Proper closure, prophylaxis can prevent retinal incarceration

Las Vegas-Following posterior scleral lacerations, attention to proper closure techniques and prophylaxis can prevent retinal incarceration. Jennifer L. Lindsey, MD, described how best to achieve this result and how to treat extensive scleral injuries here at the American Academy of Ophthalmology annual meeting.

"The initial evaluation of the patient should include a complete eye examination of both eyes, with attention to the extent of the injury and the presence and the type of foreign body," she said. "Computed tomography can be a great adjunct to this process. In addition, consideration should be given to the need for a consultation with vitreoretinal or oculoplastics colleagues before or after the initial repair has been accomplished."

Dr. Lindsey, an assistant professor of ophthalmology and visual sciences, Vanderbilt Eye Institute, Vanderbilt University, Nashville, also pointed out the need for infection prophylaxis and the all-important tetanus shot.

In some cases, Dr. Lindsey said, the signs of scleral rupture can be subtle. To illustrate this, she reported on a patient with a blunt injury and iridodialysis seen by Paul Sternberg, MD. The only sign of the occult scleral injury 180° from the area of the primary injury, she said, was a vitreous hemorrhage streaming to the site.

If an occult scleral laceration or perforation is suspected, then pressure exerted on the globe should be avoided in the operating room, according to Dr. Lindsey. "Careful repair of the injury should be done to avoid prolapsing the intraocular contents and causing further damage," she said. "A 360° peritomy should be performed to visualize the extraocular muscle insertions, and the muscles can be disinserted temporarily if needed. The landmarks, including the corneoscleral limbus when there is a corneoscleral laceration, need to be identified. Proceed with the repair, and pay careful attention to any prolapsed tissue that is present."

A scleral injury that is extensive posteriorly may have to be left unsutured because of the possibility of exerting too much pressure on the globe, she said. "If the surgeon believes that too much pressure may risk causing additional damage, it is the better part of valor to leave these injuries unsutured and allow them to close primarily," Dr. Lindsey added.