Back To The Basics: When Structure Is The Goal

The aim of this case report is to emphasize the priority of globe preservation in cases of extreme ocular trauma, advocating for primary repair over enucleation regardless the almost nil initial visual prognosis. The report highlights that a conscientious surgical technique and full commitment to anatomical restoration are essential to provide the best possible long-term structural outcome.

Clinical case reported at a tertiary level hospital, Hospital Dr. Josep Trueta, Girona, Spain. 

We report the case of a 67-year-old female who presented to Emergency Department with a severe ocular trauma in her right eye. The injury, caused by a bungee cord, resulted in a 6-hour-clock esclerocorneal rupture. Clinical examination revealed significant uveal tissue prolapse (exposure); a total hyphema was present, with no discernible iris details or posterior segment structures, and collapsed anterior chamber with loss of its architecture. (Photo 1-2) 

The visual acuity (VA) was limited to light perception (LP) with incorrect projection. And intraocular pressure (IOP) of 5mmHg. 

The patient underwent emergency surgical repair involving meticulous wound debridement and primary suturing of the sclera and cornea. 

An exploratory surgery was performed with a near-360-degree peritomy to ensure complete visualization of the laceration.  

Surgery was performed with tissue repositioning and maximal tissue preservation. Special care was taken to avoid excessive tension or globe deformities that could lead to wound dehiscence, a positive Seidel test, or dellen formation in the postoperative period. As well as subsequent conjunctival suturing to prevent scleral exposure that could lead to granuloma formation.  (Photo 3)

At the two-month follow-up, the globe remains completely watertight with no structural deformities. (Photo 4-5) Intraocular pressure (IOP) has remained stable, averaging 10 mmHg, and the patient maintains good light projection.

Open globe injuries remain a leading cause of monocular blindness. Prompt surgical intervention is crucial to preserve visual function, if possible, or at least the organ structure and prevent complications such as endophthalmitis.

In today’s world of multifocality and the daily pursuit of 20/20 vision, we wish to emphasize the importance of performing every surgery with absolute diligence, regardless of a guarded visual prognosis. In such extreme cases, the goal should extend beyond merely achieving a watertight globe; it must include the maximal preservation of tissue, structure, and form, which ultimately ensures the best possible long-term outcome for these patients.