Corneal perforation wounds

An uncomplicated penetrating wound of the cornea is not accompanied by trauma to the underlying tissues. If the wound is small and its edges are well adapted, the anterior chamber is preserved, and the iris does not contact the wound. But it happens that in the presence of the anterior chamber, moisture oozes out. As a minimal intervention, biological glue or y-globulin is applied followed by a soft hydrogel contact lens or a small amount of autologous blood is introduced into the anterior chamber, and there is no need to enter the anterior chamber with a cannula, since the fistula is already there. After the blood is introduced, the patient is laid face down for 2 hours to form a hyphema in the area of the corneal injury. If these procedures in sealing the fistulizing wound, especially if it is located on the periphery, are ineffective, a conjunctival coating is made according to Kunt.

After epibulbar and subconjunctival anesthesia, in which novocaine is injected shallowly - under the epithelial layer of the conjunctiva, an apron flap is cut out by separating the conjunctiva along the limbus and superficially separating it in the desired sector with sharp scissors. When cutting out the flap, it is necessary to visually control the level of each section of the submucosal tissue in order to avoid accidental perforation, especially in the area that should shift to the corneal wound. The main sutures are applied at the corners of the conjunctival incision near the limbus, capturing the epithelial tissue. Thick, slowly cutting silk is used.

An uncomplicated corneal wound, especially an extended one, can be sealed with stitches, but this causes additional trauma - the iris may fall out and chamber fluid may leak through the suture channels, since it contains almost no protein.

An uncomplicated penetrating corneal wound with poorly adapted edges, even if it does not fistulate, is subject to hermitization. If the wound is sufficiently straight, a continuous suture of 09-010 synthetic material is applied.

In the case of a curved wound, a continuous suture should not be applied, since when tightened it tends to straighten out and can deform the cornea. If it is not tightened well, the edges of the wound will come together, but their tight closure will not be ensured. In this case, knotted sutures made of 08 snap should be applied.

In case of complex wounds without tissue defects, both types of sutures can be combined, applying separate interrupted sutures to particularly important areas. The frequency of sutures (stitches) in the anterior direction should correspond to 1 per 1 - 1.5 mm of tissue. In case of an oblique wound direction in the stroma, sutures are applied less frequently. Interrupted sutures are usually applied first, which restore the general shape of the cornea. Particular care is taken when the anterior chamber is absent or empties when applying the first stitches, and the lens is transparent (especially when manipulating the central zone of the cornea). In case of peripheral wounds, it is especially necessary to carefully monitor the iris, which can be imperceptibly stitched when applying the next, even non-through, suture. To avoid this, the suture is applied on a spatula, with which the assistant very carefully presses the pericrystalline diaphragm deep into the eyeball. Particular attention must be paid to the precise alignment of the edges of the wound on the section that has not yet been sutured.

To reduce the risk of iris infringement in the wound, the sutures should be carried out to Descemet's membrane or even with the capture of its slightly separated edges, so that the sutures also close the deepest parts of the wound edges. Before tying the last suture, the anterior chamber is filled with sterile air taken through the flame of an alcohol lamp. A thin cannula is inserted only slightly into the wound so that its inner edges provide a valve effect, not releasing air from the anterior chamber. The air bubble should not be excessively large, since pressing the pupillary edge to the lens can lead to an acute increase in intraocular pressure. It is not necessary to introduce a lot of air in peripheral wounds, since the gas at first quite correctly forms the anterior chamber, but then, after the fusion of individual bubbles and the restoration of the turgor of the eye, the air bubble is compressed and acquires an almost spherical shape, the lens is pressed back by it, and the root of the iris is moved forward and comes into contact with the area of the corneal wound.

If the fluorescence test shows that the sutured wound is not hermetically sealed somewhere, then 1-2 drops of the patient's autologous blood are "injected" into the chamber between the sutures, after which the patient is laid face down for 1 hour, but without resting the injured eye on the pillow.

Corneal wound with iris incarceration. If the corneal wound is not closed and the prolapsed iris is trapped in it, and only a few hours have passed since the injury, it is washed with an antibiotic solution. It is freed from fibrin deposits and adhesions with the wound edges, and then carefully immersed in the anterior chamber, placing corneal sutures on a spatula. If there is any doubt about the viability of the prolapsed iris, its contamination or defect, the iris is excised within the unchanged tissue, i.e. each time the iris is slightly pulled into the wound so that the incision falls on those parts of it that were previously in the anterior chamber (with maximum sparing; this especially concerns the iris sphincter). If the size of the cornea is sufficient and the iris is moderately excised, then the defect formed in the iris can be sutured with an automatic needle with a 010 synthetic needle. Then the corneal wound is sealed.

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Corneal penetrating wound with lens damage

In case of lens injury, surgical treatment consists of complete removal of the lens substance. Both cloudy and barely transparent masses in children are easily washed out through the wound using a well-wiped, not very tight syringe with a medium curved cannula. At the moment of aspiration, the lens substance is crushed and then easily washed out of the anterior chamber in successive portions of isotonic sodium chloride solution heated in a water bath to 30-35 °C. The pupil (even if its edge is damaged) is first dilated by introducing 0.2 ml of a 1% mesaton solution into the chamber. This facilitates control over the complete removal of the lens substance.

With similar dilation in an adult, it is rarely possible to remove the hard core of the lens through the wound. With an ultrasonic or mechanical fan fragmentator, this can be done.

A small peripheral corneal wound is accompanied by an extensive rupture of the anterior lens capsule and rapid swelling of the soft cataract. An extensive peripheral corneal wound is accompanied by damage to the lens without significant trauma to the iris.

It is possible to plan the implantation of an artificial lens during the primary surgical treatment of a complicated corneal wound only in the absence of signs of wound infection, the absence of intraocular foreign bodies, and the normal functioning of the visual-nerve apparatus.

A penetrating corneal wound with damage to the lens and vitreous exit into the anterior chamber or into the wound is difficult to surgically treat, since it is almost impossible to aspirate the lens substance from the more viscous vitreous. Such wounds must be treated with special devices, such as the Kossovsky mechanical phacofragmenter.

If such devices are not available, then first the main corneal sutures are applied, part of the iris is excised if necessary, catarrhal masses are aspirated, and then through the same wound a lenevitreectomy is performed, capturing blocks of cloudy lens substance with the vitreous body stroma with spoon tweezers.

The main part of the mass is removed from the eye only together with the lens bag - in whole or in parts.

The resulting deficiency of the contents of the eyeball is replenished with one of the vitreous body substitutes with the obligatory addition of sterile air at the end of the procedure, which is necessary for the remnants of the vitreous body at the back.

A penetrating corneal wound with signs of purulent infection should not be sealed. The anterior chamber is washed with an antibiotic solution, purulent-fibrinous films from the cornea, iris, from the anterior chamber are removed with spatulas and tweezers if possible, and the wound is covered with a conjunctival apron flap, which does not interfere with repeated therapeutic manipulations in the chamber and at the same time protects the wound from further infection. After such treatment, intensive general and local therapy is started.