Partial Vitrectomy for Open-Globe Trauma Involving the Posterior Segment

COVER STORY Partial Vitrectomy for Open-globe Trauma Involving the Posterior Segment

Avoiding hyaloidectomy and base shaving in early surgery could result in less iatrogenic damage.

BY FRANCESCO BOSCIA, MD; AND CLAUDIO FURINO, MD

pen-globe trauma involving the posterior segment is a significant cause of visual loss, despite advances in our knowledge of the pathophysi- An early limited vitrectomy may O ology, our ability to identify prognostic factors, be useful to stabilize the eye and and the improvements in surgical techniques and instru- prevent vitreoretinal traction in cases mentation introduced over the past few decades.1-3 of open-globe trauma. The standard of practice includes repairing the open ocular wound at the earliest opportunity, followed by vitreoretinal surgery in eyes with concurrent intraocular dam- cases of open-globe trauma. This approach, avoiding age. A near complete pars plana vitrectomy (PPV) with complete hyaloidectomy and vitreous base shaving, removal of the posterior hyaloid within 14 days of an open could result in less potential iatrogenic damage. globe injury, to relieve vitreoretinal traction and to remove the scaffold for future traction and prevent stimulus of the CASE REVIEW wound healing response, has become the standard of care We reviewed all open-globe injuries involving the pos- to reduce the risk of tractional retinal detachment.4-5 terior segment treated at the University of Bari, Italy, in Early PPV reduces the risks of posttraumatic endoph- 2009 and 2010. We included 10 patients with penetrating thalmitis, development of severe inflammatory changes or perforating trauma, with or without intraocular for- and fibroblastic tissue within the vitreous, and secondary eign body (IOFB) and/or retinal breaks (RB). We excluded complications such as retinal detachment and cyclitic patients with retinal detachment (RD), choroidal detach- membrane. On the other hand, induction of posterior ment, or endophthalmitis. vitreous detachment (PVD) results in a significantly high- All patients underwent partial PPV under general er incidence of intra- or postoperative retinal breaks, or anesthesia within 48 hours of trauma. The surgical man- both,6 due to the difficulty of detaching the posterior agement was the same for all cases. The corneal or scle- hyaloid. This is especially true because the population ral wound was sutured, and traumatic cataract was primarily at risk for eye injury is young people,7 who have extracted in 8 patients: in 5 eyes by means of pha- strong adhesion between the posterior vitreous cortex coemulsification and in 3 eyes using pars plana lensec- and the internal limiting lamina (ILL). tomy. Among the 8 patients who underwent combined Therefore, an early limited vitrectomy may be useful to cataract extraction during partial PPV, 6 received a pos- stabilize the eye and prevent vitreoretinal traction in terior chamber hydrophilic acrylic intraocular lens (IOL)

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Figure 1. Postoperative appearance of a patient implanted Figure 2. A chorioretinal scar on the nasal side of the optic with an iris claw IOL. nerve of the same eye. at the time of primary surgery. The 2 patients left apha- Figure 1 shows a the postoperative appearance of a kic at primary surgery underwent secondary implanta- patient implanted with an iris claw IOL. Figure 2 shows a tion of an iris-enclavated anterior chamber IOL, 1 at chorioretinal scar on the nasal side of the optic nerve of the 5 and 1 at 11 months after the first surgery. same eye. In 3 cases a 23-gauge vitrectomy system was used, and in the other 7 standard 20-gauge PPV was carried out. In DISCUSSION all cases, PPV was limited to the central vitreous, remov- We think that early partial PPV could be responsible for ing the hemorrhage and the area overlying the point of the satisfactory results observed in this series, combining the impact on the retina or the retinal tear. Neither posterior advantages of an early PPV with those of avoiding complete hyaloid removal nor vitreous base shaving was performed in hyaloidectomy and vitreous base shaving, which may lead any case. to less potential iatrogenic damage. Chung et al,6 in a retro- Eight eyes out of 10 had at least 1 IOFB; 1 eye had mul- spective comparative study, showed that induction of PVD tiple IOFBs. Of these eyes, 4 had the IOFB embedded in causes a high incidence of intra- and postoperative RBs. the retina partially or completely. In 3 eyes the IOFB was Open-globe trauma involving the posterior segment within the vitreous cavity, and in 1 eye it impacted the preferentially affects young patients with strong attach- fovea, causing retinal hemorrhage. The IOFBs were visual- ment of the vitreous, and forcing PVD in these eyes can ized, freed of tissue incarceration or fibrin encapsulation, lead to iatrogenic RBs. Avoiding PVD induction and vitre- and removed using forceps. Intraoperative laser photoco- ous base shaving with scleral depression could have other agulation was carried out around the retinal breaks. No beneficial effects. Mei et al8 analyzed 5 traumatized eyes tamponading agent was used at the end of surgery. in which suprachoroidal hemorrhage had occurred intra- Mean follow-up was 10.6 months (range, 4–18). operatively and found that in 1 (20%) eye the supra- Preoperative visual acuity ranged from light perception to choroidal hemorrhage occurred during the creation of 20/20 and improved significantly postoperatively in all high pressure to induce PVD, and in 2 (40%) it occurred patients, ranging from 20/200 to 20/20. Five eyes (50%) during scleral depression for vitreous base shaving. achieved a final visual acuity of 20/20. In 8 eyes final visual In our series, all patients had vitreous hemorrhage of acuity was >20/40. varying degrees. Hsu and Ryan9 showed in experimental The retina was fully attached in all eyes. No new RBs, models that scleral laceration with vitreous loss inducing endophthalmitis, or PVR occurrence were observed until full-thickness RB, but without intravitreal blood injection, the end of follow-up. Two patients showed minimal macu- did not result in RD. In eyes with blood injection, fibroblas- lar wrinkling. B-scan ultrasonography demonstrated the tic proliferation ensued, with the development of cyclitic, presence of residual vitreous and showed that a sponta- epiretinal, and intravitreal membranes, resulting in traction- neous posterior vitreous detachment had occurred in all al RD. For this reason we carried out complete removal of eyes a few days after surgery (mean, 10 days). At the last fol- all hemorrhage from the vitreous cavity, clearing vitreous low-up, the lens was still clear in the 2 patients left phakic. (Continued on page 75)

