Management of open globe injury: a narrative review

Open globe injuries are a significant global cause of visual loss, including unilateral and bilateral blindness. Prognosis is predicted by injury severity, with lower presenting visual acuity and more posterior injuries associated with poor visual outcomes, although even the most severely injured eyes with no perception of light vision may regain some visual function. In addition to severity of the primary injury, the secondary injuries and complications causing poor outcomes include proliferative vitreoretinopathy (PVR) and endophthalmitis. Endophthalmitis is common after open globe injury, affecting up to 16.5% of patients. Systemic antibiotic prophylaxis is commonly used, with a limited evidence base, while intraocular antibiotics are less commonly used but have stronger supporting evidence of efficacy. Endophthalmitis rates are also reduced by prompt primary repair, which may also support recovery of visual acuity. PVR is not prevented or treated by any pharmacologic interventions in current clinical practice, but the incidence of post-traumatic PVR may be reduced by early vitrectomy within the first 4-7 days after injury. Ocular trauma training is often limited in Western ophthalmic surgical training programmes, and patients with ocular trauma often require the input of multiple subspecialists. In this context, it is important that patients have an overview and coordination of the different aspects of their care, with ownership by one lead clinician.

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.

An interpretable model predicts visual outcomes of no light perception eyes after open globe injury

BACKGROUND

The visual outcome of open globe injury (OGI)-no light perception (NLP) eyes is unpredictable traditionally. This study aimed to develop a model to predict the visual outcomes of vitrectomy surgery in OGI-NLP eyes using a machine learning algorithm and to provide an interpretable system for the prediction results.

METHODS

Clinical data of 459 OGI-NLP eyes were retrospectively collected from 19 medical centres across China to establish a training data set for developing a model, called 'VisionGo', which can predict the visual outcome of the patients involved and compare with the Ocular Trauma Score (OTS). Another 72 cases were retrospectively collected and used for human-machine comparison, and an additional 27 cases were prospectively collected for real-world validation of the model. The SHapley Additive exPlanations method was applied to analyse feature contribution to the model. An online platform was built for real-world application.

RESULTS

The area under the receiver operating characteristic curve (AUC) of VisionGo was 0.75 and 0.90 in previtrectomy and intravitrectomy application scenarios, which was much higher than the OTS (AUC=0.49). VisionGo showed better performance than ophthalmologists in both previtrectomy and intravitrectomy application scenarios (AUC=0.73 vs 0.57 and 0.87 vs 0.64). In real-world validation, VisionGo achieved an AUC of 0.60 and 0.91 in previtrectomy and intravitrectomy application scenarios. Feature contribution analysis indicated that wound length-related indicators, vitreous status and retina-related indicators contributed highly to visual outcomes.

CONCLUSIONS

VisionGo has achieved an accurate and reliable prediction in visual outcome after vitrectomy for OGI-NLP eyes.

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.

Outcomes of pars plana vitrectomy following ocular trauma at varying surgical time points

Background

The optimal timing of pars plana vitrectomy (PPV) following ocular trauma is an ongoing debate. Early vitrectomy post-trauma enables the rapid assessment of retinal disease by removing the scaffold that fosters proliferative vitreoretinopathy. On the other hand, late vitrectomy is less challenging as there is a lower risk of bleeding and posterior vitreous detachment induction is easier. The purpose of this work is to report the functional and anatomical outcomes following ocular traumatic injuries in a United States-based cohort, emphasizing the time of intervention.

Methods

This was a retrospective case series of 110 patients with traumatic ocular injuries who underwent PPV between 2008 to 2020. Patients were grouped into four timing categories: same day (0 days), early (1–7 days), delayed (8–14 days), and late (> 14 days). Multivariable regression models controlling for confounding were implemented to assess the impact of vitrectomy timing on anatomical and functional outcomes. Visual acuity (VA) at baseline and after surgery, proliferative vitreoretinopathy (PVR), and enucleation for each vitrectomy timing category were recorded.

