OcuLearning › Trauma

Conjunctival Laceration

URGENT — Trauma

Symptoms

  • Ocular pain and redness.
  • Persistent foreign body sensation.
  • Clear history of blunt or sharp trauma.

Clinical Findings

Clinical appearance

  • Fluorescein-staining linear defect of the bulbar conjunctiva.
  • Edges may be rolled or retracted, potentially exposing the bare white sclera.
  • Surrounding subconjunctival hemorrhage and chemosis are common.

Management by size

  • Small Lacerations (<1 cm): Usually heal spontaneously within days with prophylactic antibiotics; no sutures required.
  • Large Lacerations (>1–2 cm): Mandate careful exploration to rule out underlying injury.

The "occult" open globe

  • Bullous Hemorrhage: Thick, elevated, 360° subconjunctival hemorrhage is a major red flag for occult scleral rupture.
  • Peaked pupil, marked hypotony, or visible dark uveal tissue within the wound confirms an open globe.

Etiology

Mechanisms

  • Sharp trauma (fingernails, twigs, glass) or blunt concussive forces.
  • Iatrogenic: Post-surgical complications (strabismus or pterygium surgery) or contact lens insertion trauma.

Clinical concern

  • Chemosis and blood can easily hide a globe perforation—the mobile conjunctiva must be manipulated to inspect the underlying scleral bed.

Red Flags

  • Bullous subconjunctival hemorrhage: High suspicion for underlying scleral laceration.
  • Dark uveal tissue: Indicates a full-thickness prolapse/rupture.
  • Retained organic material: High risk of infection; necessitates aggressive debridement and broad-spectrum coverage.
  • Canalicular involvement: Lacerations near the medial canthus require intubation within 24–48 hours.

Investigations

Ocular exploration

  • Slit-lamp exam: Use proparacaine and a sterile cotton-tipped applicator to gently shift the mobile conjunctiva.
  • Scleral inspection: Inspect the entire area of sclera beneath the defect to ensure it is intact.
  • Seidel test: To rule out aqueous leak if the injury is near the limbus.

Imaging

  • CT Orbit (1-mm sections): Without contrast to rule out intraocular or intraorbital foreign bodies (IOFB).
  • B-scan ultrasound: Only if the globe is confirmed to be closed and the posterior segment view is obscured.

Surgical exploration

  • General anesthesia exploration in the OR if a scleral rupture cannot be ruled out at the bedside.

Treatment

Medical therapy

  • Topical antibiotic (e.g., Polytrim or a Fluoroquinolone) QID for 7 days.
  • Tetanus prophylaxis as indicated by immunization history.

Surgical repair

  • Indications: Gaping wounds, lacerations >1 cm, or anatomic restoration needs.
  • Technique: 8-0 or 9-0 Vicryl sutures with buried knots.
  • Crucial: Never close a conjunctival laceration until the underlying sclera is confirmed intact.

Clinical Pearl

A bullous or 360° subconjunctival hemorrhage after trauma is an occult scleral rupture until proven otherwise. Always manipulate the mobile conjunctiva to see the bare sclera underneath.

Differential Diagnosis

  • Subconjunctival hemorrhage (isolated)
  • Scleral laceration (open globe)
  • Conjunctival cyst
  • Perforating ocular injury

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