwise lacerate the iris or perhaps even puncture the lens capsule. Therefore, the surgeon should not continue to insert the blade centrally but rather cut radially to increase the length of the paracentesis wound after the tip of the blade has penetrated the endothelium and entered the anterior chamber.
Care should be taken to maintain a sharp vertical angle of the blade during incision creation, effectively diving more posterior with the tip of the blade than would normally be performed in a formed eye. This ensures the length of the incision within the stroma is not too long. In hypotonic eyes, it is easy to inadvertently create long paracentesis incisions if the blade trajectory is too “flat.” Long wounds limit the ability to utilize and maneuver secondary instruments during subsequent anterior chamber repair. It is also important to direct the paracentesis toward the corneal laceration (as opposed to toward the center of the pupil), to make it easier to perform manipulations near the wound (Video 1, Appendix 1).
Video 1.
Paracentesis creation in open globe with hypotony.
(GWA)
Linear Wounds
Proper repair of corneal wounds is a major determinant of best corrected visual outcomes after zone I OGI repair. Linear corneal wounds can present as shelved or nonshelved defects, each with unique properties that require special attention during repair.2
As discussed elsewhere in this curriculum (Video-based surgical curriculum for open-globe injury repair, III: surgical repair, “Suture Selection”), corneal wounds are repaired commonly with 10-0 nylon sutures, with proper placement at a depth of 80%–90% of the corneal stroma. It should be noted that some sources posit that corneal wounds can be 100% depth and still provide adequate closure in trauma, although this is considered controversial in OGI, because there are no clinical trials comparing the outcomes of partial versus full-thickness sutures.3 Therefore, management largely depends on surgeon and institutional preference. Sutures are placed so that there is equal length of suture on both sides of the wound. Non-shelved areas have no self-sealing properties; thus, compression of the wound by the suture itself is critical to obtain corneal wound closure. Very short-shelved wounds may intermittently self-seal but require suturing to maintain wound apposition. It is important to ensure that suture bites are symmetric in depth on each side of the wound to prevent corneal override.1 In shelved wounds in particular, the deepest component of the suture should be placed so that it reapproximates the posterior wound. On the superficial surface, due to the shelved nature of the tissue, the suture material may appear longer on one side of the wound than the other, but this is to be expected. We encourage the use of a slip knot (see Video-based surgical curriculum for open-globe injury repair, III: surgical repair, “Surgical Knots”), which is tied and buried in the corneal stroma. Care should be taken to ensure that sutures are appropriately taut: overtightening can result in unwanted astigmatism, whereas laxity can result in wound leak and increased risk of infection.
Video 2 (see also Appendix 2) shows repair of a central, zone I laceration. The surgeon placed three interrupted nylon sutures with a spatulated needle and secured the sutures and the wound with slip knots. Tension was confirmed and sutures were secured.
Video 2.
Surgical repair of central zone 1 corneal laceration.
(IL, SB, CC)
Stellate Wounds
Stellate corneal lacerations present a unique challenge because they are often difficult to close given the complex structure and fragility of corneal tissue at the apices of each wound flap. First, we recommend visualization and documentation (with possible drawing or slit-lamp biomicroscopy photography) of corneal wounds as soon as possible after initial injury. Corneal edema will worsen over time—there are often delays in getting the patient to the operating room—which can change the appearance of the wound.2 Careful planning of suture placement is also essential, because excessive repositioning of sutures can tear or macerate friable corneal tissue, making appropriate wound closure more difficult.
Second, the first suture is very important: the apices of the wound should be aligned, otherwise there may be gaps allowing leak at the apex. One should use the ship-to-shore method described elsewhere in this curriculum (Video-based surgical curriculum for open-globe injury repair, III: surgical repair, “Ship-to-Shore Suturing”). For V-shaped lacerations with a single flap of tissue, a single suture across the apex can be used to hold a thin flap of tissue in place. However, this alone is often not enough to close the wound appropriately, and often multiple sutures are needed along each wound edge at an angle to direct the forces toward the apex, allowing for tighter apposition of the wound edges.4
When approaching a stellate wound with multiple flaps of corneal tissue, a common issue is that closing one flap can open an adjacent flap. This leads to repeated adjustment and repositioning of sutures to close all the flaps. While the use of multiple adjustable sutures may be helpful in this situation, there are two additional suture techniques that can be used to bring together multiple apices with a single suture. These techniques allow for a more equal distribution of forces across all the flaps and are often used in addition to traditional suture techniques.