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(Continued from page 61) and hemorrhage from the impacted retinal area if present. In cases with retinal pathology that required treatment, we performed endoscopic laser photocoagulation. This induces less breakdown of the blood-retinal barrier in comparison with cryotherapy, resulting in less intraocular inflammation and intravitreal dispersion of retinal pigment epithelial cells, and therefore less scar tissue for- mation, reducing the chance of RD.10

CONCLUSIONS In this series, retinal attachment was maintained even though only limited core vitrectomies were performed and the posterior hyaloid was not removed. A limited vitrectomy alone, performed early, may be useful to stabilize the eye, remove vitreous hemorrhage and IOFB, and prevent vitreoretinal traction. Further study is war- ranted to assess long-term outcomes with this approach. The encouraging results of our series should be regard- ed from the perspective that our cases represent relative- ly “good” trauma cases. In fact, none of the patients pre- operatively demonstrated endophthalmitis, RD or choroidal detachment, or rupture injuries, and none had serious posterior segment insults. It should be recog- nized that when these complications occur, complete PPV may be the safer approach to the management of an open-globe injury involving the posterior segment. ■

Francesco Boscia, MD, is Medical Director in the Department of Ophthalmology at the University of Bari in Italy. Dr. Boscia states that he is a paid consultant for Alcon, Allergan, Bayer, and Novartis. He may be reached at +39 0805594027; or via email at [email protected]. Claudio Furino, MD, is in the Department of Ophthalmology at the University of Bari.

1. Coleman DJ. Early vitrectomy in the management of the severely traumatized eye. Am J Ophtalmol. 1982;93:543-551. 2. Brinton GS, Aaberg TM, Reeser FH, et al. Surgical results in ocular trauma involving posterior segment. Am J Ophthalmol. 1982;93:271-278. 3. De Juan E Jr, Sternberg P Jr, Michels RG. Penetrating ocular injuries: types of injuries and visual results. Ophthalmology. 1983;90:1318-1322. 4. Gregor Z, Ryan SJ. Complete and core vitrectomies in the treatment of experimental posterior penetrating eye injury in the rhesus monkey. I. Clinical features. Arch Ophthalmol. 1983;101:441-445. 5. Gregor Z, Ryan SJ. Complete and core vitrectomies in the treatment of experimental posterior penetrating eye injury in the rhesus monkey. II. Histologic features. Arch Ophthalmol. 1983;101:446-450. 6. Chung SEE, Kim KH, Woong KS. Retinal breaks associated with the induction of posterior vitreous detachment. Am J Ophthalmol. 2009;147:1012-1016. 7. Sebag J. Age-related differences in the human vitreo-retinal interface. Arch Ophthalmol. 1991;109:966-971. 8. Mei H, Xing Y, Yang A, Wang J, Xu Y, Heiligenhaus A. Suprachoroidal hemorrhage during pars plana vitrectomy in traumatized eyes. Retina. 2009;29:473-476. 9. Hsu HT, Ryan SJ. Experimental retinal detachment in the rabbit. Penetrating ocular injury with retinal laceration. Retina. 1986;6:66-69. 10. Jaccoma EH, Conway BP, Campochiaro PA. Cryotherapy causes extensive breakdown of the blood-retinal barrier. A comparison with argon laser photocoagulation. Arch Ophthalmol. 1985;103:1728-1730.

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