NAVIGATING SURGICAL CHALLENGES: MANAGEMENT OF A SECONDARY CORNEAL SCAR AFTER A HISTORY OF COMPLETE CORNEAL LACERATION AND TRAUMATIC CATARACT

In the following case, we will present the challenges encountered in ocular trauma that required management of a full-thickness corneal laceration and traumatic cataract  in the first stage and penetrating keratoplasty (PK) after 3 years

Keywords: corneal laceration, traumatic cataract, IOL implantation, scleral fixation, Penetrating keratoplasty

A 59 year old  male patient presented in our Emergency Department Unit in December 2021 after an accidental penetrating ocular injury to the left eye  due to a  sharp nail hitting the eye at high velocity. At the time of presentation, the visual acuity of the injured eye was light perception. The left eye had low pressure on palpation and biomicroscopical evaluation of the anterior pole revealed: linear vertical nasal paracentral cornean laceration of aprox. 6mm,  positive Seidel sign, narrow AC, fibrin strains and pigment in the AC, a deformed unresponsive midriatic pupil, punctured anterior capsule and a complete opacification of the lens wich did not allow evaluation of the posterior pole. Emergency head CT excluded retained intraocular foreign body. The initial management of this case consisted of tetanus prophylaxis,  sistemic large spectrum antibiotics and corticosteroids and emergency surgery for wound closure and therapeutic contact lens placement  followed by topical medication : mydriatic agents, antibiotics, corticosteroids and eye lubricating gel. After weekly follow-up  of the healing process,  1 month later , the patient was admitted again for emergent surgical management of the traumatic cataract . After aproximately 4 months, IOL implantation with scleral fixation (suture less- Carlevale IOL). After one monts, the patient suffers a new trauma that, untreated, leads to infection and heals with a corneal scar. After 3 years, the patient benefits from penetrating keratoplasty for visual rehabilitation, with fresh donor cornea from the donor. 

Good postoperative evolution, 2 months after surgery, the patient had a satisfactory outcome, with a stable posterior chamber IOL and a best corrected visual acuity of 20/40, transparent graft, continent corneal threads. He was advised with a long-term recommendation for the use of topical corticosteroids, artificial tears and preservative free.

The visual prognosis in this case was  satisfactory on short term, but on long term there is an increased risk for corneal grafts rejection. Management of a traumatic cataract in an eye with a preexisting ocular surface disease, in this case, corneal scarring, imposes for every surgeon a challenge in putting forward a proper surgical conduct that would lead to a desireable outcome. Penetrating keratoplasty in an eye with prior ocular trauma and inflammation is challenging and carries many risks of rejection. For long-term success after PK,  is desirable for both the surgeon and the patient to be constantly aware of ocular changes so that the problems can be promptly treated.