Results

Patient demographics and severity of ocular trauma were comparable across timing categories. Final VA in LogMAR was found to have a stepwise worsening as the time of ocular trauma to vitrectomy was increased (p < 0.05). For every one-step increase in the vitrectomy timing category, there was an adjusted 0.24 (CI 0.04–0.44) increase in final VA. No patient in the same day vitrectomy group had an enucleation or PVR, while patients who had late vitrectomies had the largest number of both enucleations and PVR (44.4% and 52.0%, respectively). In adjusted analysis, there was 3.11 increased odds (CI 1.03–9.42) of developing PVR for a one-step increase in vitrectomy timing (p < 0.05).

Conclusion

Vitrectomy on the same day of injury has the best final VA, and the lowest incidence rates of PVR and enucleation in comparison to other timing categories, regardless of etiology.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40942-022-00399-9.

Guideline for the treatment of no light perception eyes induced by mechanical ocular trauma

Severe mechanical ocular trauma with no light perception (NLP) predicts a poor prognosis of visual acuity and enucleation of the eyeball. Since the innovative treatment concept of exploratory vitreoretinal surgery has developed and treatment technology has advanced, the outcomes of severe ocular trauma treatment in NLP patients have greatly improved. However, there remains a lack of unified standards for the determination, surgical indication, and timing of vitrectomy in NLP eye treatment. To address these problems, we aimed to create evidence-based medical guidelines for the diagnosis, treatment, and prognosis of mechanical ocular trauma with NLP. Sixteen relevant recommendations for mechanical ocular trauma with NLP were obtained, and a consensus was reached. Each recommendation was explained in detail to guide the treatment of mechanical ocular trauma associated with NLP.

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.

Surgical management and outcomes of pediatric open globe injuries requiring vitrectomy

PURPOSE

To describe surgical management and establish visual outcomes of open globe injury (OGI) in pediatric patients requiring vitrectomy.

METHODS

Forty-eight eyes of 48 pediatric patients underwent vitrectomy for OGI with secondary vitreoretinal complications in the eye center of Jilin University were included. Characteristics of patients, details of ocular examination and operation, presenting and final visual acuity were recorded.

RESULTS

Presenting visual acuity less than 20/400 was found in 44 eyes (91.7%), which included no light perception (NLP) in four eyes. At last visit, there was no eyes with visual acuity of NLP, and 19 eyes (39.6%) had a vision recovery to 20/400 or better. Mechanisms of injury, intraocular contents prolapse, presence of hyphema, intraocular foreign body, vitreous hemorrhage, retinal detachment, and total time from injury to PPV > 2 weeks were significant predictors of visual prognosis. Logistic regression analysis showed that hyphema was a significant predictive factor for poor visual outcome.

CONCLUSION

Visual acuity was improved in most of the patients with OGI in this study. Hyphema is an important presenting ocular sign in estimating the post-vitrectomy visual outcome for OGI in children. Proper timing of vitrectomy is suggested, and in this study patients may benefit more with early vitrectomy as less proliferative vitreoretinopathy (PVR) was found together with a better visual acuity.

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.

Rupture of the Globe: What to Do, What not to Do

Due to their complexity, globe ruptures are highly compromising traumas for the patient. This is due on the one hand to the eye injury itself with the accompanying loss of vision and on the other hand due to the need for extended treatment with uncertain prognosis and the resulting psychological stress. Globe ruptures are among the prognostically most unfavorable injuries due to the force and peak pressure impacting the eye. Furthermore, contusional retinal necrosis may be of significance prognostically. In the present review, we discuss treatment of globe ruptures involving retinal surgery. We discuss the primary sugery, its chronological planning and extent as well as the necessity for follow-up interventions. We also discuss the origin of traumatic retinal detachment with differential diagnosis of giant retinal tear versus oradialysis as well as secondary sequelae of traumas such as formation of macular holes and their treatment. On this basis, the use of buckling surgery versus pars-plana vitrectomy is discussed. Further focus is set on the role of the iris lens diaphragm in surgery of globe ruptures.

