OCULAR TRAUMA AND ER PROCEDURES SHELBY REINSTEIN, DVM, MS, DACVO
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and full-thickness lacerations will usually involve a misshapen globe, collapsed anterior chamber, iris prolapse or hyphema. The initial assessment of this injury involves MINIMAL manipulation and possibly placing an e-collar on the patient to start. NO tonometry or Schirmer tear test should be performed and these patients are often very painful and may need pain control/ sedation with topicals (proparacaine or tetracaine) or parenterals (methadone, buprenorphine or torbugesic). Small, sealed lacerations (not actively leaking) can be handled medically but anything that requires suturing or is full-thickness should warrant an emergency referral. LEARN MORE
the goal of treatment is to save the globe, not necessarily vision. Good prognostic indicators include minimal globe displacement/1 torn muscle, clear cornea or superficial (exposure) ulcer, no hyphema and intact consensual or especially a direct PLR. When prepping patients for surgery, it is important to only use dilute betadine SOLUTION since betadine SCRUB has alcohol and will scrub o ff the cornea! The main things to remember post- op in these patients is to treat with topical antibiotic drops TID-QID, AVOID topical or oral steroids due to the high risk for corneal ulceration, oral antibiotics like cephalosporine or doxycycline (anti-inflammatory benefit), and a hard plastic e-collar in addition to oral NSAIDs and pain control and atropine eye drops unless there is significant hyphema. Remember that enucleation is always an option later or may be initially indicated with compromised vascular/ nerve supply when >2 rectus muscles are avulsed, severe corneal disease with deep ulceration or pigmentation, penetrating trauma with corneal lacerations or scleral perforation (decreased turgor of the globe), pre- existing eye disease like cataracts or retinal disease (e.g. PRA), or with lack of consensual PLR indicating loss of vision in the proptosed eye. When performing an enucleation, HemaBlock (hemostatic powder) can really help to minimize bleeding and be EXTRA careful medially especially with brachycephalics because they have a large venous sinus there that
can bleed a lot if you’re not careful with pointing your instruments away from that area. A three-layer closure with an orbital rim mesh using 3-0 or 4-0 PDS to allow eyelid edges to form fibrous scar and prevents sinking in (implants not used since may cause more complications later), subcutaneous tissues with 3-0 or 4-0 PDS and skin using 3-0 or 4-0 Ethilon can provide better cosmesis without all the complications of implants, which the author no longer recommends or performs). 3 EYELID LACERATIONS The most common cause of eyelid lacerations are bite wounds and the biggest indication for surgical repair is if the eyelid margins are a ff ected. Third eyelid lacerations are less common and repair is only indicated for deep avulsions and can suture or remove that portion of the third eyelid if the gland is not involved. Utilize a 3 step closure in which the author preferentially uses 5-0 Vicryl. The most important suture placement is a figure of 8 at the eyelid margin to ensure accurate apposition. Then the subconjunctival layer is sutured only if it is a very large defect, followed by simple interrupted “French braided” for the skin. 4 CORNEAL LACERATIONS These occur most commonly due to bite wounds or cat claw injury and can be partial or full-thickness. It is important to di ff erentiate partial vs. full- thickness for treatment and prognosis
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