ORIGINAL STUDY
Glaucoma After Open-globe Injury at a Tertiary Care University Hospital: Cumulative Causes and Management Essam A. Osman, MD, FRCS, Ahmed Mousa, PhD, Samir M. Al-Mansouri, MD, and Hani S. Al-Mezaine, MD
Purpose: To investigate causes and treatment modalities of traumatic glaucoma after open-globe injury (OGI). Materials and Methods: The medical records of all patients with postrepair follow-up of OGI at a tertiary care university hospital from January 1996 to December 2010 were reviewed. These patients had persistent elevated intraocular pressure (IOP) of >21 mm Hg at 2 consecutive visits, with or without optic disc damages. Results: Over the 14-year study period, 41 eyes of 41 patients with repaired OGI that developed glaucoma were identified. In the early stage (within 1 mo), high IOP levels occurred owing to the presence of unremoved lens particles in 11 patients (26.8%), inflammation in 6 patients (14.6%), and hyphema in 3 patients (7.3%). In the intermediate stage (2 to 6 mo), the IOP increased owing to the presence of synechial angle closure in 9 patients (21.9%) and ghost cells in 3 patients (7.3%). In the late stage (>6 mo), the IOP rose owing to the presence of unremoved lens particles in 2 patients (4.8%), angle recession in 4 patients (9.7%), and synechial angle closure in 3 patients (7.3%). Surgical interventions included trabeculectomy in 9 eyes (22%), lens aspiration in 9 eyes (22%), cyclophotocoagulation (CPC) in 5 eyes (12.2%), anterior chamber washout in 3 eyes (7.3%), and tube surgery in 2 eyes (4.9%). Conclusions: Traumatic glaucoma is not uncommon long-term complication after OGI. It is important to inspect the association between the initial cause and achieving a successful treatment. Surgical intervention may be crucial in the majority of cases. Key Words: glaucoma, open-globe injury, postrepair follow-up, Saudi Arabia, traumatic glaucoma
(J Glaucoma 2016;25:e170–e174)
A
n open-globe injury (OGI), defined as full-thickness wounds of the ocular wall, often causes damage to multiple ocular structures and represents a vision-threatening eye injury.1–2 As a consequence of ocular trauma, glaucoma can secondarily develop through different possible mechanisms, which include hyphema, angle recession, synechial angle closure, lens injury, trabecular meshwork injuries, and inflammation.3–7 Management of traumatic glaucoma can involve observation, medicinal control of the inflammation, or different surgical interventions, including Received for publication February 12, 2014; accepted August 23, 2014. From the Department of Ophthalmology, King Abdul-Aziz University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia. Disclosure: The authors declare no conflict of interest. Reprints: Essam A. Osman, MD, FRCS, Department of Ophthalmology, King Abdul-Aziz University Hospital, College of Medicine, King Saud University, P.O. Box 245, Riyadh 11411, Saudi Arabia (e-mail: [email protected]). Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/IJG.0000000000000162
filtration surgery, tube surgery, and cyclophotocoagulation (CPC). Few studies have reported on the causes and/or management of traumatic glaucoma after OGI.8–9 In the current study, we aimed to investigate different causes and treatment modalities of glaucoma after repair of OGI at a tertiary care university hospital in Riyadh, Saudi Arabia.
