AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

A corneoscleral laceration may occur following blunt or penetrating ocular trauma. This ocular trauma may be sustained at work, during sports, following a motor vehicle accident, or in a brawl. The laceration may be the only injury. The uvea, the retina, or the vitreous may prolapse through the wound. Loss of corneal or scleral tissue may occur. A corneoscleral laceration is more likely to occur in an eye that has undergone a previous surgery, such as radial keratotomy or corneal transplantation.

Frequency

United States

The exact incidence of corneoscleral laceration in the United States is unknown, but the overall estimated rate of all eye injuries ranges from 8.2-13 per 1000 population. Eye injury rates are highest among individuals in their 20s, males, and whites.

International

The incidence rate worldwide is unknown.

Mortality/Morbidity

Predicting the visual outcome in patients with corneoscleral lacerations is difficult. The outcome is generally poor in patients who have poor visual acuity at presentation, in patients with delayed presentation, and in patients who sustain agricultural-related injuries.

Sex

Corneoscleral lacerations are more common in young men than in young women.

Age

Corneoscleral lacerations are more common in younger persons. Wound dehiscences after ocular surgery, such as cataract surgery and corneal transplantation, are more common in older patients.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Obtaining a good history about the traumatic event is important.
• • The place, the time, and the activity that caused the injury must be elicited. Events after the injury, including any first-aid measures, should also be noted.
  • Patients should be asked about their use of safety glasses in work-related eye injuries.
  • Patients should be queried about other injuries, especially head injuries. Even if patients deny them, they must be carefully evaluated for such injuries. Life-threatening injuries must be managed first.
• Past medical and surgical histories should be obtained. Immunization status for tetanus should be included.
• Past ocular history is required in patients with corneoscleral injuries.
• • Dates and particulars of previous eye examinations or school vision screenings may help the physician in understanding the status of the eye prior to the trauma.
  • History of amblyopia (lazy eye), eye patching, and muscle surgery for strabismus must be ascertained.
  • Any previous trauma and/or eye surgery should also be included.
• Patients should be asked about other symptoms, such as headache, eye pain, nausea, or vomiting.

Physical

A good history helps the physician in performing an appropriate physical examination.

• In conscious and cooperative patients, visual acuity should be obtained.
• • Visual acuity at the bedside may be obtained with reading cards.
  • In the presence of ecchymosis and lid swelling, a wire speculum may be used after instilling topical anesthetics, but no external pressure should be placed on the eye.
• The anterior segment is ideally examined with a slit lamp.
• • Pay particular attention to the corneoscleral laceration. The location and the length of the laceration should be noted.
  • If the intraocular contents prolapse through the laceration, the rest of the eye examination should be deferred and performed in the operating room.
  • Measurement of the intraocular pressure is also deferred because any pressure on the globe can result in extrusion of the intraocular contents.
• The size and the shape of the pupil and its reaction should be checked. Whenever possible, the pupils should be checked for a relative afferent pupillary defect.
• Confrontation visual fields must be assessed.
• The fellow eye should be carefully evaluated, including a dilated fundus examination.
• After a corneoscleral laceration is diagnosed, an eye shield is applied, and the head of the bed is elevated.
• Pain, nausea, and vomiting must be appropriately managed.

Causes

A corneoscleral laceration may occur following blunt or penetrating ocular trauma. Patients who have undergone previous ocular surgery may develop a wound rupture with relatively mild trauma.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Patients with corneoscleral lacerations should have cultures performed in the operating room if the wound appears infected.
• • Cultures from the wound should be obtained before the patient is prepared for surgery with Betadine.
  • Cultures can also be obtained from any intraocular foreign bodies or tissue resected during surgery.
• Blood agar, chocolate agar, thioglycolate, and Sabouraud agar are recommended. Gram and Giemsa stains can also be obtained.

Imaging Studies

• Imaging should be considered when an intraocular foreign body is suspected. X-ray films and CT scans are quick and can be readily obtained. MRI should not be obtained if any possibility exists of a metallic foreign body in the eye or the orbit.
• A CT scan is also useful in assessing any injury to the orbital bone in patients who have sustained blunt trauma.
• A B-scan ultrasound examination that is gently performed by an expert may be helpful in identifying an intraocular foreign body.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

A corneoscleral laceration is surgically treated. Medications play a secondary role. Intravitreal, intracameral, topical, and systemic antibiotics are used for prophylaxis against infections. Topical steroids are used to reduce postoperative inflammation. Cycloplegics may be used to relieve ciliary muscle spasm. Elevated intraocular pressure is not uncommon as a result of the injury per se or due to associated inflammation. Under these circumstances, aqueous suppressants are indicated.