Butterfly Suture
In this simple technique, a “figure of 8” suture in which each pass is used to cross different flaps produces tissue compression in multiple meridia. The suture is initiated within the wound so that the final knot is buried. A more sophisticated variant of the butterfly suture uses a star-shaped suture to close stellate lacerations.5 The first pass starts inside the wound, and the next bite is a full-thickness clockwise bite across the opposing fork. A full-thickness bite is then made in an opposing fork before returning to the fork next to the one originally sutured. The final bite is half thickness in the original fork to allow the knot to be buried inside the wound (Video 3; see also Appendix 3).
Video 3.
Butterfly suture.
Purse String Suture
Purse string sutures are an alternative single-suture solution. They are entirely buried and the circular profile produces even tissue compression in all meridia at the wound fork. However, purse string sutures can be quite technically challenging to place and align correctly. A modified technique6 was developed for placing a purse string suture in which partial thickness incisions are made between the arms of the laceration and a purse string suture is passed through these grooves and tightened to approximate the apices of the wound. The suture is buried when it is tied, and it is left in place indefinitely.
(NP)
Foreign Bodies in the Cornea and Anterior Chamber
Full-thickness intracorneal foreign bodies and anterior chamber foreign bodies must be removed in the operating room, and the entry site must be repaired. Intraocular foreign bodies can cause damage by direct mechanical injury, metallosis, or endophthalmitis.7 Prompt removal is important to prevent these sequelae, but the approach must be tailored to the specific case. Preoperative evaluation should include computed tomography of the orbits. If there is a loose foreign body in the anterior chamber, preoperative dilation should either be deferred or should be performed cautiously because of the risk of the foreign body falling posteriorly to the iris.8
Embedded penetrating corneal foreign bodies can either be pulled out externally with forceps or pushed out of the anterior chamber using an instrument such as intraocular forceps or a cyclodialysis spatula. Care should be taken to remove these objects along the path through which they entered the eye to prevent excess trauma, and the anterior chamber should be maintained with viscoelastic prior to removal. Video 4 provides an example of a patient with a thorn embedded in the central cornea that was removed using a cyclodialysis spatula and toothed forceps (see also Appendix 4). For foreign bodies that lie entirely within the anterior chamber, a paracentesis incision may be created, and the foreign body can be removed with intraocular forceps. Removal of an anterior chamber foreign body through the entry wound is discouraged, because excess manipulation of the wound may increase scarring and corneal damage.7
Video 4.
Removal of foreign body from 3 patients with zone I corneal laceration.
Viscoelastic may be used to protect intraocular structures and prevent the foreign body from migrating posteriorly during retrieval. Video 4 shows two additional examples: (1) a patient with a zone I corneal laceration with removal of an eyelash from the anterior chamber, and (2) a patient with a zone I corneal laceration and a small piece of wood embedded in the iris. In the second of these examples, intraocular forceps were used to dislodge the foreign body and remove it through the paracentesis.
(NDR)
Using Cyanoacrylate Glue
Cyanoacrylate glue is a useful tool in corneal wound repair on account of its adhesive and bactericidal properties.2 Scenarios in which to consider using cyanoacrylate include persistent wound leak after suturing, complex wounds with significant corneal edema and friable tissue, delayed open-globe injury presentation, small focal wounds (especially ones that could be infected or are at risk of perforation), and new postoperative wound leaks.9–11 Different techniques of cyanoacrylate glue application have been reported in the literature. Video 5 (see also Appendix 5) shows our preferred technique, which allows for controlled application of glue.
A 3 mm skin biopsy punch is used to cut out a small circle of plastic from a sterile drape.
A small dot of antibiotic ophthalmic ointment is applied to the noncotton end of a sterile cotton tip applicator and used to hold the plastic button.
A small drop of cyanoacrylate is applied to the button. This allows for focal placement on a wound—if glue were placed directly on a wound, it would spread diffusely.
The wound is dried using a Weck-Cel sponge tip, and the button is placed over the wound with the glue facing the ocular surface.
It can be helpful to place a small air bubble in the anterior chamber before applying the glue to ensure that the wound remains dry while the glue hardens.10 The cotton tip applicator is held gently with the button over the wound for several seconds until the glue dries fully around the disc—there is a visible change after a few seconds, as the glue sets and appears like a window frosting over.
Further discs can be applied as described above until leaking stops; a bandage contact lens is applied at the end.
Video 5.
Use of cyanoacrylate glue in corneal wound repair.
Postoperatively, the bandage contact lens improves patient comfort and keeps the glue buttons in place as the wound heals. It is common for a wound to be Seidel negative at the time of repair but become Seidel positive as the corneal edema improves. If there is concern for a nonhealing or leaking wound, the glue can be removed slowly over several visits, or glue reapplication can be considered; the patient will need to continue bandage contact lens wear and topical antibiotic drops until glue removal is complete. Finally, it is important to continue regular follow-up visits until the glue is completely removed, because long-standing cyanoacrylate application can incite an inflammatory reaction (eg, anterior uveitis, elevated intraocular pressure, corneal and iris neovascularization) due to its degradation products, cyanoacetate and formaldehyde.
