Prophylactic chorioretinectomy for eye injuries with high proliferative-vitreoretinopathy risk

Visual outcomes and prognostic factors of early pars plana vitrectomy for open globe injury

OBJECTIVES

To identify the clinical features and outcomes of early vitrectomy in patients with open globe injury (OGI) and the prognostic factors for visual outcome.

METHODS

This retrospective observational case series included 390 eyes in 389 patients diagnosed with OGI receiving vitrectomy within four days after injury. Preoperative parameters included the injury types, wound locations, consequent tissue damages, initial visual acuity (VA), and ocular trauma score. Postoperative outcome measures included surgical procedures, retinal (re)attachment, complications, and final VA. The logistic analysis evaluated the prognostic factors for visual outcome.

RESULTS

Intraocular foreign bodies (59.2%) and penetrating injuries (28.7%) were the most common injury types. Among the 165 eyes with retinal detachment (RD), 121 (73.3%) had retinal reattachment during early primary vitrectomy, and 32 (19.4%) were repaired during a second or subsequent surgery. Thirteen eyes (3.3%) were enucleated. The final VA improved from the initial level in 207 eyes (55.2%), remained unchanged in 123 (32.8%), and decreased in 45 (12.0%). Multivariable regression revealed that the injury zone, initial VA, RD, and endophthalmitis were associated with poor visual outcomes (P < 0.05).

CONCLUSIONS

Higher zone injury, low initial VA, RD, and endophthalmitis are predictors of poor visual outcome in eyes undergoing early vitrectomy for OGI.

Retinotomies and retinectomies: A review of indications, techniques, results, and complications

Retinotomy refers to "cutting" or "incising" the retina, whereas retinectomy denotes "excising" the retina. Retinotomies and retinectomies aid in tackling traction and retinal shortening that persist following membrane dissection and scleral buckling. We performed a literature search using Google Scholar and PubMed, followed by a review of the references procured. All relevant literature was studied in detail and summarized. We discuss the indications of retinotomies and retinectomies for relaxing retinal stiffness, accessing the subretinal space for choroidal neovascular membrane, hemorrhage and abscess clearance, drainage retinotomies to allow retinal flattening, radial retinotomies to release circumferential traction, harvesting free retinal grafts, and prophylactic chorioretinectomies in trauma.

Long-term functional and structural outcomes after large chorioretinectomy for ruptured globe following blunt trauma

BACKGROUND

The purpose of this study was to present a modified surgical technique involving pars plana vitrectomy with large chorioretinectomy for eyes with rupture of the globe due to severe ocular blunt trauma.

METHODS

This retrospective study included consecutive patients with rupture of the globe due to blunt trauma who were treated at the King Khaled Eye Specialist Hospital (Riyadh, Saudi Arabia). All patients underwent 25-gauge pars plana vitrectomy with large chorioretinectomies involving all the tissue around the posterior scleral wounds. Outcome measures included best-corrected visual acuity (BCVA), anatomical success and globe survival, rates of complications.

RESULTS

15 eyes of 15 patients were included. Mean BCVA was 2.88 ± 0.13 logMAR at presentation, and significantly improved to 0.83 ± 0.28 logMAR (P < 0.001), with 10 patients (67%) achieving a final BCVA ≥ 20/200. Anatomical success and globe survival were achieved in 11 (73%) and 15 (100%) of eyes, respectively. Postoperative complications included retinal detachment in 6 eyes (40%), epiretinal membrane in 6 (40%), hypotony in 4 (26%), PVR in 2 (13%).

CONCLUSIONS

Pars plana vitrectomy with large chorioretinectomy is an effective treatment for globe rupture following severe blunt trauma, yielding good visual outcomes and anatomical success rates.

