Scleral and Limbic Lacerations

What is Scleral and Limbic Lacerations?

Trauma is a major factor contributing to blindness caused by cornea injuries, with only corneal ulcers causing more severe vision loss. This issue is particularly prevalent in developing countries, causing loss of sight in one eye due to injuries from sharp objects such as scissors, thorns, nails, fish hooks, or wood pieces. These kinds of injuries, known as open globe injuries, can lead to permanent vision problems and cause both financial difficulties and emotional stress for the patient and their family.

Typically, patients who’ve suffered such injuries will experience immediate symptoms like pain, redness, and sudden vision loss. The circumstances of the injury—including the object involved, its onset, and duration—are important to record. A detailed examination with a special microscope called a slit lamp is required to check for specific types of eye injuries and conditions, like tears in certain parts of the eye, foreign objects lodged inside the eye, infection, and inflammation.

To ensure that no fluid leak from the eyeball is missed, a test called Seidel’s test should be done. Additionally, different types of scans, like a B scan, X-ray, CT scan, and MRI, may be needed to check for other possible complications like retinal detachment (when the layer at the back of your eye peels off), choroidal detachment (when another layer of your eye comes off), nucleus drop (abnormal position of the lens inside the eye), or to find any trapped foreign objects.

In cases where the laceration (a wound caused by a cut or tear) is infected, a smear and culture test, which examines a sample of the affected tissue under a microscope to identify the bacteria causing the infection, may be required. Once the patient undergoes surgery, further scans may be needed to ensure the eye is healing correctly. Understanding the patient’s visual acuity (clearness of vision) before and after treatment is also crucial. The standard treatment for these injuries is suturing (stitching) the wound, but it is important to note that the surgery tends to take a significant amount of time, and the chances of full recovery are often low.

What Causes Scleral and Limbic Lacerations?

Scleral and limbic lacerations, or cuts on the white part and edge of the eye, usually happen when sharp and pointed objects hit the eye with a lot of force. These types of eye injuries are most common in places like work sites, factories, and homes, particularly for children.

These injuries typically occur due to accidents in the home, or as a result of violence, chemical exposure, fire, or accidents at work. Even blunt trauma, like a punch or hit to the eye, can also lead to these kinds of lacerations.

An earlier study from the US found that the most common causes of these injuries are things like rocks, fists, baseballs, and weight-related accidents. Children are often hurt by pencils, knives, scissors, stones, iron nails, screwdrivers, cranes, swans, cat paws, and wires.

In older people, the most common way these injuries happen is through falls, slips in the bathroom, and falls from two-wheel vehicles. Foreign objects getting stuck in the eye, like pieces of iron, wood, or thorn, iron nails, and stones account for about 40% of open eye injuries.

Risk Factors and Frequency for Scleral and Limbic Lacerations

Injuries to the white part (sclera) and the colored ring (limbus) of the eye often affect males more than females, with males being five times more likely to have these injuries. The majority of these injuries, known as open globe injuries, occur in people under 40 years old. In fact, 50% of the patients with such injuries are below this age.

Studies show that in their 30s, for every 4.6 males that suffer these injuries, there’s 1 female. This ratio increases to 7.4 males for every 1 female in their 40s. Also, half of these patients experience related harm to their retina, and roughly 77% need to have surgery to treat these injuries.

• Open globe injuries most commonly occur in males, five times more frequently than in females.
• Approximately 50% of patients are under 40 years old.
• The ratio of males to females with these injuries increases with age, from 4.6 to 1 in the third decade to 7.4 to 1 in the fourth.
• About 50% of these patients also have retinal trauma.
• About 77% of these patients require surgery.

Based on data from the United States and Hungary, about 6% of US patients and 52% of Hungarian patients with these injuries were below 30 years old, and approximately 80% were males. From where these injuries happen, home injuries were the most common cause in both countries. However, in the US, gun injuries led the way while in Hungary, it was champagne cork injuries.

