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Ocular trauma treated with pars plana vitrectomy: early outcome report
Mohammad
Reza Mansouri, Seyed Ali Tabatabaei, Mohammad Soleimani, Mohammad Yaser Kiarudi, Saber Molaei, Mehdi Rouzbahani, Meysam Mireshghi,
Mohsen Zaeferani, Mehrbod Ghasempour
Department of Ocular Trauma and
Emergency, Eye Research center, Farabi Eye Hospital, Tehran University of
Medical Sciences,
Tehran 1336616351, Iran
Correspondence to: Mohammad
Soleimani. Department of Ocular Trauma and Emergency, Eye
Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences,
Tehran 1336616351, Iran.
Soleimani_md@yahoo.com
Received:
2015-07-16
Accepted: 2015-09-20
Abstract
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.
Keywords:
ocular trauma; vitrectomy; visual
outcome; timing
DOI:10.18240/ijo.2016.05.18
Citation: Mansouri MR, Tabatabaei SA, Soleimani M, Kiarudi MY, Molaei S, Rouzbahani
M, Mireshghi M, Zaeferani M, Ghasempour M. Ocular trauma treated with pars plana vitrectomy: early outcome report. Int J Ophthalmol 2016;9(5):738-742
Ocular trauma is known to cause
remarkable morbidity as well as pain, psychosocial stress, and economic burden[1]. Proper diagnosis and treatment can
decrease related morbidity and increase the patients’ quality of life[2].
A major advancement in the management of all forms of
posterior segment trauma has been the advent of pars plana vitrectomy. Using
this method, previously hopeless traumatized eyes could be managed with better
anatomic and also functional outcomes[3-7]. Vitrectomy allows the reconstruction of the posterior segment, clears
vitreous opacities, controls the healing process and prevents endophthalmitis.
Using the injury model
with blood injection into the eyes of monkeys, it has been shown that pars
plana vitrectomy performed after trauma markedly decreases the incidence of
tractional retinal detachment. By excising both the blood and vitreous from these eyes, the
stimulus and scaffold for fibroblastic proliferation are removed and tractional
retinal detachment is prevented[6-7]. There is controversy in the management of posterior
segment injuries and the timing of the surgery for perforating injuries with some
advocating early (within 2d) versus delayed (7-14d) surgeries[8-11].
The aim of this study was to evaluate
demographic variables of ocular injuries and also determine visual outcome of
those injuries managed with vitrectomy and to compare pre-
and post-operative variables among these patients. In this study we focused on
posterior segment injuries requiring vitrectomy and evaluated the results of
vitrectomy in ocular trauma.
SUBJECTS AND METHODS
This retrospective
study involved all patients diagnosed with a open globe injuries whether by
blunt or sharp force presenting to the Farabi Eye Hospital
from March to September 2010 requiring vitrectomy. Farabi Eye Hospital is a
major eye trauma centre managing the majority of serious ocular injuries in
Iran. This center offers both emergency eye care and specialized care for
patients of all ages with specific and complicated ocular or orbital diseases
and conditions with a full time ophthalmic emergency department. The research
adhered to the tenets of the Declaration of Helsinki. The study was approved by
the ethics committee of Tehran University of Medical Sciences, Tehran, Iran,
and all participants were gave an informed written consent form before the
patient being included into the study.
The records of all
patients were studied to determine the age, sex and place of occurrence of
trauma, initial and final visual acuity, anatomical site, nature of the trauma,
operations performed, complications, wound length and timing of the vitrectomy
as well as the follow up results. The difference of visual acuity (VA) was defined as the difference between postoperative VA at
6mo and preoperative VA. The minimum follow-up from presentation was 6mo. The
zone of injury was defined as follows: Zone I (isolated to cornea), Zone II
(limbus to a point 5 mm posterior into the sclera) and Zone III (posterior to the
anterior 5 mm of sclera) for penetrating injuries.
The Ocular Trauma Score (OTS) was measured as
described by Kuhn et al[12].