Case report: Bilateral eye injuries in members of one family due to a cluster munition in Ukraine

The aim of the study was to report the effects of surgical treatment of three victims of a cluster munition in Ukraine. A 32-year-old woman and her sons-6-year-old male twins-presented in Poland after 18 days of delay in treatment. All ocular injuries were bilateral. One of the boys presented with total retinal detachment and a post-traumatic cataract as well as corneal sutures in one eye and a post-traumatic cataract in the other eye. The other boy had already developed atrophy in one eye and a vitreous hemorrhage in the other eye. The woman suffered from bilateral post-traumatic cataract with multiple glass intraocular foreign bodies (IOFBs). The surgical treatment included cataract surgery with intraocular lens implantation in three eyes, removal of IOFBs in one eye, and enucleation of the atrophic eye with implantation of an ocular prosthesis preventing constriction of face tissues. The eye with retinal detachment underwent pars plana vitrectomy, and the vitreous hemorrhage resolved itself. Postoperatively, visual acuity improved significantly in four of six eyes. Only in the eye with an open-globe injury and persistent retinal detachment, the final visual acuity was still poor. In conclusion, cluster munition may lead to bilateral ocular trauma with IOFBs, open-and close-globe injuries, and severe vision loss if left untreated. Modern ophthalmic surgery leads to vision with IOL improvement and solving the eyes after severe combat injury.

The impact of primary repair timing on longitudinal visual outcomes after open globe injury

BACKGROUND

The urgency with which to repair open globe injuries is a debated topic that lacks grounding in longitudinal visual outcomes data. We aim to test the association between primary repair timing and visual recovery potential following OGI.

SUBJECTS/METHODS

We performed a retrospective cohort study of medical records from a US academic medical center (7/2017 to 11/2021). We included all patients with a principal diagnosis of OGI, a documented date and time of injury, presentation, repair, and ≥ 3 months of complete follow-up data on visual outcomes. We excluded those with prior OGI in the same eye. We also tested the correlation of injury to repair time (ITR) in hours with best corrected visual acuity (BCVA, in logMAR units) at last follow-up in the general cohort and select subpopulations and the impact of repair delay on visual improvement over the follow-up period.

RESULTS

One hundred twenty-nine patients with OGI were analyzed (91 patients with ≥ 3 months of follow-up). The majority were male (105/129, 81%) with a median age of 45 years. Most OGI involved zone 1 (57%), followed by zone 3 (24%), and zone 2 injuries (19%). Median ocular trauma score (OTS) was 60 (IQR 37-70); mean presenting BCVA was logMAR 1.9 (median 2.3, IQR 1.0-2.7). Median ITR was 22 h (IQR 15-30 h, range 5-199 h). ITR time did not significantly correlate with final BCVA (n = 91, β = - 0.003, 95% CI - 0.009-0.002, P = 0.233), nor did it significantly increase the odds of developing ocular complications or requiring secondary ocular surgeries (OR 0.985, 95% CI 0.967-1.002, P = 0.085). Additionally, the rate of BCVA improvement over subsequent months of follow-up did not significantly differ based on ITR time. Presenting BCVA (R² = 0.701, P < 0.001) and OTS (R² = 0.477, P < 0.001) significantly correlated with final BCVA, independent of repair delays.

CONCLUSIONS

In this cohort of OGI patients, repair timing does not significantly correlate with final BCVA, and delays beyond 24 h do not significantly correlate with worse visual recovery potential. Repair time alone should be emphasized to a lesser extent as a prognosticator of visual potential, in favor of significant predictors such as the ocular trauma score and presenting visual acuity.

Outcomes and Prognostic Factors Following Pars Plana Vitrectomy for Intraocular Foreign Bodies-11-Year Retrospective Analysis in a Tertiary Care Center

Aim: To evaluate the visual outcome of penetrating ocular injuries with a retained intraocular foreign body (IOFB) managed by pars plana vitrectomy (PPV) and to describe the risk factors associated with poor visual acuity and retinal detachment (RD) development. Methods: Medical records of 56 patients with IOFB that were removed by PPV over a period of 11 years (1 January 2010−31 December 2020) were reviewed. We extracted the demographic data, initial and final best corrected visual acuity (BCVA) using standard Snellen chart, IOFB characteristics, complications and surgical details. Outcome was evaluated according to the final BCVA: poor <0.1, good 0.1−<0.5 or excellent ≥0.5. Results: The mean age was 36.1 ± 14.1 (range, 16−71) years and the majority of patients were males (55 out of 56, 98.2%). IOFB was retinal in 27 (48.2%) cases and intravitreal in 29 cases (51.8%). IOFB size was ≤3mm in 26 (46.4%) cases and >3mm in 30 (53.6%) cases. Preoperative RD was identified in 12 (21.4%) cases and endophthalmitis in 17 cases (30.4%). IOFBs larger than 3 mm and retinal location were associated with RD development. Poor visual outcome was associated with initial BCVA, retinal location, RD and endophthalmitis. Conclusion: Initial BCVA, retinal foreign body, RD and endophthalmitis were risk factors for poor visual outcome.