Optimal timing of vitrectomy for severe mechanical ocular trauma: A retrospective observational study

Mechanical ocular trauma could lead to disastrous visual outcomes. There has been a controversy regarding the timing of vitrectomy for such cases. This study aimed to find out the optimal timing of vitrectomy for severe mechanical ocular trauma. Patients with severe mechanical ocular trauma who had undergone vitrectomy were enrolled and followed up for at least 6 months. Clinical data were collected including ocular trauma score (OTS), the timing of vitrectomy upon injury, visual acuity, vitrectomy results, post-operation complications and etc. All cases were classified according to the timing of vitrectomy upon injury into 3 groups: group A 1–7 days, group B 8–14 days, group C more than 14 days. A total of 62 cases were enrolled, including 20 eyes in group A, 25 eyes in group B, and 17 eyes in group C. No significant differences were shown of the gender, age or OTS among the 3 groups. Both functional success rate and visual outcome were optimal in group B, then in group A, and worst in group C. These results suggested that the best timing of vitrectomy for severe mechanical ocular trauma is 8–14 days upon injury; second best is 1–7 days; worst is after 14 days.

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.

Visual outcomes and prognostic factors in open-globe injuries

BACKGROUND

Ocular trauma is an important cause of visual loss worldwide. Improvements in our knowledge of the pathophysiology and management of ocular trauma during the past 30 years, in conjunction with advances in the instrumentation and techniques of ocular surgery, have improved the efficacy of vitreoretinal surgery in injured eyes. The aim of the current study was to determine the visual outcomes and prognostic factors of open-globe injuries in the Japanese population.

METHODS

Retrospective study of 59 eyes of 59 patients presented with open globe injuries between September 2008 and March 2014 at Nagasaki University Hospital was conducted. Demographic factors including age, gender, and clinical data such as cause of injury, presenting visual acuity (VA), location of injury, type of injury, lens status, presence of intraocular foreign body, types of required surgeries, and final VA were recorded. According to the classification of Ocular Trauma Classification Group, wound location was classified into three zones. Chi-square test was used to compare presented data.

RESULTS

Out of the 59 patients, 46 were placed in the Light Perception (LP) group, and 13 were placed in the No Light Perception (NLP) group. Work-related trauma was the most common cause (27 eyes) followed by falls (19eyes). Work-related trauma was common in males (P = 0.004), while falls was significantly common in females (P = 0.00001). Zone III injuries had statistically significantly poor prognostic factor compared to other zones (P = 0.04). All cases of NLP group (100%) presented with rupture globe. Poor VA at first visit (P = 0.00001), rupture globe (P = 0.026), history of penetrating keratoplasty (PK) (P = 0.017), retinal detachment (RD) (P = 0.0001), vitreous hemorrhage (VH) (P = 0.044), and dislocation of crystalline lens (P = 0.0003) were considered as poor prognostic factors.

CONCLUSION

Poor VA at first visit, rupture globe, zone III injuries, history of penetrating keratoplasty, RD, VH, and dislocation of crystalline lens were found to be poor prognostic factors. PPV had a good prognostic value in open globe injuries associated with posterior segment involvement.

Surgical Management of Traumatic Retinal Detachment with Primary Vitrectomy in Adult Patients

Purpose. To evaluate functional and anatomical results of pars plana vitrectomy (PPV) in the retinal detachment (RD) followed by severe eye trauma. Methods. Retrospective analysis of medical records of forty-one consecutive patients treated with 23-gauge PPV due to traumatic RD. Age, gender, timing of PPV, visual acuity, and presence of intraocular foreign body (IOFB) and proliferative vitreoretinopathy (PVR) were included in the analysis. Results. Mean age of patients was 47 years; the majority of patients were men (88%). Closed globe injury was present in 21 eyes and open globe injury in 20 eyes (IOFB in 13 eyes, penetration injury in 4 eyes, and eye rupture in 3 eyes). Mean follow-up period was 14 months; mean timing of PPV was 67 days. Twenty-seven (66%) eyes had a functional success; 32 eyes (78%) had anatomical success. As a tamponade silicone oil was used in 33 cases and SF6 gas in 8 cases. Conclusions. Severe eye injuries are potentially devastating for vision, but vitreoretinal surgery can improve anatomical and functional outcomes. Among analysed pre- and intra- and postoperative factors, absence of PVR, postoperative retinal attachment, and silicone oil as a tamponade were related to significantly improved visual acuity.

