bubble_chart Overview

Perforating wounds of the eyeball refer to ruptures caused by cuts or stabs from objects with sharp edges or points, foreign debris entering the eyeball, or blunt force trauma to the eyeball. Double perforating wounds that penetrate the entire eyeball from the front and exit through the back are called penetration wounds of the eyeball, which are a type of perforating wound.

bubble_chart Diagnosis

The diagnostic basis for penetrating eye injuries can be summarized as follows: (1) History of trauma; (2) Eye wound; (3) Decreased intraocular pressure; (4) Shallowing of the anterior chamber; (5) Iris perforation; (6) Pupil deformation; (7) Lens opacity; (8) Vitreous trauma pathway; (9) Retinal injury; (10) Foreign body retention; (11) Decreased vision.

Some of these signs may be inconspicuous or absent, especially in small penetrating injuries, where even all symptoms may be subtle. Therefore, for every patient suspected of having an eye injury, it is essential to take a detailed history and conduct a thorough examination to avoid misdiagnosis and delayed treatment.

bubble_chart Treatment Measures

Penetrating eye injuries vary in their causes, location, and severity, and thus their treatment methods also differ. Penetrating eye injuries primarily require surgical intervention. Below, we will only outline the treatment principles and key considerations.

1. **Preventing Infection**: Penetrating eye injuries often introduce pathogenic microorganisms directly into the eye at the time of injury, or infection may develop later due to an open wound. Therefore, the first priority in managing penetrating eye injuries is to prevent infection and control any existing infection. The approach involves first assessing the injury site and condition, then cleaning the eyelid and surrounding skin with physiological saline swabs (avoiding irrigation). If contamination is suspected, use a 1:5000 mercuric chloride solution or oxycyanide mercury solution for cleaning. After thorough examination and proper wound closure, administer subconjunctival antibiotics, apply antibiotic eye drops to the conjunctival sac, and cover with a sterile gauze bandage. For larger or deeper wounds, or those exposed for an extended period, intraocular antibiotic injection, systemic antibiotics, or Chinese medicinals for clearing heat and removing toxins may be necessary, along with tetanus antitoxin or toxoid injections.

2. **Wound Closure**: Proper wound management is essential to ensure tight closure, preventing secondary infection, prolapse of intraocular contents, controlling bleeding, restoring intraocular pressure, and maintaining normal tissue alignment. The treatment methods are as follows:

⑴ **Small Wounds**: Corneal and scleral wounds should, in principle, be tightly sutured. However, very small wounds that are not gaping and show no prolapse or incarceration of intraocular contents may not require suturing. After the aforementioned treatment, cover the eye with a bandage or protective shield, and advise bed rest.

⑵ **Corneal Wounds**: Immediate direct suturing is necessary. Under a surgical microscope, use 10-0 or 9-0 sutures with a spatulated needle, penetrating at least 2/3 of the corneal thickness. For oblique wounds or those with corneal edema, sutures should reach 3/4 of the thickness but must not penetrate fully. Minimize sutures in the central cornea, ensuring tight closure to maintain normal curvature. After suturing, inject balanced saline or sterile air into the anterior chamber to prevent iris adhesion. If corneal tissue is too fragmented for suturing, perform corneal transplantation or cover with a conjunctival flap if transplantation is not feasible.

⑶ **Scleral Wounds**: Regardless of whether the conjunctiva is ruptured, scleral wounds should be sutured promptly. Some scleral wounds extend far posteriorly or beneath the extraocular muscles—these must be fully exposed and sutured at their posterior end. If bleeding persists on the scleral surface, cauterize to stop it. Vascularized tissue should be thoroughly scraped away and must not be trapped within the wound. Very small, simple scleral wounds with intact or healed conjunctiva may not require suturing.

⑷ **Large Wounds with Prolapsed Contents**: If prolapsed uveal tissue is contaminated or necrotic, excise it. However, if clean and viable, even if prolapsed for some time, thoroughly irrigate with antibiotics and reposition before suturing. Uveal tissue prolapsed under the conjunctiva can usually be repositioned without excision unless necrosis is evident. Incarcerated vitreous should be excised, repeatedly removed with sponge swabs or cotton tips until none remains in the wound. Ideally, use a vitrectomy instrument to clear the wound. Disrupted lens fragments must be completely removed.

⑸ **Foreign Bodies in the Wound**: Remove any visible foreign bodies before managing the wound.

⑹ **Severe Injuries with Extensive Wounds**: The decision to preserve the eye should consider the risk of sympathetic ophthalmia.

3. Preventing hemorrhage: When the injury involves the uveal membrane and retinal membrane, attention should be paid to preventing hemorrhage. For those who have already experienced bleeding, more active treatment is required. Clinically, it is common to see cases where wounds in various parts of the eyeball have been properly treated and healed satisfactorily, but hemorrhage and the resulting vitreous opacity and organization become the main factors affecting vision, even leading to blindness. To prevent hemorrhage, various hemostatic agents, including Western medicine and Chinese medicinals, can be used. The patient should rest quietly, with the injured eye or both eyes bandaged and covered with a protective eye shield to avoid vibration and pressure on the eyeball. For cases with significant hemorrhage and slow absorption, vitrectomy may be performed.

4. Preventing inflammatory reactions: For more severe penetrating injuries, especially those involving the uveal membrane, it is important to prevent inflammatory reactions. Measures include pupil dilation, local and systemic application of corticosteroids, or oral administration of non-steroidal anti-inflammatory drugs such as sodium salicylate, aspirin, or indomethacin, as well as Chinese medicinals with heat-clearing and wind-dispelling properties.

5. Early vitrectomy: For severe penetrating eye injuries, vitrectomy may be performed as necessary during the initial wound closure procedure. This involves removing injured vitreous or vitreous hemorrhage, as well as fragmented lens material. Entering through the pars plana with the vitrectomy instrument to remove hemorrhage or injured lens and vitreous is a relatively safe and reliable approach. Additionally, post-vitrectomy examination of the fundus allows for further treatment. Early vitrectomy also helps prevent severe complications such as retinal detachment caused by subsequent vitreous contraction. Furthermore, in cases of suppurative endophthalmitis or panophthalmitis in the early stages, vitrectomy combined with intraocular antibiotic injection yields favorable therapeutic outcomes.

6. Management of perforating eye injuries: Perforating eye injuries, also known as double-penetrating injuries or secondary perforations, require treatment of both the anterior and posterior wounds. For smaller posterior wounds requiring suturing, transvitreal diathermy can be performed to coagulate the surrounding retina and choroid. If the posterior wound is large or significant retinal detachment is already present, the scleral wound should be sutured, followed by transscleral diathermy, cryotherapy, or scleral buckling. Early vitrectomy is recommended for perforating eye injuries.

7. Management of blast injuries: Blast injuries often involve trauma to other parts of the body in addition to the eyes. Treatment should prioritize life-saving measures while addressing cranial, visceral, and limb injuries. Blast injuries typically affect both eyes, with multiple wounds or retained foreign bodies. Fragments from explosions are often contaminated with dirt and debris, necessitating special attention to infection prevention. Treatment should be tailored to the injury site and severity, following the aforementioned methods.

8. Treatment of traumatic leukocoria and lens dislocation: See lens diseases.

9. Treatment of suppurative endophthalmitis and panophthalmitis: See exogenous endophthalmitis and panuveitis in vitreous diseases, as well as endogenous endophthalmitis.

10. Prevention and treatment of sympathetic ophthalmia: See uveitis.