Pars-plana vitrectomy combined with retinectomy in severe open-globe injuries: A systematic review and meta-analysis

BACKGROUND

This review summarized prophylactic retinectomy technique and its effect on anatomic and functional outcomes in severe open globe injuries (OGIs).

METHODS

A comprehensive search in PubMed (MEDLINE), Embase, Scopus, and EuropePMC databases was performed up until 8 January 2020. Enrolled studies include case series, studies involving pars plana vitrectomy (PPV) combined with retinectomy in severe penetrating injuries with or without IOFB, perforating injuries, and globe ruptures. Primary outcome was best-corrected visual acuity (BCVA) ⩾20/200 at the end of the study. Secondary outcomes were the rate of proliferative retinopathy (PVR), globe survival rate and retinal reattachment rate.

RESULTS

A total of seven studies, involving 275 eyes with severe OGIs, is included in this study. Meta-analysis indicates that final BCVA ⩾20/200 was achieved in 61% (95% CI 49%-73%). Meta-regression analysis showed that improvement was inversely affected by the presence of pre-operative direct macular injury (p = 0.001) and corneal scar (p = 0.015). The proportion of pre-operative BCVA <20/200 was statistically insignificant to the final BCVA ⩾20/200 (p = 0.569). One study showed that the rate is higher in the retinectomy group than the non-retinectomy group (54% vs 11%). Meta-analysis showed that anatomical success can be achieved in 85% (95% CI 78%-91%) of the patients. Meta-regression analysis indicates that the anatomical success did not vary with age (p = 0.653), retinal detachment (p = 0.525), corneal scar (p = 0.596), and lens involvement (p = 0.450).

CONCLUSION

Early PPV combined with retinectomy was associated with acceptable visual improvement and anatomical success.

[Management of posttraumatic ocular hypotony]

The posttraumatic ocular hypotony (3% after ocular contusion, 50-74% after open globe injury) can lead to severe secondary damage of the eyeball. In addition to corneal folds, ciliary body and choroidal detachment, papilledema e vacuo and macular folds, the shrinking of the eye can lead to substantial visual impairment. Subsequently, the contralateral eye may react with ocular hypertension. The cause of the hypotony must be identified and causally treated. A preservation of the globe is possible if more than 210 ° of the ciliary body are intact. One of the major causes of posttraumatic hypotony is cyclodialysis. Smaller cyclodialysis clefts respond to a cycloplegic treatment, larger clefts require a surgical approach. The direct cyclopexy can be combined with primary wound repair or pole to pole surgery. An alternative consists of silicone oil endotamponade or occlusion of Schlemm's canal. The posttraumatic ocular hypotony is complex and requires exact diagnostics to be able to differentially and specifically treat the causes of hypotony.

Pars plana vitrectomy timing in deadly weapon-related open-globe injuries

OBJECTIVES

The objective of this study is to evaluate the effect of vitrectomy timing on anatomical and functional outcomes in cases with open-globe injuries caused by improvised explosive devices (IEDs).

METHODS

A retrospective review of ocular injuries caused by IEDs was undertaken. The eyes were classified into four groups based on the timing of vitrectomy: early (Group-1; 2-4 days), delayed (Group-2; 5-7 days), late (Group-3; 8-14 days) and very late (Group-4; >14 days).

RESULTS

The medical records of 351 patients were reviewed, and 212 patients were excluded. A total of 189 eyes of the remaining 139 patients were analysed. Visual improvements were statistically significant compared to the baseline values in all groups (p < 0.001). The early group showed better functional and structural outcomes when compared to the other groups. There was also no proliferative vitreoretinopathy (PVR) in the early group, while PVR was at the highest rate (25%) in the very late group and constituted the most significant reason for recurrent retinal detachment.

CONCLUSION

Both functional and anatomical outcomes were better in the early group. Delayed surgery may be indicated for some cases, but 1-week interval seems to be an optimal time-frame in open globe injuries due to IEDs.

