Video of the month | May 2024 | Surgical management of extensive corneal laceration, traumatic cataracts and intraocular foreign bodies - Ocular integrity first

Presented by: Miltos Balidis MD, PhD, FEBOphth, ICOphth

Edited by: Penelope Burle de Politis MD

Severe penetrating ocular trauma that compromises multiple structures and functions within the eye can ultimately be compared to polytrauma to the body with involvement of several organs and systems. Just like in advanced systemic support, where the primary goal is life maintenance via a predetermined action sequence, the surgical management of deep ocular trauma must be aimed at globe viability, so that eventual procedures to restore visual function can remain feasible in the future.

Full-thickness corneal laceration, associated cataract formation, damage to anterior chamber structures, and presence of intraocular foreign bodies make up a complex scenario that carries a series of threats to the eye’s integrity, from polymicrobial infection to panuveitis and phthisis bulbi. The ophthalmic surgeon shall have in mind that the priority in such cases is to preserve chamber dynamics, remove potential inflammation-infection triggers, and minimize ocular injuries despite the limited transoperative visibility and unpredictable intraocular conditions.

In this video, recorded in the main operating room of the Ophthalmica Eye Institute, in Thessaloniki, Greece, Dr. Miltos Balidis, MD, PhD, FEBOphth, ICOphth operates on an ocular trauma caused by a wood fragment that hit the eye during wood chopping. Aside from the diametrical, full-thickness, irregular corneal wound and secondary corneal edema, a traumatic cataract had developed and eyelashes could be retrieved from the interior of the eye. The main surgical steps and timing in the video are as follows: temporary suture of the corneal laceration (00:05). Endoillumination for anterior segment exploration (00:17), with evidentiation of inflammatory membranes, a capsule tear, and an intralenticular foreign body (eyelash). Methylene-blue injection (00:55) for capsule visualization. Membranectomy and partial capsulorrhexis (01:25) for foreign body removal. Identification of zonular dehiscence (02:20) and a second eyelash behind the nucleus, anterior to the vitreous body. Aspiration of softer nucleus parts (03:00). Viscoexpression (03:10) and slow phaco (low power, low irrigation, very low vacuum) to gently emulsify the hard nucleus in the anterior chamber (03:15). Last inspection with endoillumination (04:00) for detection of other possible foreign bodies. Dry aspiration for nucleus remnants (04:10). Corneal resuturing (04:35). Sealing of sideports (04:45). The emergency procedure ends with a temporarily aphakic but rather stable ocular globe (04:48), so that an intraocular lens can be electively implanted afterwards.

“By failing to prepare you are preparing to fail.” (Benjamin Franklin)