Conjunctival Laceration

This individual presented to our office with a history of sudden-onset ocular pain and injection in his left eye. While he was working in his yard, a tree branch had struck his eye just outside the limbus, leading to the clinical presentation seen in this image. Presenting visual acuities were OD 20/20 and OS 20/25. His corneas were clear, and his anterior chambers were quiet. After irrigating the affected eye, we noted a laceration of the temporal conjunctiva with accompanying hemorrhage. Intraocular pressures were 17 mmHg OD and OS. Instillation of sodium fluorescein (Seidel’s sign) showed no evidence of penetration of the globe, and dilated fundus evaluation was unremarkable; the peripheral and central retinas were attached, and no retinal breaks or tears were noted.

Conjunctival laceration is an uncommon and—if it involves penetration of the globe—a potentially sight-threatening condition.¹ For this reason, it is essential that penetrating injury be ruled out in individuals presenting with conjunctival laceration.² Historically, Seidel’s sign has been used as an indicator of penetrating ocular injury. It is also very important to perform a dilated fundus evaluation to rule out retinal involvement.²

Pediatric individuals constitute a significant segment of patients who present with ocular trauma.³ Shah et al reported the results of a five-year study of ocular trauma in a pediatric population in which 7,546 (59.4%) eyes were open-globe ocular injuries and 5,328 (41.9%) were closed-globe injuries. Twenty-four percent of the subjects who had closed-globe injuries had severe vision loss in the affected eye.³

In evaluation of trauma, particularly in conjunctival laceration, it is important to rule out penetrating injury. As noted previously, this traditionally has been done using sodium fluorescein to evaluate for the leakage of global contents onto the ocular surface (Seidel’s sign). In some cases, a penetrating injury may exist in the absence of this finding. Couperus et al reported an interesting and unusual case in which a 31-year-old male who was in an automobile accident suffered a penetrating corneal injury from glass shards.⁴ In his case, the fragments prevented aqueous from escaping the anterior chamber.

In our patient’s case, no Seidel sign was noted. Dilated fundus evaluation showed no evidence of retinal breaks or tears and no maculopathy. We instilled a topical antibiotic and pressure patched the eye. Because the injury involved vegetative material, there was increased risk for possible fungal infection,⁵ so we initially evaluated him on a daily basis. Ultimately, the laceration healed without any evidence of scarring or reduction in vision.

REFERENCES

1. Ajamian. PC. Slice of Life. Rev Optom. 2020 May 15. Available at https://www.reviewofoptometry.com/article/slice-of-life . Accessed Jan. 25, 2021.
2. Rathi A, Sinha R, Aron N, Sharma N. Ocular surface injuries & management. Community Eye Health. 2017;30:S11-S14.
3. Shah SM, Shah MA, Singh R, Rathod C, Khanna R. A prospective cohort study on the epidemiology of ocular trauma associated with closed-globe injuries in pediatric age group. Indian J Ophthalmol. 2020 Mar;68:500-503.
4. Couperus K, Zabel A, Oguntoye MO. Open Globe: Corneal Laceration Injury with Negative Seidel Sign. Clin Pract Cases Emerg Med. 2018 Jun 12;2:266-267.
5. Thomas PA, Kaliamurthy J, Mycotic keratitis: epidemiology, diagnosis and management. Clin Microbiol Infect. 2013 Mar;19:210-220.