Elsevier

Survey of Ophthalmology

Volume 44, Issue 3, November–December 1999, Pages 215-225
Survey of Ophthalmology

Review
Controversies in the Management of Open-Globe Injuries Involving the Posterior Segment☆

https://doi.org/10.1016/S0039-6257(99)00104-6Get rights and content

Abstract

There are numerous unresolved issues and controversies regarding the management of open-globe injuries involving the posterior segment. These areas include, but are not limited to, the following issues. Although vitrectomy has been shown to improve visual outcomes and allow retention of the eye in many cases, the extent of visual improvement is often limited because of the nature of the injury. Timing of vitrectomy surgery has been and will continue to be debated by proponents of early versus delayed intervention. The multiple features of acute ocular injury make it very difficult to interpret retrospective data regarding the most appropriate timing for surgical intervention. The use of prophylactic cryotherapy, in the setting of a scleral laceration with possible retinal damage, is not as controversial at present, as there is now sufficient data indicating that cryotherapy may actually exacerbate intraocular proliferation and worsen the situation. The role and benefit of a prophylactic scleral buckle is very widely contested, and it is not known if it truly decreases the risk of subsequent retinal detachment. Another area of debate centers on the use of antibiotics. When there is a known clinical infection, intravitreal antibiotics are the mainstays of therapy. However, in the absence of clinical infection, the use of prophylactic antibiotics and their routes of administration are quite controversial. Although there are significant data regarding the use of antibiotics in the postoperative setting, this information cannot be extrapolated into the setting of open-globe injuries, as organisms and virulence factors differ. Similarly, the use of vitrectomy versus vitreous tap in the setting of traumatic endophthalmitis is not fully resolved, although vitrectomy is used in most cases to repair concurrent damage from the injury itself. Finally, the placement of intraocular lenses in the acute trauma setting is controversial, as the risk of complications is quite high. Prospective, controlled clinical studies have not been done. This article reviews pertinent data regarding these management issues and controversies, and provides recommendations for treatment based on the available published data and the authors' personal experience.

Section snippets

Role of Vitrectomy

Many surgeons now agree that vitrectomy is indicated for traumatic open-globe injuries with retinal detachment on presentation58, 72, 77 and for perforating ocular injuries (previously called double-penetrating or through-and-through injuries).99, 124 As will be outlined in detail in the following paragraphs, these two scenarios have a dismal prognosis without vitrectomy because of the organization of the vitreous into tractional bands. Controversy still exists regarding the need for vitrectomy

Timing of Vitrectomy

Despite a general consensus about many of the indications for the use of vitrectomy in open-globe injuries, the timing of this intervention remains highly controversial. Most surgeons will agree that immediate vitrectomy is indicated for posttraumatic endophthalmitis or IOFB with high risk of infection, but timing of surgery with other scenarios is less clear.80, 120 There are arguments with theoretic and experimental rationale for vitrectomy within 3 days of injury,32, 33, 35, 44, 52 from 4 to

Prophylactic Cryotherapy

Traditional management of a posterior scleral laceration included the use of cryotherapy applied to the edges of the wound after closure in an effort to create an adhesion at sites of probable retinal damage.10 This practice has fallen into disfavor, because several experimental findings have demonstrated that this exercise may actually increase the chance of developing a retinal detachment.

Cleary and Ryan showed that a scleral laceration with vitreous loss but without intravitreal blood

Prophylactic Scleral Buckle

Some authors have recommended that all eyes that undergo vitrectomy for open-globe injuries should have an encirling scleral buckle placed at the time of surgery, even if no retinal detachment is present.43, 78 There is a viable rationale for this assertion. Many of these eyes have dense vitreous hemorrhages, and visualization of the anterior retina is difficult at best. Scleral buckling in this situation may tamponade undetected retinal tears, as well as guard against possible later

Intravitreal antibiotics

Endophthalmitis is a frequent (2%–11% of cases) complication of open-globe injury.17, 19, 49, 121, 125 The incidence of endophthalmitis is higher in patients whose trauma occurs in a rural setting (30%) or involves an IOFB (10%–15%). In addition to an increased frequency, endophthalmitis in trauma patients often involves more virulent organisms such as Bacillus (up to 26%), resulting in poorer visual outcomes than are seen in other settings even with appropriate management.19, 121 Given these

Vitrectomy Versus Vitreous Tap for Traumatic Endophthalmitis

The Endophthalmitis Vitrectomy Study (EVS) recently showed that vitreous tap with injection of antibiotics is equivalent in efficacy to pars plana vitrectomy in patients with post-cataract endophthalmitis who have hand motions or better vision on presentation.2 This information should be extrapolated to post-traumatic endophthalmitis with caution. Post-traumatic endophthalmitis often involves multiple and more virulent organisms than those encountered in routine post-cataract endophthalmitis

Concurrent Intraocular Lens Implantation

Several authors have shown that combined cataract extraction, vitrectomy, and intraocular lens (IOL) implantation with either pars plana lensectomy or anterior segment techniques can result in good visual outcomes for patients with a variety of trauma-induced conditions.68, 115 Primary IOL implantation in cases of open-globe trauma has been advocated by some for cases in which the visual prognosis is good and the risk of late retinal detachment is low (e.g., small IOFB).27, 104, 113 This

Summary

A variety of unresolved controversial issues remain in the management and treatment of open-globe injuries. Over the past decade, there has been minimal additional progress in the management of the majority of these controversies.117 A number of these issues, unfortunately, will most likely never be fully resolved. Although a controlled, prospective clinical trial would be ideal, it is difficult to control for the significant differences that occur with each individual injury. This makes it

Method of Literature Search

The literature was searched with the aid of the Medline database, encompassing all publications from 1966 to the present, in all languages. Non-English articles were translated into English. Articles were included in the reference list only when they were pertinent to the content of this manuscript. Numerous key words were utilized, though not limited to, the following: open-globe injuries, penetrating ocular injuries, perforationg ocular injuries, retained intraocular foreign bodies, ruptured

Acknowledgements

Supported in apart by an unrestricted grant from the Research to Prevent Blindness, Inc., New York, NY, and by a core grant EY01931 from the National Institutes of Health, Bethesda, MD, USA.

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