Surgical Care

• The patient is prepared for surgery as soon as possible and should be medically and neurosurgically cleared.
• The time of the last meal or drink determines when surgery is scheduled. To prevent aspiration, at least 6 hours should have elapsed since the last meal. Once the physician decides to repair the laceration, the patient should be kept NPO.
• The primary aim of surgery is to restore the anatomical integrity of the globe.
• Repairing corneoscleral lacerations under general anesthesia is recommended.
• • Anesthesia should be achieved without any increase in intraocular pressure, which can occur during intubation or because of anesthetic agents.
  • Depolarizing agents (eg, succinyl choline) are not used. Although succinyl choline possesses several advantages, it contracts extraocular muscles and increases intraocular pressure.
  • External pressure from the mask can also increase intraocular pressure.
  • Local anesthesia is generally not used as an anesthetic agent because it may increase intraorbital and intraocular pressures. Injecting it is also difficult because the normal globe anatomy is lost as a result of the trauma. The patient may also squeeze the eye while the physician administers the injection.
• The eye should be prepared and draped with care. Pressure should not be applied to the globe. The eye is irrigated with a sterile balanced salt solution (BSS) to remove any superficial foreign bodies.
• The eye is gently examined to evaluate the extent of damage. If the globe appears unstable, sutures are first applied prior to exploration of the wound.
• • First, a suture is applied to the limbus, and the wound is tightly secured. This suture helps to anatomically approximate the wound.
  • The author recommends the use of 9-0 or 10-0 nylon sutures.
  • After the first suture is applied, an iris prolapse or a vitreous prolapse is treated. In the presence of an iris prolapse, see Iris Prolapse for a description of the surgical procedure. In the presence of a vitreous prolapse, a vitrectomy is performed with cellulose sponges or an automated vitrector. During the vitrectomy, traction on the vitreous should be avoided. Any vitreous in the anterior segment may be removed using a vitrectomy machine.
  • To close the corneal wound, 10-0 nylon sutures are applied.
  • A traumatic cataract may be present. Unless lens material is fluffed up into the anterior chamber or the lens has become intumescent, the cataract is often not removed at this time. A more controlled cataract extraction with better visualization can be performed at a later date. Intraocular lens (IOL) calculations with keratometry and axial length measurements may not be available in an emergency situation.
  • If the cataract must be removed at the time of the corneoscleral laceration repair, it is typically performed through a limbal incision once the laceration has been repaired.
• After the corneal wound is repaired, the scleral wound is explored. This exploration is achieved by performing a limbal peritomy at the site of the limbal wound. The author recommends the placement of interrupted full-thickness scleral sutures using 9-0 nylon.
• • Segments of scleral laceration are explored and repaired. This method helps to stabilize the eye and to prevent uveal or vitreous prolapse. Scleral laceration should be repaired as far posteriorly as possible; far posterior scleral ruptures may be left unsutured. While repairing scleral lacerations, care must be taken to not exert pressure on the globe.
  • In the presence of uveal prolapse, the prolapsed tissue is reposited. The author avoids excision of the prolapsed uveal tissue unless it is necrotic because it causes excessive bleeding.
  • Vitreous prolapse is managed by performing a vitrectomy with cellulose sponges and scissors or by using an automated vitrector. The sutures are placed closely together and tied to achieve a watertight closure.
  • Intravitreal antibiotics may be injected through the scleral laceration.
  • The conjunctiva is sutured using 8-0 or 9-0 Vicryl. A patch and a shield are applied to the eye.
• Postoperatively, patients should be carefully monitored for signs of infection.
• • Pain, photophobia, redness, tearing, or a deterioration of vision should alert the physician to look for signs of endophthalmitis.
  • Conjunctival injection, chemosis, corneal edema, and elevated intraocular pressure may be present but are not diagnostic of infection.
  • A more than expected anterior chamber reaction and cells in the vitreous are most suggestive of endophthalmitis.

Consultations

Appropriate consultation must be obtained from the physicians in the emergency department to rule out other injuries. Patients must also be cleared for general anesthesia.

Diet

Postoperative fluids are administered and then advanced as tolerated.

Activity

Patients should be instructed to wear polycarbonate (which is a shatterproof material) eyeglasses while working with mechanical tools or playing sports. Patients should be advised to not engage in contact sports for several months after the laceration repair. If the patient has difficulty with depth perception because of poor vision in the injured eye, the patient should be advised not to work with sharp, cutting, or power tools and where depth perception is essential.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Systemic antibiotics are routinely used for prophylaxis against infection. Endophthalmitis is uncommon but has a poor prognosis in the setting of ocular trauma. In one study, delayed repair, ruptured lens capsule, and dirty wound were each independently associated with the development of posttraumatic endophthalmitis. Antibiotics should cover both gram-positive and gram-negative organisms, including Bacillus, which is the most common cause of posttraumatic endophthalmitis.

No controlled studies are available that show any benefits of systemic antibiotics.

Drug Category: Antibiotics

Therapy must cover all likely pathogens in the context of this clinical setting. Any of the fluoroquinolones may be used safely as ophthalmic drops.