(CBK)
Corneal Penetrating Keratoplasty Wound Dehiscence
Corneal wound dehiscence from blunt trauma is an infrequent complication of penetrating keratoplasty.12,13 The risk of developing wound dehiscence persists throughout the patient’s lifetime. Keratoplasty dehiscence can lead to severe damage of intraocular structures and permanent vision loss.
The goal of the initial repair is to reposition uveal tissue into the eye and close the wound with interrupted sutures as soon as possible. Because globe irregularity, donor graft override, and corneal edema are not uncommon in the setting of graft dehiscence, these wounds are often best approached using radial, interrupted sutures to continually bisect the open wound.14
Sutures should be placed symmetrically, so that there is an equal amount of tissue on both sides of the graft-host junction, and slightly longer passes can ensure adequate closure in the setting of possible tissue maceration. It is preferred to have slightly tighter sutures than would otherwise be used in a fresh corneal graft given that corneal edema at the time of initial repair will undergo deturgescence over time. Anterior vitrectomy can be performed as needed at the time of initial repair, but other procedures, such as secondary intraocular lens placement or vitreoretinal procedures, should be delayed. Video 6 (see also Appendix 6) demonstrates successful wound closure in a patient with wound dehiscence of the penetrating keratoplasty in the left eye after accidental trauma.
Video 6.
Wound closure in a patient with wound dehiscence of the penetrating keratoplasty.
(KKM, SOT)
Rotation and Burial of Corneal Suture Knot
Proper rotation of corneal sutures, resulting in buried knots, is critical to long-term success in ocular trauma cases. After proper suture placement, tying forceps are used to gently grasp the suture, and apply either a pulling or pushing force that is parallel with the suture track. The instrument should be held as flat as possible against the corneal surface, having the tips point in the direction of rotation of the suture.15 Care should be taken to bury the knot in the stroma on either side of the laceration but not leave the knot in the corneal defect. The knot should be rotated away from the pupillary axis. Proper technique prevents breakage of sutures in burying them. An example of a patient who suffered a central zone I laceration is provided in Video 7 (see also Appendix 7). The surgeon placed 7 interrupted 10-0 nylon sutures with a spatulated needle to secure the wound. Notably, in this case, Colibri 0.12 forceps was used to stabilize the eye by grasping the episclera and providing countertraction during suture rotation.
Video 7.
Corneal suture rotation.
Exposed sutures can lead to a variety of sequelae, including foreign-body sensation, granulomatous inflammation, and corneal neovascularization; it may also serve as a nidus for infection.11 Proper technique is crucial for the burial of corneal sutures, which ultimately leads to resolution of pain and decreased risk for a subsequent infection.
(TB, GWA)
Key Learning Points
Paracentesis creation requires careful technique to prevent further damage to a hypotonic eye during OGI repair. During paracentesis creation, firmly grasp the episcleral tissues adjacent to the selected incision site and enter vertically with the paracentesis blade.
Proper corneal laceration repair improves visual outcomes and prevents infection.
Proper technique minimizes abnormal corneal shape and unwanted astigmatism.
Corneal wound repair requires special attention to depth, distance from the wound, and tension to ensure the best visual outcome.
Corneal wounds may become edematous with time, necessitating early visualization and documentation for proper repair.
Careful planning of suture placement and alignment of the apices are important initial steps when approaching a stellate wound.
Closing one flap of a stellate wound may open an adjacent flap; different suture techniques may close stellate wounds by evenly distributing tension across multiple flaps.
Full-thickness intracorneal foreign bodies and anterior chamber foreign bodies should always be removed in the controlled setting of the operating room, even if they are accessible externally.
Prompt removal of foreign bodies can minimize the risk of intraocular toxicity and infection.
Due to its adhesive and bactericidal properties, cyanoacrylate glue is a useful tool in complex corneal wound repair and in sealing corneal wound leaks.
Proper technique and careful postoperative follow-up increase the likelihood of a watertight wound seal, prevents superfluous glue application, which can be irritating for the patient, and reduces the risk of inflammatory sequelae and scarring related to longstanding cyanoacrylate application.
During repair of a dehisced corneal penetrating keratoplasty, uveal tissue should be reposited in the eye and anterior vitrectomy performed as needed, but further procedures should be delayed after primary closure.
Dehisced penetrating keratoplasty grafts should be closed by repeatedly placing radial interrupted sutures half-way along the open wound.
Slightly longer suture passes and tighter sutures are preferred in cases of traumatic wound dehiscence.
Proper burial of a corneal suture knots improves patient comfort and may prevent infection and mucous build-up.
Proper technique in burying sutures minimizes the risk of breaking the suture.
References
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