Management Of A Complex Corneo-Scleral Penetrating Injury Complicated By A Long Vertical Upper And Lower Eyelid Laceration

To describe the acute management and long-term treatment of a severe corneo-scleral globe injury with a complex eyelid laceration.

A 41 year-old Chinese man presented to King’s College Hospital Emergency Department, following a left-sided facial injury from an angle grinder, resulting in a corneo-scleral laceration and a vertical upper and lower eyelid defect. Left visual acuity (VA) was light perception. Computerised tomography showed a deformed globe, with no intra-ocular or -orbital foreign bodies and a stable orbital floor fracture. Exploration and primary repair under general anaesthesia was performed within 24 hours.

A V-shaped, shelved, full-thickness corneal defect was present. The apex was inferior at 6 o’clock; one arm travelled upwards, 3mm past the central cornea and the other along limbus to a 3 o’clock position. The wound extended inferiorly to transect the inferior rectus (IR). There was total anterior iris loss with an intact lens. The corneal wound was closed first using 10.0 nylon, then scleral and IR repair with 6.0 vicryl. The vertical eyelid wound was 15cm long; started sub-brow and ended at the nasolabial fold. There was <25% eyelid tissue loss and direct closure with 5.0 and 6.0 vicryl was achieved. Limited skin Z-plasty with 7.0 vicryl and deep fornix sutures with 6.0 vicryl were undertaken. No horizontal lid tightening was performed. 

Post-operative regime; oral 400mg Moxifloxacin once a day, Maxitrol ointment three times a day to the lid wounds, Moxifloxacin drops four times a day and Maxidex drops 2 hourly to the left eye. From the onset, the globe was comfortable and well-sealed. VA improved to counting fingers and IOP to 14. Corneal oedema limited fundal view but B-scan showed a flat retina. 4 weeks later, lid wound contraction ensued, with a 1mm lagophthalmos.This resolved with 6 months of hydrocortisone 0.1% cream and massage. 16 months on, the globe was well-formed with no appreciable volume loss. There was corneal scarring and a white cataract. Anterior segment OCT showed good corneal alignment with some adhesion to the lens capsule temporally and intact zonules.

Despite a severe ocular injury, this patient achieved stable globe integrity with visual potential, as well as excellent eyelid functionality and cosmesis. VA and IOP remained stable from the early post-operative period till most recent follow-up.  In complex traumatic ocular injuries involving multiple structures, the globe must take priority in repair. In this case, the eyelids would usually have been repaired with horizontal lid tightening in anticipation of the subsequent long vertical wound contraction, however this was avoided to minimise pressure on the globe, which would have caused globe distortion and ultimately leakage.