Drug Category: Carbonic anhydrase inhibitors

These agents are used to treat elevation of intraocular pressure associated with ocular injuries or inflammation. By slowing the formation of bicarbonate ions with subsequent reduction in sodium and fluid transport, it may inhibit the enzyme carbonic anhydrase in the ciliary processes of the eye. This effect decreases aqueous humor secretion, reducing intraocular pressure.

Drug Category: Anticholinergic agents

These are thought to work centrally by suppressing conduction in the vestibular cerebellar pathways. They may have an inhibitory effect on the parasympathetic nervous system.

Drug Category: Corticosteroids

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli. Corticosteroids may be used to reduce postoperative inflammation.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Patients may be treated on an inpatient basis with 1-3 days of intravenous antibiotics.

Further Outpatient Care

• Patients being treated with oral antibiotics can be seen on an outpatient basis.
• If treated on an outpatient basis, patients should be seen on postoperative days 1 and 2. If their condition is improving, they can be seen 3-7 days later. Patients may be seen more frequently depending on the status of the eye. Further outpatient care is provided depending on the progress of the eye.

In/Out Patient Meds

• The author recommends oral antibiotics for 1 week, although no established controlled study supports this recommendation.
• The author uses a topical steroids and antibiotics for a few weeks. Cycloplegic agents are also recommended. Depending on the intraocular pressure, topical antiglaucoma medication may be needed.

Deterrence/Prevention

• The patient should be instructed to wear shatterproof eyeglasses with polycarbonate lenses while working with mechanical tools or playing sports. The patient should be advised to not engage in contact sports for several months after the laceration repair.

Complications

• The following complications are associated with corneoscleral lacerations:
• • Endophthalmitis (This occurs in 2-7% of patients with ocular trauma.)
  • Cataract
  • Iris damage
  • Glaucoma (This can occur acutely or later, possibly related to angle recession.)
  • Hyphema
  • Vitreous hemorrhage
  • Retinal detachment
  • Epithelial downgrowth
  • Fibrous ingrowth
  • Uveitis
  • Cystoid macular edema
  • Sympathetic ophthalmia (This can occur anytime after the trauma. One case of sympathetic ophthalmia occurred 50 years after the initial trauma.)

Prognosis

• Prognosis depends on several factors.
• • Patients with a small corneoscleral laceration without any other intraocular injury have a better prognosis.
  • Patients with other intraocular injuries, intraocular foreign bodies, endophthalmitis, late presentation, or agricultural-related injuries tend to have a poor prognosis.

Patient Education

• For excellent patient education resources, visit eMedicine's Eye and Vision Center. Also, see eMedicine's patient education article Eye Injuries.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Other intraocular injuries, head injuries, and bodily trauma must be ruled out. The fellow eye should be carefully examined, including a dilated fundus examination, to rule out any injury to that eye.
• Tetanus status should be noted. Tetanus toxoid should be appropriately administered.
• Although sympathetic ophthalmia is a rare complication of any ocular trauma, the patient must be informed about it. The patient should be advised of the symptoms of sympathetic ophthalmia and instructed to immediately seek medical attention in the occurrence of such symptoms. The physician must carefully examine the patient for signs of sympathetic ophthalmia and document any such signs during each examination.
• Informed consent must be obtained for every ocular trauma repair. Even if the injuries appear superficial, this discussion must include the possible presence of or subsequent occurrence of traumatic cataract, vitreous hemorrhage, retinal detachment, glaucoma, and sympathetic ophthalmia. In severe injuries, informed consent should include enucleation. (The author does not perform primary enucleation.)

Special Concerns

• In the setting of trauma in children (or in uncooperative adults), if an adequate examination to rule out a ruptured globe cannot be performed in the office, an evaluation under anesthesia (EUA) is required.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Albert DM, Jakobiec FA. Principles and Practice of Ophthalmology. Vol 6. WB Saunders Co;2000:5179-5217.
• Barr CC. Prognostic factors in corneoscleral lacerations. Arch Ophthalmol. Jun 1983;101(6):919-24. [Medline].
• Brinton GS, Topping TM, Hyndiuk RA, et al. Posttraumatic endophthalmitis. Arch Ophthalmol. Apr 1984;102(4):547-50. [Medline].
• Essex RW, Yi Q, Charles PG. Post-traumatic endophthalmitis. Ophthalmology. Nov 2004;111(11):2015-22. [Medline].
• McGwin G, Hall TA, Xie A. Trends in eye injury in the United States, 1992-2001. Invest Ophthalmol Vis Sci. Feb 2006;47(2):521-7. [Medline].
• McGwin G, Xie A, Owsley C. Rate of eye injury in the United States. Arch Ophthalmol. Jul 2005;123(7):970-6. [Medline].
• Ryan SJ, Allen AW. Pars plana vitrectomy in ocular trauma. Am J Ophthalmol. Sep 1979;88(3 Pt 1):483-91. [Medline].
• Schemmer GB, Driebe WT Jr. Posttraumatic Bacillus cereus endophthalmitis. Arch Ophthalmol. Mar 1987;105(3):342-4. [Medline].

Article Last Updated: Jul 14, 2006