MATERIALS AND METHODS The current study, which was approved by the Institutional Research and Ethics Board (IREB) of the College of Medicine, King Saud University, Riyadh, Saudi Arabia, was carried out in adherence to the principles of the Declaration of Helsinki for research involving humans. The files of all patients with a confirmed diagnosis of traumatic glaucoma during the period from January 1996 to December 2011 at King Abdul-Aziz University Hospital, Riyadh, Saudi Arabia, were retrospectively searched and retrieved. The inclusion criteria were the presence of traumatic glaucoma as a secondary complication after an incident of ocular trauma and a minimum follow-up period of 6 months after the first intervention. All cases that had evidence of a previous increase in intraocular pressure (IOP) or that had required further follow-up for being a glaucoma suspect or at high risk for developing glaucoma before the traumatic event were excluded. Patients who had undergone primary repair before presentation and/or ocular comorbidity with endophthalmitis, as well as those who had undergone primary enucleation for irreparably traumatized eyes, were also excluded so as to avoid any confounding effects other than the incident trauma. Thus, we aimed to recruit those with a clear diagnosis of secondary glaucoma attributed to trauma. A data collection sheet, which included demographic data and necessary clinical indices associated with glaucoma, was developed to facilitate data retrieval. Clinical data from the clinical eye examination chart were doublechecked and meticulously reviewed for any conflict and/or inconvenience. Additional data for the follow-up, including modality of management (medical treatments, minor or major surgical interventions) and the endpoint of treatment in terms of complete and qualified success or failure, were recorded. Furthermore, we categorized our series into 3 major groups according to the time of onset at which the patient had experienced the disease: (1) early stage (within 1 mo after ocular trauma), (2) intermediate stage (>1 to 6 mo), and (3) late stage (>6 mo). The rationale behind our classification was the presumption that time of onset would more likely be preliminarily associated with severity and, consequently, with the required action or treatment modality.
e170 | www.glaucomajournal.com J Glaucoma Volume 25, Number 3, March 2016 Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Glaucoma
Volume 25, Number 3, March 2016
In the current study, we primarily aimed to assess the causes and outcomes of different treatment modalities administered to eyes with confirmed diagnosis of traumatic glaucoma. We also endeavored to relate the success rate to both the time of onset (as a surrogate for severity) and the treatment modality. Therefore, the primary outcome measure was success rate, and the secondary outcome measure was the reduction in IOP. In the current study, the complete success rate is defined as achieving postintervention IOP of 6 mo). Gonioscopy of these glaucoma cases showed that 23 patients (56.1%) had openangle glaucoma, 14 patients (34.1%) had closed-angle glaucoma, and 4 patients (9.8%) had angle-recession glaucoma. Furthermore, among those 20 subjects who developed glaucoma in the early stage, the increase in IOP occurred owing to the presence of unremoved lens particles in 11 patients (26.8%), ocular inflammation in 6 patients (14.6%), and hyphema in 3 patients (7.3%). In the intermediate stage, synechial angle closure was detected in 9 patients (21.9%), ghost cell glaucoma in 3 patients (7.3%), and unremoved lens particles in 2 patients (4.9%). In the advanced stage, the IOP gradually rose in 4 patients (9.7%) owing to angle recession and in 3 patients (7.3%) owing to synechial angle closure (Table 1). The selected treatment modality was highly dependent on the etiology and the severity of the glaucoma. Overall, 10 cases (24.4%) were treated only with medication, and 2 cases (4.9%) were treated with medication in addition to pars plana vitrectomy (PPV). All 12 cases in the medical treatment group were treated with a combination of corticosteroids and cycloplegic agents. Sufficient