OTS is a system for predicting the prognosis of trauma based on one
functional (initial VA), and five anatomical
(rupture, endophthalmitis, perforating injury, retinal detachment, afferent
pupillary defect) characteristics. The OTS value is immediately available at
the conclusion of the evaluation/initial surgery with reasonably reliable
prognostic implications.
The
initial VA
was the acuity measured on presentation to the hospital. The final VA
was taken 6mo after vitrectomy. All vitrectomies were performed by two surgeons
(Tabatabaei SA and Mansouri MR). The indications for vitrectomy were injury in
Zone III, retinal detachment, vitreous hemorrhage and the presence of intra
ocular foreign body (IOFB) according to the decision made by these two
experienced surgeons. Tamponing was performed using silicone oil or gas if
necessary. Vitrectomy was performed using 3-port standard technique. We did not
use any encircling or local scleral buckle in these cases. No case underwent
silicone oil removal during this early outcome report.
The timing of vitrectomy was different
for different cases but was performed at the latest two weeks after trauma.
Vitrectomies performed within seven days were considered early. In cases of
penetrating injury, the laceration was repaired firstly and then vitrectomy was
performed one week later. Exclusion criteria were: previous ocular
trauma, history of any ocular disease, and inadequate follow up (less than
6mo).
Statistical Analysis Data
were analyzed using SPSS version 16.0 (SPSS, Inc., Chicago, IL, USA).
Frequency distributions were created for injury type and the cause of injury.
Statistical analysis of quantitative data, including descriptive statistics,
parametric and non-parametric comparisons, was performed for all variables by
analysis of variance (ANOVA) and t
test. Frequency analysis was performed using the chi-square test. t-test was used to evaluate differences
between pre-
and post-operational
values. P-values less than 0.05 were
considered statistically significant.
Results
Ninety patients (77 men, 13 women) with
the mean age of 32.7±15.8 (Range: 18-92)y were included over the
6-month period. The majority of trauma occurred in the
workplace (47 patients), followed by home (14 patients).
Seventy-three patients had sharp trauma
whereas 17 patients had blunt trauma. In cases of open globe injury, the
average wound length was 4.79±3.77 mm.
In patients with blunt trauma the average wound length was 7.5±2.87 mm
versus 3.5±1.65 mm in patients with sharp trauma.
The indications for vitrectomy are
summarized in Table 1.
Table 1 Preoperative, postoperative and the difference of pre- and postoperative VA in different causes
of trauma managed with vitrectomy
Causes of
vitrectomy |
Preop. VA |
Postop. VA |
Diff VAa |
Lensectomy |
Silicone oil injection |
Gas (SF6) injection |
IOFB (n=29) |
2.02±0.91b |
0.97±0.67 |
-1.03±0.84 |
15 |
6 |
3 |
Retinal
detachment (n=39) |
2.69±0.36 |
1.98±1.03 |
-0.70±0.85 |
31 |
37 |
2 |
Endophthalmitis
(n=11) |
1.92±0.85 |
1.74±1.31 |
-0.18±0.75 |
10 |
10 |
0 |
Vitrous
hemorrhage (n=7) |
2.47±0.34 |
0.39±0.22 |
-2.07±0.53 |
3 |
2 |
2 |
Dislocated
lens (n=4) |
2.36±0.30 |
1.93±1.33 |
-0.66±1.33 |
4 |
0 |
1 |
IOFB:
Intraocular foreign body; VA: Visual acuity. aDiff VA
was defined as difference between postoperative VA at 6mo and preoperative VA; b
Numbers are presented based on logMAR.
The mean OTS was 47.21±14.59. Eyes were
categorized based on OTS as follow: category 1 (0-44), category 2 (45-65), category 3 (66-80), category 4 (81-91),
and category 5 (92-100). The details of the preoperative and postoperative VA
for these categories are summarized in Table 2.