[Bilateral eye injuries by external transversal force]

A 49-year-old female victim of violent crime with an acute bilateral loss of vision was referred to our hospital. The ophthalmological evaluation showed complete subconjunctival hemorrhage of both eyes, bilateral hemophthalmos and hypotonia of the left eye. These raised the suspicion of an occult scleral rupture. We immediately performed exploratory surgery and found a perforating scleral lesion of the left eye and a penetrating scleral lesion of the right eye. Furthermore, a small, cruciform wound was detected on the left temple. In cooperation with the department of radiology, the extraordinary injury pattern was reconstructed: a horizontal stab wound with perforation of the left eye and penetration of the right eye caused by a screwdriver. Visual rehabilitation necessitated further surgical interventions. Besides the intraoperative approach, immediate primary wound management within 100 h of trauma plays a pivotal role for long-term outcome.

Ocular trauma treated with pars plana vitrectomy: early outcome report

AIM

To evaluate demographic variables and visual outcomes, among patients with ocular injuries involving the posterior segment, managed with pars plana vitrectomy.

METHODS

The records of patients were studied retrospectively from March to September 2010, to determine the age, gender, place of occurrence of trauma, visual acuity, anatomical site, nature of injury, wound length, the presence of an afferent pupillary defect, and the timing of vitrectomy. The Ocular Trauma Score was measured. The minimum follow-up from presentation was 6mo.

RESULTS

Ninety patients (77 males, 13 females), with a mean age of 32.7±15.8y were included over the 6-month period. The majority of cases occurred in the workplace (47 patients), followed by home (14 patients). The mean visual acuity (logMAR) of patients significantly improved from 2.36±0.72 preoperatively to 1.50±1.14 postoperatively. Twenty-three patients had preoperative vision better than 2.0 logMAR, the postoperative visual acuity was significantly better among these patients than patients with worse than 2.0 logMAR (P<0.001). Visual improvement between groups with early vitrectomy (<7d) and delayed vitrectomy (>7d) was not significantly different (P=0.66). Postoperative visual acuity was not significantly different between patients with injury in Zone I and II (P=0.64), but patients with injury in Zone III had significantly poorer visual acuity (P=0.02). Patients with relative afferent pupillary defect had significantly poorer postoperative visual acuity (P=0.02). Preoperative visual acuity, the difference of preoperative and postoperative visual acuity, and postoperative visual acuity were significantly different between groups with different ocular trauma scores (P<0.001).

CONCLUSION

Trauma is more likely to occur in men under 40y of age and in the workplace. The favorable final visual outcome is associated with the absence of afferent pupillary defect, ocular trauma score and presenting visual acuity as well as the zone of injury, and not associated with the timing of vitrectomy.

The role of computed tomography in the immediate workup of open globe injury

PURPOSE

Immediate primary closure is indicated in cases of traumatic open globe injury. Orbital computed tomography (CT) is performed prior to primary closure in order to rule out possible intraocular foreign bodies (IOFB) and/or damage to adjacent extraocular as well as intraocular structures. The aim of the present study is to evaluate the yield of orbital CT scan in immediate clinical decision-making in cases of open globe injury.

METHODS

All cases of open globe injury treated in our institute during a 10-year period were reviewed. All underwent a CT scan before any surgical intervention, regardless of trauma severity. The influence of the CT scan results on decisions regarding the immediate treatment of the open globe injury was analyzed.

RESULTS

A total of 125 cases of open globe injury were included in the present study. In none of these cases did the CT scan results have any influence on immediate treatment. The CT scan results did influence decisions that were made after the immediate operative stage.

CONCLUSIONS

Computed tomography scan has limited value in immediate clinical decision-making in cases of open globe injury scheduled for primary closure. While not crucial prior to the initial procedure, it is of value in managing the case during the following few days as well as later on. This study suggests that a CT scan performed after the initial globe exploration and suturing procedure is a valid alternative to stalling the definite globe suturing process until a CT scan is obtained and interpreted.