control of IOP levels was achieved in all these cases. Of the 31 cases (75.6%) that were treated by different surgical interventions (including those 2 cases treated with PPV and medication), lens aspiration was performed in 7 cases (17.1%), trabeculectomy plus mitomycin C (MMC) in 7 cases (17.1%), CPC in 5 cases (12.2%), anterior chamber (AC) washout plus PPV in 2 cases (4.9%), lens aspiration and PPV in 2 cases (4.9%), antiglaucoma medications plus PPV in 2 cases (4.9%), lens aspiration plus trabeculectomy in 2 cases (4.9%), PPV solely in 1 case (2.4%), and AC washout solely in 1 case (2.4%). In addition, 2 cases underwent tube surgery, and 1 case received only lens aspiration (Table 2). Cases can be categorized into 3 groups of severity based on the range of IOP at presentation: 7 cases (17.1%) in the range of Z22 to
Glaucoma After Open-globe Injury at a Tertiary Care University Hospital: Cumulative Causes and Management Essam A. Osman, MD, FRCS, Ahmed Mousa, PhD, Samir M. Al-Mansouri, MD, and Hani S. Al-Mezaine, MD
Purpose: To investigate causes and treatment modalities of traumatic glaucoma after open-globe injury (OGI). Materials and Methods: The medical records of all patients with postrepair follow-up of OGI at a tertiary care university hospital from January 1996 to December 2010 were reviewed. These patients had persistent elevated intraocular pressure (IOP) of >21 mm Hg at 2 consecutive visits, with or without optic disc damages. Results: Over the 14-year study period, 41 eyes of 41 patients with repaired OGI that developed glaucoma were identified. In the early stage (within 1 mo), high IOP levels occurred owing to the presence of unremoved lens particles in 11 patients (26.8%), inflammation in 6 patients (14.6%), and hyphema in 3 patients (7.3%). In the intermediate stage (2 to 6 mo), the IOP increased owing to the presence of synechial angle closure in 9 patients (21.9%) and ghost cells in 3 patients (7.3%). In the late stage (>6 mo), the IOP rose owing to the presence of unremoved lens particles in 2 patients (4.8%), angle recession in 4 patients (9.7%), and synechial angle closure in 3 patients (7.3%). Surgical interventions included trabeculectomy in 9 eyes (22%), lens aspiration in 9 eyes (22%), cyclophotocoagulation (CPC) in 5 eyes (12.2%), anterior chamber washout in 3 eyes (7.3%), and tube surgery in 2 eyes (4.9%). Conclusions: Traumatic glaucoma is not uncommon long-term complication after OGI. It is important to inspect the association between the initial cause and achieving a successful treatment. Surgical intervention may be crucial in the majority of cases. Key Words: glaucoma, open-globe injury, postrepair follow-up, Saudi Arabia, traumatic glaucoma
(J Glaucoma 2016;25:e170–e174)
A
n open-globe injury (OGI), defined as full-thickness wounds of the ocular wall, often causes damage to multiple ocular structures and represents a vision-threatening eye injury.1–2 As a consequence of ocular trauma, glaucoma can secondarily develop through different possible mechanisms, which include hyphema, angle recession, synechial angle closure, lens injury, trabecular meshwork injuries, and inflammation.3–7 Management of traumatic glaucoma can involve observation, medicinal control of the inflammation, or different surgical interventions, including Received for publication February 12, 2014; accepted August 23, 2014. From the Department of Ophthalmology, King Abdul-Aziz University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia. Disclosure: The authors declare no conflict of interest. Reprints: Essam A. Osman, MD, FRCS, Department of Ophthalmology, King Abdul-Aziz University Hospital, College of Medicine, King Saud University, P.O. Box 245, Riyadh 11411, Saudi Arabia (e-mail: [email protected]). Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/IJG.0000000000000162
filtration surgery, tube surgery, and cyclophotocoagulation (CPC). Few studies have reported on the causes and/or management of traumatic glaucoma after OGI.8–9 In the current study, we aimed to investigate different causes and treatment modalities of glaucoma after repair of OGI at a tertiary care university hospital in Riyadh, Saudi Arabia.
