Treatment Plan

Evaluating and Treating Conjunctival Lacerations

By William L. Miller, OD, PhD, FAAO

Some estimate that up to 3 percent of emergency room visits are a result of trauma to the eye (Bord and Linden, 2008). The potentially least serious of these would include superficial wounds involving the bulbar conjunctiva. Although uncommon, eyecare practitioners must be prudent in addressing conjunctival lacerations to determine their seriousness and eventual management and treatment options.

Evaluating a Laceration

The key to defining the proper course of action includes a careful history and visual acuity. The history should elicit the circumstances surrounding the injury, when and how it occurred, and the general health of the patient.

Symptoms may vary widely depending on the extent and depth of the conjunctival laceration. Any involvement of underlying Tenon’s capsule or sclera would certainly exacerbate the amount of pain. Your biomicroscopic exam may reveal an alteration in the conjunctival surface with a possible exposure of the deeper, translucent Tenon’s capsule.

Contingent on what is discovered during the history, it is also essential to carefully assess the underlying sclera and adjacent ocular tissues for damage. Use a drop of topical anesthetic or an anesthetic-soaked, cotton-tipped applicator before manipulating the conjunctiva to inspect for deeper involvement. A subconjunctival hemorrhage may be present as well as conjunctival injection and chemosis. Depending on the severity, your patient may have a concomitant anterior uveitis that may require topical steroid and mydriatic drops.

A dilated exam may be warranted if a foreign body is suspected to have penetrated the globe. Fluorescein application and looking for Seidel’s sign can help with determining whether the globe has been penetrated, although care must be taken when Seidel’s sign is negative and a suspected uveal incarceration has plugged the penetration. A penetrating injury will necessitate a CT scan (axial and coronal views), MRI (unless a metallic object is involved or suspected), and possible B-Scan ultrasound.

Management Options

Conjunctival lacerations that are less than 1cm are usually allowed to heal without intervention, as this is a fairly rapid process. It may be prudent to apply a topical broad-spectrum antibiotic solution or ointment as a prophylaxis against a possible infection until the wound is completely healed. Small, non-penetrating lacerations may not require any subsequent follow-up examinations.

Wounds larger than 1cm or cases of tissue avulsion or poor wound apposition will typically require sutures (CPT 65270), which can include nylon or dissolvable types ranging in size from 6-0 to 11-0; the most common may be the 7-0 Vicryl (Ethicon) absorbable suture. An interrupted technique can be used starting in the middle of the wound, with subsequent sutures dividing each segment in half until the wound edges are gently in apposition. Avoid capturing Tenon’s capsule while suturing. The sutures will remain in place until the wound is healed or non-dissolvable ones removed. As with smaller wounds, a broad-spectrum topical antibiotic or ointment is indicated for at least seven to 10 days. In the case of a large (>1cm), non-penetrating conjunctival laceration, have the patient return for follow up in about a week or sooner if the patient experiences pain. CLS

For references, please visit www.clspectrum.com/references.asp and click on document #206.

Dr. Miller is an associate professor and chair of the Clinical Sciences Department at the University of Houston College of Optometry. He is a member of the American Academy of Optometry and the AOA. He is a consultant or advisor to Alcon and Vistakon and has received research funding from Alcon and CooperVision and lecture or authorship honoraria from Alcon and B+L. You can reach him at wmiller@uh.edu.