Trauma repair techniques with suturing

1. Traumatic Corneal and Scleral
Wound Repair
Dr. Deepayan Sarkar

2. References
1. Eye Trauma –Bradford Shingleton Chap 372 & 374
2. Principles and Practice of Cornea –Copeland & Afsari. Section 19, Volume 1.
3. Trauma Suturing Techniques - Marian S. Macsai and Bruno Machado Fontes
4. Corneal Surgery –Brightbill Pg. 622-640.

3. Assessment of Wound :
1) Initial recording of vitals and look for any life threatening injuries.
2) Initial presenting vision to be recorded- Helps to assess the visual prognosis and also for medicolegal
documentation.
3) Extent of Injury-
a) Zone of injury-
Zone 1- Injury upto the corneo-scleral limbus.
Zone 2- Injury upto anterior 5mm of sclera from corneo-scleral limbus.
Zone 3- Injury beyond 5mm posterior to the limbus.
b) Assessment of the Cornea –
Assessment of the wound by Slit lamp examination-
-Note Length, Breadth and Depth of the wound.
- Full thickness or partial thickness wound.
- The wound if extending beyond the corneo-scleral margin into the sclera.
- Uveal tissue incarceration in the wound.
- Presence of infiltrates around the wound.
- Presence of any FB in the wound.

4. c) Assessment of Sclera-
- Note Length, Breadth and Depth of the wound.
- Full thickness or partial thickness wound.
- Conjunctival peritomy to assess the extent of the scleral wound to be done intra-
operatively.
-Uveal tissue incarceration to be noted.
d) Anterior chamber-
- AC formed/not.
- To look for presence of Hyphema.
- To look for presence of Lens matter in AC.
- To look for Presence of vitreous in AC.
e) Pupillary reaction- If pupillary reaction is visible look for RAPD/APD, it helps to assess any posterior
ocular injury and helps to assess visual prognosis.
f) Lens-
- Clear/Opaque
- Insitu/not
- Lens rupture to be noted.
g) Posterior Segment assessment- -To look for Vitreous Haemorrhage/Retinal Haemorrhage/Retinal
detachment.

5. Open Globe injury
Classification:

6. OTS Scoring:

7. 1) Any perforating injury
2) Any wound with tissue loss
3) Any clinical suspicion of globe rupture requires exploration and possible repair.
4) Active bleed with uveal tissue prolapse.
Surgical Indication for repairing corneo-scleral wound
Timing of surgery-
-Primary repair should be planned as soon as possible if the patient is stable and has
no life threatening complications.

8. Pre-op preparation
1) Explain visual prognosis, complications, need for future surgeries. Obtain written consent.
2) Tetanus Prophylaxis.
3) Patch the eye with eye shield. Avoid any topical medications.
4) Ask patient to refrain from activities that involve straining or Valsalva Maneuver.
5) Xray of orbit in AP-Lateral view/NCCT to be obtained to look for any FB that needs to be removed
during primary repair
6) Systemic Antibiotic Prophylaxis (oral/intravenous)
7) Routine Blood investigation and serology may be done pre-operatively, but not mandatory for
surgery.
8) GA is preferred. IV Mannitol administered if IOP is high.
9) Avoid Betadine drops, gentle periocular painting, draping and speculum insertion.

9. Surgical Goals:
1) Restoration of normal anatomy.
2) Watertight wound closure.
3) Restoration of optimal visual function.
4) Prevention of possible future complications.
The overall goal is to restore the native corneal contour with minimal scarring. Corneal tissue should be
conserved as much as possible to avoid wound distortion or misalignment resulting in irregular
astigmatism.
Infection should be assumed,and the wound and any intraocular samples should be submitted for culture
and sensitivity.

10. Instruments required:
• Lid speculum
• Sutures
• Microsurgical forceps
• Microsurgical tying forceps
• Needle holder
• Vannas scissors
• Iris repositor
• Muscle hooks
• Viscoelastic
• Cellulose sponges
• Phacoemulsification, irrigation, and aspiration,
and automated vitrectomy units should be available

11. Corneal Suturing
• Ideal suture material- Monofilament suture (Nylon/Polypropelene) – causes low tissue reaction.
• Ideal needle- Spatulated needle –Maintains suture depth.
• Most stable suture configuration- Planar Loop for interrupted sutures

