Online Photo Diagnosis
By William Townsend, OD, FAAO
A 20-year-old male was referred by the local university health center for evaluation after being “poked in the right eye with a finger” the previous evening. He was taking a systemic antibiotic for acne, but used no ophthalmic medications. Presenting acuities without correction were 20/20-1 OU. There was no restriction of EOM function; biomicroscopy showed a large (approximately 22mm) horizontal laceration of the right superior conjunctiva; there was no Seidel sign and no evidence of involvement of the superior rectus insertion. The anterior chambers were deep and quiet; the corneas were clear and non-staining OU. We observed a small degree of ptosis on the affected side.
Conjunctival laceration results from force applied in a manner that tears the conjunctiva and dissects it away from the underlying Tenon's capsule and episclera. The offending object may be blunt or sharp. In cases of conjunctival laceration, it is important to rule out potentially sight-threatening complications. Carefully evaluate underlying tissue for evidence of uveal avulsion through the sclera. Seidel sign should be evaluated for percolation of aqueous through a break in the cornea or sclera. Intraocular pressures should be approximately equal; unilateral hypotension in the affected eye suggests a loss of aqueous. Rupture of EOMs has been documented to occur in conjunction with conjunctival laceration.
Despite the common occurrence of conjunctival laceration, the literature regarding management of this condition is relatively scant and to some extent conflicting. Some have advocated suturing of all lacerations. Most recommend surgical intervention when the length of the laceration is greater than one-to-two centimeters. Our patient's laceration was actually more than two centimeters in length, so we recommended that he see an anterior segment specialist for possible surgical intervention. We pressure patched the eye with ciprofloxacin ophthalmic solution and sent him to our colleague, who recommended continuing the prophylactic antibiotic, but only observation. Over time, the laceration healed without further intervention.
Given our experience with this patient, we would now manage such a patient's case with observation. In numerous instances, we have successfully followed large conjunctival lacerations by managing patient discomfort (which is often remarkably mild) and administering prophylactic antibiotics. If we do not observe progressive closure of the lesion, we would consult an anterior segment specialist. As is the case with any type of laceration, we instruct the patient to report any signs of infection including increase in pain, increased redness or discharge and any change in vision status.
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