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Innovative Treatment for Severe Ocular Trauma
• the rate of previously operated eyes among the ruptures declined to perfluorocarbon liquids, endolaser cerclage and, finally, an exchange
two of nine (22%) in 1994, and further to three of 19 (16%) between of perfluorocarbon liquids for silicone oil. This procedure takes about
1996 and 1999. 2.5–3.5 hours. It is mandatory that the surgeon is experienced in all
of the difficulties in posterior and anterior segment surgeries. In the
In the 1980s most surgeons used wide corneal or corneoscleral incisions for past, the surgical tasks were split between the anterior and posterior
cataract surgery. In the early 1990s smaller cornescleral tunnel incisions were segment surgeons. However, today more and more of the younger
introduced, which we regard as being the reason for the decline in the generation of posterior segment surgeons are also able to perform
absolute number of ruptures.
3
However, due to demographic changes, the difficult anterior segment surgeries, and therefore are qualified
rate of rupture is now increasing again. to perform ‘pole-to-pole’ surgery, a term coined by the Italian
Cesare Forlini.
Extent of Injury
If the injury is restricted to the anterior segment of the eye, the majority of Retrospective Evaluation of
eyes will regain reading ability. However, if the retina is involved, only Primary Internal Reconstructions
a minority of eyes will reach a useful functioning level again. In our series, We retrospectively analysed the outcome of 71 perforating injuries and
half of the eyes with retinal involvement became blind or had to ruptures treated at the University Eye Hospital of Wuerzburg. At six
be enucleated.
3,4
months after trauma, 25% of these eyes had a visual acuity of 20/200 or
more, 25% became blind (no light perception) or phthisical or had to be
Surgical Approach enucleated and the remaining 50% regained only ambulatory vision.
Thirty-five years ago attempts were made not to limit primary surgery to
wound closure, but to also proceed with an internal reconstruction by If the secondary vitrectomy was performed more than four days after
using the newly developed pars plana vitrectomy.
5
It was already known trauma, only three of 29 eyes (10%) reached a visual acuity of 20/200 or
that lens fragments and vitreous haemorrhage induced a chronic better, while six of 29 (21%) became blind (no light perception),
inflammatory reaction that enabled the development of strands, phthisical or had to be enucleated. Following primary vitrectomy (within
membranes, retinal detachment, hypotony or phthisis. Retinal detachment 12 hours of the trauma) or early vitrectomy (within 100 hours), nine of
was found in 37% of all open globe injuries and a reattachment could be 27 eyes (33%) regained visual acuity of 20/200 or better, while three
achieved in 66% of these cases.
5
Lemmen and Heimann reported on (11%) became blind or had to be enucleated. There is a trend for more
severe ocular injuries that could be anatomically and functionally patients to regain useful vision when internal reconstruction is performed
sufficiently reconstructed by early intervention with pars plana vitrectomy within one week of trauma.
and silicone oil.
6
However, the question remains as to when this internal
reconstruction is best performed. Theoretically, an internal reconstruction Prospective Evaluation of Early Vitrectomy
becomes easier after a spontaneous vitreous detachment has developed. As even in specialised institutions a trauma surgeon is not always
However, if a pars plana vitrectomy is performed between days seven and available, Kuhn and the current author developed the concept of a
14, in many cases PVR has already developed, impairing the vitrectomy or pragmatic approach that on the one hand supports the idea of acting
even making an internal reconstruction impossible. On the other hand, if before PVR with synechiae, retinal detachment and tractional folds can
a pars plana vitrectomy is performed within the first few post-traumatic develop to prevent the expected complications related to vitreous
days, there is a higher risk of bleeding and surgery might become more traction, vitreous haemorrhage or retinal incarceration,
8
but on the other
difficult because of haemorrhage. However, it may be easier because hand to leave a time-frame of 100 hours.
membranes and strands have not yet developed. It is possible that an early
intervention may reduce the rate of PVR. In November 2004, Kuhn and the author developed the protocol for a
prospective multicentre trial, the Proactive Management of Eyes with
Wound Closure Combined with Perforating/Rupture/intraocular foreign bodies (IOFBs) Injuries study. The
Primary Internal Reconstruction aim of this study is to compare the anatomical and functional results of
We attempted to combine primary wound closure with internal early vitrectomy (within 100 hours of the trauma) with vitrectomy in the
reconstruction for severe ocular ruptures of perforating injuries in second post-traumatic week. The results of early vitrectomy will be
Wuerzburg if there was a retinal surgeon available. If no retinal surgeon compared with matched cases from the WEIR database. The inclusion
was available, we performed the primary wound closure in the classic way, criteria are:
with reconstruction taking place at around post-traumatic day seven.
• perforations, i.e. eye injuries with a corneal or scleral entry wound and
The typical procedure was as follows. In addition to the wound closure a scleral exit wound;
procedure, an encircling band was sutured on with only gentle • intraocular foreign bodies with an impact deeper than the retina, i.e.
indentation. Three classic ports were prepared for 20-gauge with chororidal or scleral involvement; and
vitrectomy. An anterior vitrectomy was performed via this pars plana • ruptures reaching behind the muscle insertions.
approach and the crystalline lens was removed if it had not already
been expelled by the trauma. Frequently, a refixation of the ciliary Those with endophthalmitis are excluded, as the condition develops
body or the iris base was necessary using the MacCannel technique independently of the surgical approach and will interfere with the
modified by Mackensen.
7
A complete pars plana vitrectomy was anatomical and functional outcome. The occurrence of PVR and
performed with induction of a posterior hyaloid detachment (which full-thickness retinal folds will be compared between the two treatment
is often difficult at this time) and the retina was stabilised with groups. The primary surgical procedure will be the wound closure plus a
EUROPEAN OPHTHALMIC REVIEW 33
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