How do you diagnose a scleral laceration?

Diagnosing Scleral Laceration

Scleral laceration diagnosis requires a systematic slit-lamp biomicroscopy examination combined with careful inspection for signs of ocular trauma, including evaluation for corneoscleral wounds, iris abnormalities, and anterior chamber disruption, with ultrasound biomicroscopy or B-scan ultrasonography when direct visualization is limited.

Clinical History and Presentation

• Obtain detailed history of trauma mechanism, as scleral lacerations typically result from penetrating or blunt ocular injury 1, 2, 3
• Document timing of injury, as delayed presentations may show infectious complications or wound dehiscence 1, 4
• Note symptoms including pain, photophobia, decreased vision, and any history of prior ocular surgery that may predispose to wound dehiscence 4

Essential Examination Components

Visual Acuity Assessment

• Measure visual acuity under standard lighting conditions with and without correction 5
• Document baseline corrected distance visual acuity, as this ranges from hand movements to 20/20 depending on injury severity 2, 3

External and Anterior Segment Examination

• Assess pupil shape, size, and position for irregularities suggesting trauma 5
• Look for sphincter rupture as evidence of past trauma 5
• Examine for iris transillumination defects, iridocorneal adhesions, peripheral anterior synechiae, or posterior synechiae as evidence of trauma 5
• Check for iris prolapse, which may be jammed into the scleral wound 2

Slit-Lamp Biomicroscopy Findings

• Identify healed or recent corneoscleral wounds using various slit-lamp techniques including sclerotic scatter, specular reflection, and indirect illumination 5
• Document areas of scleral thinning associated with previous surgery or trauma 5
• Assess for conjunctival hyperemia overlying the injury site 1
• Evaluate anterior chamber depth and look for hyphema or flat anterior chamber 2, 3
• Perform Seidel test to detect active aqueous leak (though may be negative in sealed wounds) 4

Intraocular Pressure Measurement

• Measure IOP, noting that hypotony (pressures as low as 7-8 mm Hg) suggests full-thickness injury with aqueous leak 4
• Use alternative tonometry methods if corneal abnormalities preclude Goldmann applanation 5

Advanced Diagnostic Imaging

Ultrasound Biomicroscopy

• Perform ultrasound biomicroscopy when scleral laceration is suspected but not clearly visible, as it can reveal dome-shaped masses overlying partial-thickness scleral lacerations or other structural abnormalities 1
• This technique is particularly valuable for evaluating posterior injuries not visible on slit-lamp examination 1

B-Scan Ultrasonography

• Obtain B-scan ultrasonography if media opacity or patient cooperation precludes adequate examination of the posterior segment 5, 6
• Use to search for retinal detachment, vitreous hemorrhage, retained foreign bodies, or other posterior segment complications 5, 6
• Repeat ultrasonographic examination within 1-2 weeks if initial findings are equivocal 5, 6

Critical Diagnostic Pitfalls

• Do not mistake infectious scleritis for simple episcleritis in post-traumatic cases—a painful scleral nodule developing after trauma warrants surgical exploration and cultures 1
• Recognize that old scleral scars can dehisce after blunt trauma, potentially forming filtering blebs even months to years after initial injury 4
• Consider that retained intraocular foreign bodies (glass fragments) may be present and require identification 3
• Evaluate for associated injuries including traumatic cataract, retinal detachment, and lens dislocation 3

Surgical Exploration Indications

• Proceed with surgical exploration when clinical suspicion is high despite negative initial findings, as this allows direct visualization, tissue sampling for cultures and histology, and immediate repair 1
• Surgical specimens should be submitted for microbiologic analysis to prevent progression to endophthalmitis 1