• 6% of US patients and 52% of Hungarian patients with these injuries are under 30.
• About 80% of patients in both countries were males.
• Most of these injuries occur at home.
• In the US, gun injuries are common, while in Hungary, champagne cork injuries are common.

Signs and Symptoms of Scleral and Limbic Lacerations

When a doctor suspects a patient may have a serious eye injury like a scleral or limbic laceration, they ask for a detailed history of any traumatic events. They need to know how the injury happened, when it occurred, and where on the body. If the patient received any first aid or other treatment, the doctor also needs to know this. Sometimes patients can prevent injuries by using safety measures, like wearing safety glasses or face shields, especially at work. The doctor also checks for other injuries, such as head or bone injuries.

It’s also important to know if the patient has a history of eye problems or surgeries, such as cataract surgery. If the patient has life-threatening injuries, those are treated first. The doctor also needs to know about any other health conditions the patient has, if they’ve received a tetanus shot, or have any allergies. The doctor should also document the last time the patient ate. If the patient already has a history of eye injuries, the doctor needs to take note of this. If the patient has ever had amblyopia (lazy eye), or surgery on their eye muscles, this should be noted. Any symptoms the patient is having like headaches, eye pain, nausea, or vomiting, need to be reported.

• Pain
• Double vision
• Vision loss
• Blurred vision
• Eye redness
• Sensitivity to light (photophobia)
• Feeling like something is in the eye (foreign body sensation)

The doctor then uses an instrument called a slit lamp to examine the eye closely. This can help the doctor see even minor injuries. The doctor may find signs of eye injury like a deep cut in the sclera (the white part of the eye), bleeding under the clear membrane that covers the white part of the eye (subconjunctival hemorrhage), or inflammation in the mucous membrane that lines the eyelids and covers the exposed part of the eyeball (conjunctival congestion). In some cases, the cornea (clear front part of the eye) may also be torn, or there may be blood in the front part of the eye (hyphema). Sometimes the lens can shift out of place, or the pupil can become misshapen. Other common findings include inflammation of the middle layer of the eye (uveitis), or a detached retina. If there’s a foreign object in the eye, this could also cause these symptoms.

The doctor also needs to check the area around the eye carefully for signs of a skull fracture around the eye socket (orbital rim fractures), or cuts in the eyelid (lid tears). The doctor may also observe bruising (contusions) or pooling of blood outside the blood vessels (ecchymosis). Sometimes, the clear gel that fills the space between the lens and the retina can push forward through a cut in the eye (vitreous prolapse). The doctor also has to check the other eye for any trauma or complications like sympathetic ophthalmia, which is an inflammation in both eyes after injury to one eye.

Finally, the doctor does a general physical exam to make sure there aren’t any other health problems. If the patient is unconscious or has a headache, nausea, vomiting, or changes in mental status, these systemic conditions need to be managed first.

Testing for Scleral and Limbic Lacerations

For eye health check-ups, Snellen’s visual acuity test is commonly performed. This test measures both your natural and corrected eyesight, and it’s recommended to document the results over time to track the eye’s condition. If you have a severe eye trauma and eyesight is uncertain, your doctor will record your perception of light and rays.

Another important test is intraocular pressure measurement, primarily done using non-contact tonometry. This test measures the fluid pressure inside your eyes. However, if you have a significant eye injury, putting pressure on the eyes can cause more harm, thus tonometry should be avoided.

The Seidel’s test is a non-invasive way to detect if fluids are leaking from your eyes, which could be a sign of a significant injury. A special dye is applied to the eye that mixes with any fluid leaks, making it easier to identify. A related test, the Forced Seidel’s test, is similar but includes squeezing the eye to find any hidden leaks that may have sealed themselves.

If there’s fear of an infection from a cut or wound, a microbiological smear and culture can help identify the type of infection and help your doctor choose the best treatment options.

Imaging is another critical tool for eye health. An anteroposterior and lateral view X-Ray can help to detect any foreign objects in the eye. Computed Tomography (CT) scans are also valuable in case of a possible bone injury or hidden foreign bodies in the eye. Additionally, CT scans help locate foreign objects, expectedly seen in 40% of such cases.