[Functional results and prognostic factors in open-globe ocular trauma with presenting visual acuity of no-light perception]

PURPOSE

To analyse the clinical ocular characteristics and determine prognostic factors for functional recovery in eyes presenting with no light perception (NLP) after open globe ocular trauma.

MATERIALS AND METHODS

In this retrospective study were included all the patients with no light perception after open globe trauma who presented to Amiens University Hospital between October 2014 and June 2018.

RESULTS

Fifteen eyes of 15 patients were included in this study. The main mechanism of the trauma was globe rupture (80 %, n=12). The most common location was zone III (66 %, n=10). The wound size was greater than 10mm in 9 patients (60 %). The ocular lesions included expulsion of the crystalline lens or posterior chamber intraocular lens, hyphema, retinal detachment, vitreous hemorrhage and ciliochoroidal lesions. Damage to the ciliary body was a negative prognostic factor for functional recovery (P=0.04). Nine patients remained with no light perception, whereas 6 patients experienced an improvement in visual acuity (2.3 logMAR in 3 patients, 0.7 logMAR in 1 patient, 0.4 logMAR in 1 patient and 0.2 logMAR in 1 patient). These 6 patients had undergone posterior vitrectomy due to vitreoretinal involvement (P<0.001).

CONCLUSION

In the case of open globe trauma with no light perception on presentation, a functional recovery is possible if there is no irreversible anatomical damage.

The Vitrectomy Timing Individualization System for Ocular Trauma (VTISOT)

Ocular trauma is a major cause of monocular blindness worldwide. Vitrectomy at correct timing can significantly improve the efficacy and prognosis, but the timing of vitrectomy has remained highly controversial for decades. Trauma cases are different from each other, thus, a flexible timing system based on the details of each individual case is recommended. Unfortunately, no such a timing system is available for clinical application up to now. To establish the vitrectomy timing individualization system for ocular trauma (VTISOT), we first identified 6 independent tPVR risk factors (including Zone 3 Injury, Zone 3 retinal Laceration, Massive Vitreous Hemorrhage, Retinal Disorder, Timing of Vitrectomy and Type of Injury) by retrospective study. Then, the tPVR score was established by binary logistic regression analysis. Most importantly and critically, the vitrectomy timing individualization system for ocular trauma was established based on the identified tPVR risk factors and the tPVR score. The following evaluation of the VTISOT showed that the patients consistent with the VTISOT principles exhibited reduced tPVR incidence and better surgical results. In short, the VTISOT principles were established, which may provide a new approach to individualize the timing of vitrectomy and improve the prognosis after trauma.

Intraocular application of Mitomycin C to prevent proliferative vitreoretinopathy in perforating and severe intraocular foreign body injuries

AIM

To assess the long-term anatomical and functional outcomes in addition to complications of a new surgical technique of localized intraocular application of mitomycin C (MMC) to prevent proliferative vitreoretinopathy (PVR) in eyes with open globe trauma.

METHODS

Prospective non-comparative interventional case series of 16 consecutive eyes with perforating and deep choroidal impact foreign body injuries presenting over a 2-year period. Patients underwent vitrectomy with intraocular application of MMC at the site of the chorioretinal injury and were followed-up for 1 year. The primary outcome measure was the rate of postoperative PVR. Secondary outcome measures were number of vitreoretinal surgeries (VRS) required, best corrected visual acuity (BCVA), final anatomical success rate and globe survival rate (GSR).

RESULTS

Patients underwent VRS at a mean time of 8.5 ± 4.6 days after the injury. Postoperative PVR developed in 2 (13 %) eyes and required only one additional VRS each. One other eye underwent further peeling of an epimacular membrane. BCVA improved from mean LogMAR 3.08 ± 0.72 preoperatively to 0.66 ± 0.79 at 1 year. All 10 eyes without a macular injury had a final BCVA of LogMAR 0.40 or better. The final anatomical success rate was 94% and GSR rate was 100%. There were no complications related to the intraocular use of MMC.

CONCLUSIONS

Vitrectomy and intraocular application of Mitomycin C may have a potential role in reducing the rate of post traumatic PVR and improving anatomical and functional outcomes in eyes with perforating and deep choroidal impact foreign body injuries.