12. Surgical Technique:
-For proper healing, the wound edges should be exactly apposed.
-Regardless of design, sutures seek their most stable geometric configuration.
Therefore, correct passage of a suture is necessary to achieve good wound
-Perpendicular parts of the wound will open under normal IOP, so initial closure of
these areas. will enhance anterior chamber formation as the shelved areas of the
incision are often self-sealing.
-Temporary sutures may be needed to obtain a watertight closure,and once the
areas are closed, the initial sutures may be replaced with more astigmatically neutral
sutures. If at all possible, suture bites through the visual axis should be avoided.
The drawing illustrates the
relationship between the
perpendicular areas of the laceration
and the shelved areas. If the
perpendicular areas are closed
initially, then the shelved areas are
self-sealing and require fewer
sutures under less tension

13. Suture Placement-
• The tip of the needle is placed perpendicular to the corneal surface and the needle is rotated through
wound along its curve, exiting perpendicular to the cut surface.
• Corneal sutures are 90% deep in the stroma and equal depth on both sides of the wound.
Full thickness sutures allow suture material to act as a conduit for microbial invasion.
• Suture pass length is approximately 1.5-2mm.
• Suture should be placed through healthy tissue as macerated/edematous tissue doesn’t hold suture.
• Interrupted sutures act by compressing the tissue within the loop and generate a plane of compression
the tissue contained within the suture loop. The plane of compression extends away from the suture
roughly triangular configuration extending approximately one half the total tissue length in either
direction of the wound. Wound closure is achieved when compression zone abuts.
Wound leakage occurs when there is insufficient overlap of compression zones to permit wound gape
and leakage.

14. a) Shows the compression zones of the interrupted sutures
donot meet and cause wound gaping
b) Shows abuting of the compression zones leading to perfect
wound apposition.

15. • Tissue compression causes flattening of the overlying surface and this causes flattening of the cornea,
giving rise to astigmatism.
Rowsey-Hays technique: Shorter minimally compressive sutures in the corneal centre and long
tight sutures in the corneal periphery.
This causes corneal flattening and central steeping causing normal corneal contour.
Long suture bites allow a greater distance between sutures, and smaller bites require more closely
spaced sutures, to overlap the zones of compression.
But excessive overlap of compression zones can lead to excessive scarring and tissue flattening.

16. Perpendicular wound:
• To avoid wound override the entry and exit of suture bites must be of equal tissue depth.
Also,
the bites on either side of the perpendicular laceration must be of equal depth from the
perspective.
• Suture placement is critical to avoid tissue override and the inducement of irregular
astigmatism.
A = B
Correct suture placement
Tissue overlap

17. Oblique wound :
• If the same technique is followed for an oblique wound as is followed for a perpendicular wound
= B), tissue override will result.
• Correct closure of an oblique wound to ensure proper tissue apposition. In this technique, the
distance from the point of entry of the suture to the point of exit through the wound (C) should
measured from the posterior aspect of the cornea, and should be equal to the distance from the
wound to the point of exit (D) as measured from the posterior aspect of the cornea. As a result,
D and A ≠ B as they are measured from the anterior aspect of the cornea.
A B
C D

18. Zig-Zag Wound : Each linear aspect of the incision should be closed individually to allow self-sealing of
the wound apices and avoiding additional trauma. In repairing these lacerations , the use of slipknots is
helpful. The straight aspects of the zigzag incision are closed first with interrupted sutures. The apical
portion of the incision may then self seal. If the apical portions require suture closure,a mattress suture
technique may
be useful.
The linear aspects of the zigzag
laceration are closed initially, as
the apical portions may be
shelved and self sealing

19. Stellate Laceration :
In the stellate laceration, the straight arms of the laceration are closed initially with
interrupted sutures. The stellate portion is closed last.
2 techniques-
1) Eisner method- A partial thickness incision is made between the arms of the
and a purse string suture is passed between the grooves and tightened to approximate
apices of the wound. Overtightening of the purse string suture will result in forward
displacement of apices and wound leakage.
Eisner method
closing

20. 2) Akkin Method- No partial thickness groove is made. The suture is passed through the
tissue and over the apices of the wound to appose the tissue

21. Corneal tissue loss:
A trephine is used to mark the area around the ulcerated area. Trephination is not
performed, as the intraocular contents may extrude from the external pressure.
A sharp blade is used to cut down to a 50–60% depth. A lamellar dissection is
performed to remove the necrotic tissue. The trephine is then moved to another
peripheral area of the same cornea and used to trephine a 50% depth in the
peripheral corneal tissue. Lamellar dissection is used to harvest this donor
The donor
lenticule is secured in position with interrupted 10-0 nylon sutures to close the
perforated area. The exposed stroma where the donor lenticle was harvested is
allowed to heal
by secondary intention, with either patching or a bandage contact lens.
Donor corneal tissue
sutured at defect site

22. Burying of corneal suture knot:
• All corneal and limbal knots should be buried to reduce
corneal irritation, suture ends are trimmed short and
superficially buried in the tissue on the side away from the
visual axis.

