 Adam Jorgensen, one of our hard-working fourth-year med students who is kind enough to push his presentation back from a couple weeks ago, so he's been out hitting. Sorry, Lloyd Williams is going to go first. One of our chiefs. Sorry, Adam. Low man. Sorry, Adam. I'm here for this one. All right, so I'm going to talk about a corneal purse string suture in the context of stelae laceration in an open globe. This particular patient was an 18-year-old female, previously healthy, no ocular history who was involved in a motor vehicle accident that was pretty severe. She was the only survivor of the accident and sort of amazingly only had a jaw fracture in an open globe. She was count fingers in the left eye, which was the globe that was open. She had a upper lid laceration that was relatively minor and we repaired that during the surgery. She had a glass-form body that we found under the upper lid, but that was not actually in anything. That was easily removed. She had a three-part corneal laceration in the left eye that was obviously leaking with a shallow anterior chamber. Normal retina and optic nerve on fundus exam. Let me just go forward to the photos. This is the laceration. The way we repaired it is originally we sutured the inferior wound, which was longer, and then attempted to close the central wound with sutures across the two top parts of the Y, but then the wound centrally gaped further. Gene, Kim, suggested using a purse string that he'd read about. We did that and managed after tying it to have the wound side out negative. I'm going to talk a little bit about that purse string or I'll show it to you again. When you're dealing with a corneal injury on call at night, you want to determine the extent of the injury, whether there's an intraocular foreign body, whether or not you need to have retina involved, whether the injury is through and through the globe, whether there is in fact an open globe, the orbital injuries or other posterior segment injuries. In terms of repairing corneal lacerations, you can sometimes seal them with a bandage contact lens or glue, but generally full thickness wounds are repaired with tenon nylon. Most of the time you would close the eye first and then worry about things like cataract and other injuries at a later date, and you need to remember systemic antibodies and antibiotics and tetanus prophylaxis. When you're suturing, your goals are a 90 percent depth equal on each side and equal length on each side. You do not want to do full thickness sutures if possible, and if possible you would like to keep the visceral axis free of suture, although that's not necessarily possible in all cases, and closing the eye is the primary goal. So here's some examples of a correct way of placing a suture too shallow, not symmetric, also not symmetric, so you have an edge and too deep. The wound creates a flattening in the central cornea, and so ideally you want to repair it with longer sutures peripherally and shorter sutures centrally, which gives you less central scarring and also provides central steepening to counteract the flattening from the wound. And so here's an example of a repair of a wound through the center of the cornea. You also want to prevent material from being incarcerated in the wound, so one way to do that is to make a paracentesis and sweep material down and fill viscoelastic in that area to prevent it from coming back up into the wound as you place your suture. Severe injuries sometimes can be fixed with a patch graft, if there's tissue missing and there's really no way to suture the wound. This here? So yeah, so this is definitely an option if you're missing a large chunk of tissue and there's just no way to close it. So there are various ways of closing stellate lacerations and I've had two and Grant's had one so far this year and I think he would agree that these have been the most difficult by far on-call cases that we've done and so one way is with a bridging suture here here and here and you'll see an example of that in Grant's case. One way is with glue at the center and one way is with a purse string. So this is the technique that Gene and I used in the case. It's called the Eisner method and the reason we did this is at least in my experience and in my hands it's actually pretty hard to do a purse string suture and so this is one technique where you make stepknife incisions in the flaps of the cornea and then you pass the suture from incision to incision and come out on this end and tie it down and then all of it is at a known depth. We chose 300 microns and it's actually quite it's no more difficult to pass this suture from that stepknife incision out this stepknife incision than it is to make any other corneal suture and then you get the knot buried. One possible disadvantage of this technique is you then really don't have any way of taking this suture out at any point in the future. It's essentially starting in the incision. Does that put the knot on the surface? It's not that easy to make these. What we did is we grabbed it with the Kohan essentially right about here so that we weren't macerating the tips of the tissue because if you grab it here then you're you're mucking up this tissue and it's not going to come together well so we sort of grabbed it back here. So you start on the top come out this come out here come out here come out here come out here and end on the top again. I've got a drawing of that so I'll show that. So then this is this is the purse string that Gene and I did and I think you can see it pretty well. One thing about it that that sort of surprised me is how tight we had to make that in order to get this to seal. I almost felt nervous to pull it as tight as I did until actually Gene pulled it tight until this actually sealed and stopped leaking. But it came together nicely. You can see the the lines of tension here how tight that that actually was and where the step incision was. In retrospect we might have put the knot over here instead of so this patient is is currently 2100 uncorrected 2050 corrected Plano plus four. Yeah you can see some flattening there but that's that's post-up day one. So post-up day one count fingers day two count fingers at three feet by ten days she was 2200 and now she's 2100 uncorrected. So this is the second one that I did. I'll go to this picture maybe this shows the wound better. The wound essentially went this way around curved up that way and had this little tail sticking out there. He originally put a suture here a suture here a suture here but it still leaked from from this area. Then I tied a purse string and still had a little bit of central leakage. I think my error was that I didn't tighten it enough. Then retina took the foreign body out of his eye and by the time the eye had been pressurized at about 30 millimeters of mercury and had the lens and stuff on this was pouring out profusely at the end of the retina case and then Julia Shulman and I oversawed it with four more sutures. At the end I sort of felt like we had attempted to knit a scarf of 10-0 on his cornea and he was at this point gently leaking and we decided that discretion maybe was the better part and put a bandage contact lens. By the next morning his anterior chamber was well formed and he's been doing pretty well but I think this case for me at least illustrated the point that the more sutures you place eventually you've put so many holes in the cornea that you have a sieve that you can't repair and so like Dr. Tabin was saying developing a good plan and sort of sticking to it I think is is essential for closing these kinds of wounds because you can't put five sutures in take them out put five more in take them out put five more in and then take those out and have much left to work with but I agree I think the error I made here was on this purse string this edge of the purse string is right at the edge of the little tag and doesn't quite go through it and then I could have made it a little further out and tied it much tighter. I'll just show Grant's case this was the stellate laceration Grant had this was the original repair which was leaking at the center and the patient was brought back to the operating room the next day where Dr. Tabin helped Grant change the short sutures here and here to a long suture bridging across that triangle and then it was sealed so that's a this is another possible approach to sealing something like this so in the interest of letting Adam talk