Table 2 Preoperative, postoperative and the
difference of pre- and post-operative VA in different subgroups based on Ocular Trauma Score
OTS |
Preop. VA |
Postop. VA |
Diff VAa |
0-44 (n=30) |
2.77±0.27b |
2.65±0.54 |
-0.11±0.48 |
45-65 (n=44) |
2.49±0.48 |
1.17±.95 |
-1.32±0.94 |
66-80 (n=15) |
1.24±0.71 |
0.27±.13 |
-0.97±0.70 |
81-91 (n=1) |
0.70 |
0.05 |
-0.65 |
P |
<0.001 |
<0.001 |
<0.001 |
OTS:
Ocular Trauma Score; VA: Visual acuity. aDiff VA
was defined as difference between postoperative VA at 6mo and preoperative VA; bNumbers
are presented based
on logMAR.
Preoperative best corrected VA, the
difference of preoperative and postoperative VA, and postoperative VA
were significantly different between groups with different ocular trauma scores
(P<0.001).
Preoperative retinal detachment was observed in 39
patients. At 3mo postoperatively, 8 patients and at 6mo, 5 patients had
persistent retinal detachment. From
the 8 patients with retinal detachment after 3mo, 5 patients had proliferative
vitreoretinopathy (PVR). From
5 patients with retinal detachment after 6mo, 4 patients had PVR (4.4% PVR 6mo
postoperatively). Twenty-nine patients had IOFB and metallic foreign bodies were most common, they were found in
16 eyes. Sand, plastic, glass, and animal bone were other removed foreign
bodies .
The mean preoperative VA
(logMAR) of patients was 2.36±0.72 which significantly improved postoperatively to 1.50±1.14 (P<0.001).
Twenty-three patients had preoperative VA better than 2.0 logMAR. The
postoperative VA was significantly better among these patients (P<0.001) (Table 3).
Table 3 Postoperative VA in subgroups of patients based on preoperative VA
Preoperative |
Postoperative |
P |
VA<2 logMAR |
0.58±0.17 |
0.01 |
VA>2 logMAR |
1.82±1.08 |
0.02 |
VA: Visual
acuity.
We compared the
results of early vitrectomy (<7) with delayed vitrectomy and the change in VA
from preoperative vision was not significantly different between the two groups
(P=0.66). Twenty-four (26.7%)
patients had a relative afferent pupillary defect (RAPD) at presentation. The
mean postoperative VA in these patients (2.65±0.84)
was significantly poorer in comparison to patients
without RAPD (1.09±0.70)
at presentation (P=0.02) (Table 4).
Table 4
Postoperative VA results based on the timing of
surgery
Timing |
Preop. VA |
Postop. VA |
Difference |
P |
<7d |
2.11 |
1.22 |
0.89 |
<0.001 |
7-14d |
2.69 |
1.89 |
0.80 |
<0.001 |
P |
0.66 |
0.79 |
0.90 |
|
VA: Visual
acuity.
Thirty-six patients had injury in Zone I
and 36 patients had injury in Zone II and 18 in Zone III. Postoperative mean VA
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 VA (P=0.02) (Table 5).
Table 5
Visual aquity change based on the zone of injury
Zone |
Preop. VA |
Postop. VA |
Difference |
P |
I |
2.31±0.78 |
1.20±1.07 |
1.10 |
<0.001 |
II |
2.23±0.76 |
1.32±1.11 |
0.90 |
<0.001 |
III |
2.74±0.83 |
1.93±1.42 |
0.81 |
<0.01 |
VA: Visual
acuity.
Discussion
The majority of patients in our cohort were male and the
majority of injuries occurred in the workplace. A male preponderance is a
universal characteristic of eye trauma and is thought to be related to occupational exposure, participation in dangerous sports and hobbies,
alcohol usage and risk-taking behavior[13].
In our study, vitrectomy improved the VA
of patients significantly. Globocnik Petrovic et al[14] reported that half of the eyes managed with pars plana
vitrectomy for open eye injury after trauma had a good final visual outcome.