23. Running Suture-
• Running sutures tend to flatten the overlying corneal surface
throughout the length of the suture and to straighten curvilinear
wounds because of the continuous nature of the compressive
effect of running suture.
• The closure with running suture places the integrity of the entire
wound on a single suture which may pose safety risk of suture
untying.
• Running sutures tends to straighten curvilinear wounds causing
dog earing leading to permanent wound distortion.
• So running suture is avoided in traumatic corneal wound.

24. Scleral Tear Repair
• Careful exploration of scleral wound with conjunctival dissection to locate the
scleral wound extent.
• In case of corneo-scleral wound; the limbus is reapproximated first to restore
normal anatomic relationship .
• Closure should be performed at the exposed site with repositioning of the
intraocular contents before further posterior dissection (Hand over hand
technique)
• The extruded intraocular contents should be repositioned by spatula when
sutures are placed.
• In case of muscle insertion defects ,the muscle is disinserted and is reattached
after suturing the sclera.
• Scleral is best repaired by Polygalactin (Vicryl) 8-0 suture.
• Prolapsed vitreous should be excised carefully not to cause any traction to the
Vitreous base and the retina.

25. • Injuries with tissue loss require replacement with donor scleral
tissue. The necrotic and avulsed tissue is removed before graft
placement.
• Scleral lacerations that extend posteriorly till the optic nerve are
best managed conservatively, as surgical approach may increase
damage. The ocular soft tissue acts as a tamponade which aids
healing.
Scleral patch graft

26. Management of Incarcerated Uveal tissue
• Prolapsed iris should be repositioned and freed of incarceration strands.
• Visco-dissection and sweeping of the wound from the sideport entry with blunt
instruments facilitates iris repositioning and future reconstruction. Iris tissue that
is exteriorized for less than 24 hours and has no surface epithelialization can be
reposited.
• Necrotic ,infected and macerated iris tissue should be excised.
• Surface epithelialization indicate need for excision.
• If direct surgical manipulation is required, one must work from centre towards
periphery in order to minimize tension on the iris root, thereby reducing the risk
of bleeding.
• Ciliary body is checked for injury ,causes severe bleed.
• Definitive iris repair is done at a later stage when intraocular inflammation is low.

27. Post-op Care
1) Remove eye patch after 24 hours (approx).
2) Slit Lamp assessment for a) Suture integrity b)AC formed c)Wound leakage (Seidel’s
test) d) AC contents(blood, lens matter, vitreous) e) Intraocular structures.
3) Systemic antibiotics (Broad spectrum), Analgesics
4) Topical Fluroquinolones, Topical Steroid, Topical Cycloplegic, Topical Anti-glaucoma
drug if required.
5) Plan USG B scan to look for Foreign body(radioluscent), Air bubble in vitreous, signs of
Endophthalmitis ,any Retinal detachment.
6) Keep patient under close followup. Counsel for visual prognosis.
7) Plan secondary reconstructive procedures when inflammation subsides.
8) Plan removal of corneal sutures at 6 weeks after clinical examination of wound or
during secondary procedure. Scleral vicryl sutures are self-absorbable.

28. Complications
1) Endophthalmitis
2) Suture slippage and wound leak
3) Necrosis of intraocular structures
4) Expulsive haemmorhage
5) Retinal detachment
6) Hyphaema
7) Irregular astigmatism.
8) Blindness

29. Recent Advances:
1) Tissue adhesive glue- In case of partial thickness wound of less than 2mm in size, glue with
BCL can be used.
2)Tectonic Lamellar patch graft in case of corneal partial thickness tissue loss.
3) Vision graft – They are made from human cornea, gamma irradiated and used for emergency
and tectonic procedures.
a) C01010AL –Whole cornea with scleral rim.
b) C0300AL-90 – Whole cornea without scleral rim (200-300micron).

30. Thank You