In some circumstances, Magnetic Resonance Imaging (MRI) is needed to assess any soft tissue damage in and around the eye region. Note that MRIs are not recommended if a metal foreign body is suspected in the eye.

A B scan ultrasound is another method used to examine the eyes but is avoided before surgery to prevent extra pressure on the eye. However, it’s quite useful post surgery to rule out various conditions if vision is still blurry or the pupil appears small.

Optical coherence tomography is a testing technique helpful in ruling out conditions like the epiretinal membrane and macular edema. These conditions concern parts of the eye that involve vision processing.

Also, if doubt remains regarding the state of your vision, a confrontation test should be performed. But keep in mind, gonioscopy, forced duction test, and scleral depression during indirect ophthalmoscopy should be avoided. These tests can cause pressing on the eye globe, possibly leading to an outflow of intraocular contents.

Treatment Options for Scleral and Limbic Lacerations

Before any operation, eye drops that don’t contain preservatives are usually used to prevent them from entering the eye. If the injury involves a laceration (a cut) that has caused uveal tissue (the middle layer of the eye) and vitreous (a gel-like substance that fills most of the eye) to stick out of the eye (prolapse), the patient is usually started on a broad-spectrum antibiotic eye drop treatment to help prevent infection. Antibiotics like moxifloxacin or gatifloxacin are typically used. The patient is also given a tetanus shot and an antibiotic (like ceftriaxone) via an injection to further protect them against infection. If the patient needs to undergo general anesthesia, they are asked to stay away from food and drink for about 8 hours before the procedure.

The main goal during an eye wound repair is to restore the integrity of the eye by closing the wound without any leakage. The secondary goal is to achieve the best possible anatomic and possibly functional outcome by removing any tissues that have prolapsed, any foreign bodies, and any non-viable or dead tissue.

Repairing lacerations near the limbus (the border between the cornea and the white of the eye) is crucial in restoring the eye’s anatomy and achieving the best possible visual outcome.

A key concept in eye wound repair, the Eisner Principle, tells us that beveled incisions (angled cuts) often cause less gaping of the wound than vertical incisions. While beveled incisions might self-seal, vertical incisions usually need stitches.

Stitches play a significant role in the repair process. When applied, they cause a flattening effect on the wound, which results in the cornea becoming steeper in the center and near the visual axis (the imaginary line passing from the center of the pupil to the fovea, the most sensitive part of the retina). The suture effect comprises several components, such as compression, torque, splinting, tissue inversion, and tissue eversion.

The main thing to consider while repairing a scleral and limbal laceration (wounds involving the white part of the eye and the border area) is to restore the eye’s original structure. It’s performed by placing stitches at every hour position around the wound, helping to prevent the contents of the eye from sticking out. If the laceration is too far back, it can be left to heal naturally without the risk of losing intraocular contents. In terms of suture material, nonabsorbable sutures are used for larger defects, and absorbable sutures are used for small defects.

In cases where large scleral lacerations with tissue loss cannot be closed directly, a patch graft (a surgical procedure to cover the wound with graft material) may be necessary. Also, if there is prolapsed uveal tissue and the injury is less than 4 hours old, the iris can be put back in place if there’s no infection or necrosis. If the iris cannot be put back, it should be removed. Similarly, if parts of the vitreous are sticking out over the corneal or scleral surface, it should be removed. If necessary, other procedures, such as lens removal or automated anterior vitrectomy (removal of vitreous), can be performed.

What else can Scleral and Limbic Lacerations be?

The potential eye issues resulting from injury could include:

• Tear in the cornea (the clear front surface of the eye)
• Foreign object in the cornea
• Hyphema (bleeding in the front part of the eye)
• Iridodialysis (separation of the iris from its connection to the ciliary body)
• Tear in the iris (the colored part of the eye)
• Iris prolapse (protrusion of the iris through the cornea)
• Traumatic cataract (clouding of eye’s lens due to injury)
• Foreign object inside the eye

What to expect with Scleral and Limbic Lacerations

The outlook for people with sclerolimbic lacerations, which are injuries to the white outer layer and limbal area of the eye, often depends on several factors. These can include the severity of the injury, when the injury happened, how it was caused, the damage to nearby structures in the eye, the presence of RAPD (a test used to find abnormal function of the optic nerve), initial visual sharpness, location of the wound, size of the tear, and presence of other eye conditions like retinal detachment, choroidal detachment, vitreous hemorrhage and dislocation or subluxation (partial dislocation) of the lens.

