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Management of the Ruptured Eye
Treatment Figure 1: Evidence of an Occult Rupture
On the operating table, the surgeon must follow certain guidelines
to achieve the best possible outcome. Once the diagnosis is made
or the possibility of an occult rupture cannot be excluded, the
ophthalmologist must arrange for immediate surgery. Any
delay risks an expulsive choroidal haemorrhage, the most
devastating complication of an open-globe injury. The other very
serious complication, endophthalmitis, is less of a threat as the
object has not penetrated into the eye; even if the wound is open,
the direction of movement is for materials away from, not into, the
eye. In the case of an occult rupture, the conjunctiva provides
adequate protection. General anaesthesia is preferred; however, if
this is not available, some type of local anaesthesia has to be
considered, as opposed to automatically deferring surgery until
general anaesthesia becomes available.
Timing
The well-circumscribed lesion (dark circle) is the extruded lens.
As a general rule, the sooner the wound is closed the better. However,
this must be balanced by the availability of the facility and its Figure 2: Suture Introduction in Eyes with an
infrastructure (materials, equipment, personnel), as well as by the
Anterior Scleral Wound
surgeon’s experience. This concerns not only the wound closure itself
but also the potential need for additional surgical manipulations (see
below). An individual decision must be made taking into account
every factor, including the severity of the injury and the wishes/
circumstances of the patient.
Wound Toilette
Only when an expulsive choroidal haemorrhage (ECH) occurs is it
permissible to incarcerate tissues in the wound. In the vast majority
of cases, the wound edges must first be cleaned of all materials, be
they external (foreign bodies, debris) or internal (intraocular tissue).
2: 25% 1: 50% 3: 75%
Following proper cleansing, repositioning is the goal, except for
vitreous prolapse, which is preferably cut with the vitrectomy probe
The first suture divides the wound into two roughly identically sized wounds, which are
rather than using sponge and scissors. Even if the injury is over 24
divided in the middle again, continuing until the seal is watertight.
hours old, every attempt should be made to preserve the iris.
Figure 3: Suture Introduction in Eyes with an
Closure of a Scleral Wound
Anterior Scleral Wound
If the scleral wound is anterior, it is best to carefully open the
conjunctiva so that the entire length of the scleral wound becomes
visible. After proper wound toilette, permanent (e.g. 6-10 or 8-10
nylon) or absorbable (e.g. 6-10 or 8-10 vicryl) sutures are introduced
according to the ‘50% rule’ (see Figure 2).
If the scleral wound is posterior enough to interfere with easy access
(typically, extending past the equator), the ‘close-as-you-go’
technique is recommended (see Figure 3). The conjunctiva is opened
anteriorly only, and the sclera is closed using the above-mentioned
sutures starting from the wound’s proximal end. As the conjunctival
edge is approached, it is opened further posteriorly, exposing another
portion of the scleral wound. This approach minimises the risk of
further tissue extrusion during manipulations aimed at securing space
for closing the posterior aspect of the scleral wound. Once it becomes
obvious that the wound is so posterior that the introduction of a
suture unavoidably threatens to cause more tissue prolapse or risks
an ECH, the scleral wound is best left open. The conjunctiva is
carefully closed and a shield is placed over the eye to prevent
external pressure. The body’s scar-formation process typically firmly
closes the wound within days. Incarceration of tissues is the rule, not
the exception, in these cases; this must subsequently be addressed
from the inside. The ‘close-as-you-go’ technique for posterior scleral wounds.
EUROPEAN OPHTHALMIC REVIEW 49
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