Scleral Trauma

Scleral Trauma - Wall Woes

• Scleral injury: Blunt (rupture) or sharp (laceration, penetration, perforation).
• Causes: Trauma (sports, RTA, assault), iatrogenic.
• Rupture: Globe gives way at weakest points.
  • Common sites: Limbus, behind rectus muscle insertions, prior surgical scars.
  • Signs: ↓IOP (often < 5 mmHg), deep/shallow AC, uveal prolapse, hemorrhagic chemosis, bullous subconjunctival hemorrhage (360°), positive Seidel's test.
• Laceration: Sharp object cuts sclera.
  • Partial or full thickness.
• Diagnosis: Clinical exam, B-scan USG (if view obscured), CT scan (for IOFB).
• Management: Surgical exploration & repair (primary closure), rule out/remove IOFB, systemic antibiotics.

⭐ Thinnest Sclera: 0.3 mm just posterior to rectus muscle insertions, making it a common site for traumatic rupture.

📌 Mnemonic (Rupture Sites): "Limp Really Slow" - Limbus, Rectus insertions, Scars.

Open Globe Injuries - Globe Gone Wild

Full-thickness scleral/corneal wound. Guarded prognosis.

BETT Classification (OGI):

Features & Management:

• Signs: Peaked pupil, uveal prolapse, ↓IOP, +ve Seidel test, hemorrhagic chemosis.
• Imaging: CT scan (NO MRI if metallic IOFB suspected).
• Rx: Shield eye (NO patch). IV antibiotics. Tetanus toxoid. Antiemetics. Surgical repair ASAP.

⭐ Common scleral rupture sites (blunt trauma): Limbal (especially superonasal), under rectus muscle insertions, posterior (near optic nerve), and at sites of prior ocular surgery.

Clinical Clues & Imaging - Trauma Telltales

• Symptoms: Severe pain, ↓ vision, photophobia.
• Signs (Ocular Exam):
  • Marked conjunctival injection, chemosis, 360° subconjunctival hemorrhage.
  • Peaked pupil, uveal prolapse (dark knuckle).
  • Shallow/flat anterior chamber (AC).
  • IOP: Often low (< 5 mmHg), can be normal/high.
  • Positive Seidel's test (fluorescein stream).
  • Relative Afferent Pupillary Defect (RAPD).
• Imaging:
  • B-scan USG: Essential for opaque media. Detects rupture, vitreous/retinal/choroidal detachment, IOFB.
  • CT Scan (Orbit): For IOFB (metallic), fractures. "Flat tire" sign.
  • UBM: Details anterior scleral/ciliary body injury.

⭐ Seidel's test (fluorescein streaming) confirms aqueous leak, pathognomonic for open globe. RAPD indicates significant optic nerve/retinal damage, poor prognosis.

Scleral Repair & Recovery - Suture & Soothe

• Surgical Repair Principles:
  • Goal: Watertight, anatomical closure.
  • Timing: Urgent, ideally within 24 hours.
  • Sutures: 8-0 to 10-0 Nylon (non-absorbable), interrupted.
  • Technique: Meticulous apposition, avoid uveal incarceration, explore thoroughly.
• Post-operative Management ("Soothe"):
  • Topical: Broad-spectrum antibiotics (e.g., Moxifloxacin), potent steroids (e.g., Prednisolone).
  • Systemic: Antibiotics for penetrating injuries or intraocular foreign body (IOFB) cases.
  • Cycloplegics (e.g., Atropine) for comfort, prevent synechiae.
  • Protective eye shield.
• Key Complications:
  • Endophthalmitis, sympathetic ophthalmia, retinal detachment, phthisis bulbi.

⭐ Principles of scleral wound repair: Achieve watertight closure with meticulous apposition of wound edges, remove foreign bodies/necrotic tissue, and avoid incarceration of uveal tissue. Consider evisceration/enucleation for no light perception (NLP) with extensive damage or uncontrollable pain in a blind eye.

oka

High‑Yield Points - ⚡ Biggest Takeaways

• Scleral rupture is a full-thickness scleral defect, often occult; maintain high suspicion post-trauma.
• Common rupture sites: Limbus, under rectus muscle insertions, and the posterior pole.
• Key signs: ↓VA, uveal/retinal prolapse, hemorrhagic chemosis, low IOP (can be variable).
• Seidel's test (fluorescein streaming) confirms an active aqueous leak.
• B-scan ultrasonography (USG) is vital for diagnosis, especially with opaque media or suspected posterior rupture.
• Immediate surgical exploration and primary scleral repair are mandatory for open globe injuries.
• Poor prognostic signs include Relative Afferent Pupillary Defect (RAPD), initial VA < Perception of Light (PL), and a large wound (>10mm).