schrader.qxp 24/9/08 12:38 Page 34
Surgery Ocular Trauma
Figure 1a: Schematic Representation of a
This observational study began in November 2004, and vitreoretinal
Prophylactic Chorioretinectomy
centres are participating worldwide. After an interim analysis of the
first 21 cases from three centres, 19 reached a complete retinal
attachment. Two of the 19 suffered a secondary retinal detachment
that could be reattached in both cases. In three eyes an epiretinal
membrane had to be removed. After six months, six patients still had
a silicone oil tamponade, 10 had their silicone oil tamponade removed
and five did not need an oil tamponade (see Figure 1b). Two
of 21 patients had a visual acuity of below 20/200, 10 regained an
acuity of between 20/200 and 20/60 and nine had 20/50 vision
or better. In summary, the majority of eyes reached a satisfying
functional outcome.
Is No Light Perception Exclusion a Criterion for
1mm
Attempting a Secondary Reconstruction?
After complete vitrectomy followed by diathermy destruction of the choroid and retina,
In the 1980s, the treatment strategy was quite clear. If there was little hope
1mm of retina and choroid is cut out so that bare sclera is visible around the scar.
for a functional reconstruction, enucleation was advised to prevent
Photocoagulation is applied to the remaining edge.
sympathetic ophthalmia.
9
Any eye that had lost the ability to perceive light
Figure 1b: The Retina Is Healing without Any Traction was considered to be non-reparable. It was only 10 years ago that
Morris et al.
10
reported on their attempts to reconstruct 11 eyes with severe
ocular trauma that could not perceive light. The authors succeeded in
restoring some function in seven of 11 cases. According to an analysis in the
WEIR of 340 severely injured eyes that presented without light perception
upon initial examination, an attempt to reconstruct these eyes was
undertaken in only 28 cases.
11
Of the 312 eyes that were not reconstructed,
298 remained without light perception, six were legally blind but could
perceive light, three had some ambulatory vision, one recovered a visual
acuity of between 20/2000 and 20/50 and four recovered spontaneously to
a visual acuity of 20/40 or better. However, among the 28 eyes in which a
reconstruction was attempted, no eye had to be enucleated and no eye
remained unable to perceive light. Twenty-one patients regained light
perception and two ambulatory vision below 20/200. In four eyes, a visual
acuity of between 20/160 and 20/50 could be restored, and one eye even
received a visual acuity of better than 20/40.
11
One may conclude from this
observation that any attempt to reconstruct an eye is useful to preserve the
eye anatomically and keep the chance of a functional improvement,
limited anterior segment reconstruction with the removal of major vitreous irrespective of an initial complete functional loss.
tractions between the entry and exit wounds by a limited vitrectomy.
Within 100 hours (i.e. four days and four hours), a complete anterior and This observation not only proves that a missing light perception is no
posterior vitrectomy will be performed, including a complete posterior contraindication to an attempt to reconstruct an eye anatomically. Despite
vitreous detachment and the removal of all tractional components around repeated surgeries, the risk of sympathetic ophthamia has not risen above
the exit wound. To reach this goal, 1mm of retina and choroid around the 0.1–0.3% during the last four decades.
12,13
In 1984, despite the then
exit wound will be diathermised and removed after a retinopexy with common strategy, Belkin advised not to enucleate an injured eye only
endolaser plus an 360° endolaser cerclage has been performed (see Figures because of the risk of sympathetic ophthalmia and as long as the patient can
1a and 1b). Usually, a temporary silicone oil tamponde is used to secure the be kept under observation. On the other hand, evisceration seems to be no
retinal attachment. measure to prevent the development of sympathetic ophthalmia.
14,15
■
1. Mönestam E, Björnsti U, Eye injuries in northern Sweden, Acta 6. Lemmen KD, Heimann K, Früh-Vitrektomie mit primärer Eye, Philadelphia, 1998.
Ophthalmol, 1991;69:1–5. Silikonolinjektion bei schwerstverletzten Augen, Klin Monatsbl 11. Morris R, Management of ocular trauma: Treatment options for
2. Kuhn F, Morris RE, Witherspoon CD, et al., A standardized Augenheilkd, 1988;193:594–601. eyes with no light perception, Proceedings of the 12th Congress
classification of ocular trauma terminology, Graefes Arch Clin 7. Mackensen G, Chirurgie der Iris und des Ziliarkörpers. In: of the Societas Ophthalmologica Europæe, Stockholm 1999.
Exp Ophthalmol, 1996;234:399–403. Mackensen G, Neubauer H (eds), Augenärztliche Operationen, 12. Allen JC, Sympathetic ophthalmia: a disappearing disease,
3. Schrader WF, Epidemiologie bulbuseröffnender Heidelberg: Springer, 1989;1. JAMA, 1969;209:1090.
Augenverletzungen: Analyse von 1026 Fällen über 18 Jahre, 8. Kuhn F, Mester V, Morris R, A proactive treatment approach for 13. Liddy BSTL, Stuart J, Sympathetic ophthalmia in Canada, Can J
Klin Monatsbl Augenheilkd, 2004;221(8):629–35. eyes with perforating injury, Klin Monatsbl Augenheilkd, Ophthalmol, 1972;7:157–9.
4. Kuhn F, Morris R, Witherspoon CD, Mann L, Epidemiology of 2004;221:622–8. 14. Freidlin J, Pak J, Tessler HH, et al., Sympathetic ophthalmia
blinding trauma in the US Eye Injury Registry, Ophthalmic 9. Canavan YM, Archer DB, The traumatized eye, Trans after injury in the Iraq war, Ophthal Plast Reconstr Surg,
Epidemiol, 2006;13:209–16. Ophthalmol Soc UK, 1982;102:79–84. 2006;22(2):133–4.
5. Faulborn J, Atkinson A, Olivier D, Results of primary vitrectomy 10. Morris R, Kuhn F, Witherspoon C, Management of the opaque 15. du Toit N, Motala MI, Richards J, et al., The risk of sympathetic
in severe perforating ocular injuries, Mod Probl Ophthalmol, media eye with no light perception (NPL) after recent injury. In: ophthalmia following evisceration for penetrating eye injuries at
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34 EUROPEAN OPHTHALMIC REVIEW
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