The appropriate timing of vitrectomy is one of the challenging
issues in management of posterior segment trauma. Immediate vitrectomy is
indicated when posttraumatic endophthalmitis or IOFB with high risk of
infection is present, but timing of surgery for other causes is less clear[15]. Two major indications
for delayed vitrectomy performed within 5-14d have been described: choroidal
hemorrhage and large posterior wound in perforating globe injuries[16-21]. Early vitrectomy decreases the chance of fibrocellular
proliferation and retinal tears. However, early vitrectomy may lead to higher
rate of bleeding, wound leakage and increased difficulty to detach the
posterior hyaloids[14]. In our study, vitrectomies performed early and late had
similar prognosis. In agreement with our study, Agrawal et al[18] have
reported that the timing of surgery seems to have very little effect on the final outcome and
concluded that final VA is determined by the type and extent of
trauma rather than the timing of surgery. In
earlier vitrectomy, we could have higher risk of
intraoperative complications; conversely, in late vitrectomy,
there is higher incidence and
severity of postoperative complications such as PVR[10]. In a large review of controversial issues in the
management of open globe injury, it was suggested that vitrectomy is better to
be performed earlier after open-globe injury; although early vitrectomy is
technically more challenging due to wound leaks and greater difficulty
controlling hemorrhage. Also, delayed surgery allows one to obtain serial
echographic and or electrophysiologic data[21].
In our study preoperative retinal
detachment was seen in 39 patients and after 6mo, 5 patients remained detached.
In the patients with open globe injury the risk of PVR increases[20]. In our study, the incidence rate of PVR was 4.4% 6mo postoperatively.
The presence of relative afferent
pupillary defect is a strong predictive factor of visual outcome in the ocular
injury[14-19,22-24],
regarding this fact, 24 patients in the present study who had RAPD at
presentation, had statistically poorer postoperative VA than those without RAPD at presentation.
In Pimolrat et al[22] study pupillary reaction has been reported as an important prognostic
factor for the final visual outcome.
In other studies, preoperative VA has
been considered as a good predictor of visual outcome[19,25-26].
In our study, patients with presenting VA less than 2 logMAR, had significantly
better postoperative VA (P<0.001). This shows the
importance of careful initial examination.
In open globe injuries, more posterior
wounds are associated with poorer prognosis[27].
Lacerations confined to the cornea had a better prognosis than eyes with sclera
or corneoscleral wounds[19]. However, in our study the postoperative VA in Zone I and II were not
significantly different (P=0.64)
which may be due to improved techniques of primary repair in recent years, but
patients with injury in Zone III had significantly poorer VA (P=0.02).
With 6mo follow up after vitrectomy,
glaucoma and endophthalmitis, as complications of the surgery, occurred in 4
and 1 of our cases, respectively.
Assessment of severity of ocular injury at presentation using
a standardized scoring system is helpful in prognostication. There are various
ocular trauma-scoring systems in use today including the Trauma Index (TI),
Ocular Trauma Severity Score (OTSS), and OTS. Bhargava and Vasu[28] evaluated accuracy of these scoring systems in predicting
visual disability after open globe injuries. They found that OTS achieved the
best overall predictor value of severity with respect to grading of open globe
injuries at presentation. OTSS tends to underestimate severe injuries and TI
tends to overestimate mild injuries. In our study the preoperative VA,
difference between pre- and postoperative VA and postoperative VA were statistically different between
subgroups of OTS and the patients that had high OTS at presentation had worse
final recovery.
We showed that in 94% of eyes treated with vitrectomy, VA is
improved. Vitrectomy after globe trauma is not just an anatomic reconstruction
but it is also helps in restoration of useful vision to the patient.
In this study, data were derived from a
single hospital that limits the generalization of
the results of our survey. Further
multicentre investigations are recommended to validate the findings reported
here.
In conclusion, trauma was more likely to occur in men under 40y of age and in the
workplace. The favorable final visual outcome was associated with the absence
of afferent pupillary defect, ocular trauma score and presenting VA
as well as the zone of injury, and not associated with the timing of
vitrectomy.
ACKNOWLEDGEMENTS
Conflicts
of Interest: Mansouri MR, None; Tabatabaei SA, None; Soleimani M, None; Kiarudi MY, None; Molaei S, None; Rouzbahani M, None; Mireshghi M, None; Zaeferani M, None; Ghasempour M, None
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