The sclera is the robust, white outer layer of the human eyeball, providing structural integrity and protection for its delicate internal components. A scleral laceration refers to a cut or tear in this protective layer, representing a severe injury to the eye. This damage disrupts the eye’s integrity and exposes inner structures to potential harm. This type of injury constitutes a medical emergency that requires immediate attention to preserve vision and the eye.
Causes and Recognition
Scleral lacerations commonly arise from two main types of trauma: penetrating and blunt force. Penetrating trauma involves sharp objects, such as metal shards, glass fragments, or tools like knives and scissors, directly cutting through the sclera. These injuries often leave a distinct, full-thickness wound. In contrast, blunt force trauma, from impacts like a fist, a ball, or a car accident, can cause the eye to rupture due to a sudden increase in intraocular pressure. This “inside-out” mechanism causes the sclera to give way at its weakest points, such as near the limbus (where the cornea meets the sclera) or behind the extraocular muscles.
Recognizing a scleral laceration involves observing several signs and symptoms. Individuals often experience severe eye pain and a rapid, significant loss of vision immediately following the injury. A visible cut or tear on the white part of the eye may be present, though swelling or blood can sometimes hide it. The pupil might appear misshapen, or the iris (the colored part of the eye) could protrude through the wound, known as iris prolapse.
Hyphema, or blood collecting in the front chamber of the eye, is another common indicator. Fluid might leak from the eye, and surrounding tissues may show swelling and redness. Sensitivity to light (photophobia) can also develop. Any combination of these symptoms after an eye injury warrants immediate medical evaluation.
Emergency Response and Diagnosis
Immediate action following a suspected scleral laceration can significantly affect the outcome. Avoid certain actions: Do not attempt to remove embedded objects, rub, or apply pressure to the injured eye. Applying pressure can worsen the injury by causing further extrusion of the eye’s contents. Additionally, refrain from rinsing the eye with water or taking blood-thinning medications like aspirin or ibuprofen, as these can increase bleeding.
Instead, gently place a protective shield over the eye without touching the eyeball. A paper cup taped to the bones around the eye can serve as a temporary shield. After securing the shield, seek immediate emergency medical attention. An ophthalmologist will perform a careful examination, sometimes requiring general anesthesia if the patient cannot cooperate due to pain or other injuries.
Diagnosis often includes imaging tests to assess the damage. A computed tomography (CT) scan is frequently the preferred imaging modality, especially when globe rupture is suspected or to check for foreign bodies inside the eye. CT scans provide detailed cross-sectional images that can reveal the laceration’s depth, location, and any associated injuries to internal eye structures. While ultrasound can also image internal structures, it is generally avoided if globe rupture is suspected due to the risk of applying pressure to the eye.
The Surgical Repair Process
Surgical intervention is almost always necessary for scleral lacerations and is typically performed urgently to prevent complications and restore the eye’s structural integrity. The primary goal of this surgery is to achieve a watertight closure of the wound, preventing further leakage of intraocular fluids and tissue. Surgeons also aim to restore the eye’s normal anatomical relationships and prevent infection, which can severely compromise vision.
The procedure is usually conducted under general anesthesia to ensure the patient’s comfort and stillness, minimizing any pressure on the injured eye. The surgeon begins by carefully exposing the laceration, often through a conjunctival peritomy (incising the conjunctiva) to reveal the underlying sclera. This allows for a full assessment of the tear’s length and depth.
Fine, non-absorbable sutures, such as 9-0 or 10-0 nylon, are then meticulously placed to stitch the sclera closed. The sutures are typically full-thickness, ensuring a strong, secure closure. If any internal eye tissues, such as the iris or vitreous, have prolapsed (protruded) through the wound, the surgeon will carefully reposition or, if damaged, trim them before closing the sclera. Intraocular foreign bodies, if present, are also removed during this initial repair. After scleral wound closure, the conjunctiva is sutured back into place, and prophylactic antibiotics may be administered to reduce infection risk.
Post-Surgery Recovery and Vision Outlook
After scleral laceration repair, a structured recovery process facilitates healing and protects the eye. Patients typically wear an eye patch or a rigid eye shield for several weeks to prevent accidental rubbing or impact. This protective measure is particularly important during sleep. Antibiotic and anti-inflammatory eye drops are prescribed to prevent infection and manage inflammation, common after ocular trauma.
Patients restrict strenuous activities, heavy lifting, and bending for several weeks to avoid increasing pressure within the eye. Activities like swimming and getting tap water into the eye are often prohibited for a period to minimize infection risk. Regular follow-up appointments with the ophthalmologist are scheduled to monitor healing, assess intraocular pressure, and adjust medications as needed.
The prognosis for vision following a scleral laceration is highly variable and depends on several factors. Factors determining the final visual outcome include initial visual acuity, laceration location and size, and damage extent to other internal eye structures (e.g., retina, lens, or vitreous). Complications like hyphema (blood in the eye), vitreous hemorrhage, or retinal detachment can also influence the prognosis. While some vision loss is common, surgical repair is fundamental for saving the eye and maximizing vision recovery.