Generally, the outlook is usually good if the initial visual clarity is better than 6/60 (this means that what a normal eye can see at 60 meters, the injured eye can see at 6 meters), the wound is located towards the front of the “pars plana” (a part of the eye), the tear is smaller than 10 mm, and the injury is due to a sharp object. The “ocular trauma score”, a scoring system that predicts the likely vision after eye injury, is also a useful way to predict the eventual visual outcome.

Possible Complications When Diagnosed with Scleral and Limbic Lacerations

Possible complications and side-effects include:

• Wound leakage
• Backward pull of the transparent layer of the eye
• Infiltration of the suture
• Growth of the skin layer under the eye surface
• Fibrous tissue growth into the wound
• Infection in the transparent front part of the eye
• Glaucoma secondary to other diseases
• Glaucoma due to damage to the angle in the eye
• Bulge of the colored part of the eye through a surgical wound in the eye
• Absence of the iris (colored part of the eye)
• Clouding of the lens of the eye
• Inflammation of the middle layer of the eye wall following trauma
• Bulge of the interior jelly-like substance of the eye
• Separation of the sensory layer of the eye
• Dislocation of the vascular layer under the retina
• Tear of the vascular layer under the retina
• Bleeding into the gel-filled space behind the lens
• Inflammatory condition causing vision loss and affecting both eyes after injury to one eye
• Severe infection inside the eye
• Total infectious inflammation of the eye
• Shrinkage of the eye leading to blindness
• Shrinkage of the globe of the eye due to degeneration
• Permanent loss of vision

Recovery from Scleral and Limbic Lacerations

For people who have suffered certain types of eye injuries, known as non-infective scleral and limbic lacerations, treatment usually involves eye drops that contain steroids (like 0.1% dexamethasone or 1% prednisolone), topical antibiotics (like 0.5% moxifloxacin or 0.5% gatifloxacin), and lubricating drops (such as 0.5% carboxymethylcellulose). The steroid and antibiotic drops are often used in a decreasing dosage over a week, antibiotic drops four times a day for 15 days, and lubricating eye drops four times a day for 30 days.

To check if your retina – the part at the back of your eye that senses light – has been affected, doctors will usually recommend a test called a dilated fundus evaluation. If the doctor cannot clearly see the back of your eye because of cloudiness, an ultrasound of the eye, known as a B scan, may be needed to check for any problems.

After the initial treatment, you should ideally see your doctor for a check-up after a week, then once every two weeks. If there is continuous internal bleeding within the eye or the retina detaches, you might need a kind of eye surgery called vitreoretinal surgery. In certain severe situations resulting in ciliary shutdown or cyclodialysis (where parts of your eye stop working), there can be a gradual shrinkage of your eye referred to as Phthisis bulbi.

It’s important to note that if your eye injury is infected, the use of steroids is not recommended. Instead, you would use antibiotic eye drops and antifungal eye medications (such as 5% natamycin, 1% itraconazole, or 1% voriconazole). If you have an infected eye injury, you should be closely monitored by your doctor to prevent the development of serious eye infections, known as endophthalmitis or panophthalmitis.

Preventing Scleral and Limbic Lacerations

If you have a tear in the white part of your eye (scleral) or edge of your eye (limbic), your doctor will likely recommend surgery. They should explain the reasons why surgery is needed, and what kind of results you might expect based on different risk factors. It’s important that you understand the need to take your medications promptly and regularly check in with your doctor for follow-up care. The doctor should also help you understand the nature of your eye injury and encourage you to have realistic expectations about the outcome.