MATERIALS AND METHODS The current study, which was approved by the Institutional Research and Ethics Board (IREB) of the College of Medicine, King Saud University, Riyadh, Saudi Arabia, was carried out in adherence to the principles of the Declaration of Helsinki for research involving humans. The files of all patients with a confirmed diagnosis of traumatic glaucoma during the period from January 1996 to December 2011 at King Abdul-Aziz University Hospital, Riyadh, Saudi Arabia, were retrospectively searched and retrieved. The inclusion criteria were the presence of traumatic glaucoma as a secondary complication after an incident of ocular trauma and a minimum follow-up period of 6 months after the first intervention. All cases that had evidence of a previous increase in intraocular pressure (IOP) or that had required further follow-up for being a glaucoma suspect or at high risk for developing glaucoma before the traumatic event were excluded. Patients who had undergone primary repair before presentation and/or ocular comorbidity with endophthalmitis, as well as those who had undergone primary enucleation for irreparably traumatized eyes, were also excluded so as to avoid any confounding effects other than the incident trauma. Thus, we aimed to recruit those with a clear diagnosis of secondary glaucoma attributed to trauma. A data collection sheet, which included demographic data and necessary clinical indices associated with glaucoma, was developed to facilitate data retrieval. Clinical data from the clinical eye examination chart were doublechecked and meticulously reviewed for any conflict and/or inconvenience. Additional data for the follow-up, including modality of management (medical treatments, minor or major surgical interventions) and the endpoint of treatment in terms of complete and qualified success or failure, were recorded. Furthermore, we categorized our series into 3 major groups according to the time of onset at which the patient had experienced the disease: (1) early stage (within 1 mo after ocular trauma), (2) intermediate stage (>1 to 6 mo), and (3) late stage (>6 mo). The rationale behind our classification was the presumption that time of onset would more likely be preliminarily associated with severity and, consequently, with the required action or treatment modality.
e170 | www.glaucomajournal.com J Glaucoma Volume 25, Number 3, March 2016 Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Glaucoma
Volume 25, Number 3, March 2016
In the current study, we primarily aimed to assess the causes and outcomes of different treatment modalities administered to eyes with confirmed diagnosis of traumatic glaucoma. We also endeavored to relate the success rate to both the time of onset (as a surrogate for severity) and the treatment modality. Therefore, the primary outcome measure was success rate, and the secondary outcome measure was the reduction in IOP. In the current study, the complete success rate is defined as achieving postintervention IOP of 6 mo). Gonioscopy of these glaucoma cases showed that 23 patients (56.1%) had openangle glaucoma, 14 patients (34.1%) had closed-angle glaucoma, and 4 patients (9.8%) had angle-recession glaucoma. Furthermore, among those 20 subjects who developed glaucoma in the early stage, the increase in IOP occurred owing to the presence of unremoved lens particles in 11 patients (26.8%), ocular inflammation in 6 patients (14.6%), and hyphema in 3 patients (7.3%). In the intermediate stage, synechial angle closure was detected in 9 patients (21.9%), ghost cell glaucoma in 3 patients (7.3%), and unremoved lens particles in 2 patients (4.9%). In the advanced stage, the IOP gradually rose in 4 patients (9.7%) owing to angle recession and in 3 patients (7.3%) owing to synechial angle closure (Table 1). The selected treatment modality was highly dependent on the etiology and the severity of the glaucoma. Overall, 10 cases (24.4%) were treated only with medication, and 2 cases (4.9%) were treated with medication in addition to pars plana vitrectomy (PPV). All 12 cases in the medical treatment group were treated with a combination of corticosteroids and cycloplegic agents. Sufficient control of IOP levels was achieved in all these cases. Of the 31 cases (75.6%) that were treated by different surgical interventions (including those 2 cases treated with PPV and medication), lens aspiration was performed in 7 cases (17.1%), trabeculectomy plus mitomycin C (MMC) in 7 cases (17.1%), CPC in 5 cases (12.2%), anterior chamber (AC) washout plus PPV in 2 cases (4.9%), lens aspiration and PPV in 2 cases (4.9%), antiglaucoma medications plus PPV in 2 cases (4.9%), lens aspiration plus trabeculectomy in 2 cases (4.9%), PPV solely in 1 case (2.4%), and AC washout solely in 1 case (2.4%). In addition, 2 cases underwent tube surgery, and 1 case received only lens aspiration (Table 2). Cases can be categorized into 3 groups of severity based on the range of IOP at presentation: 7 cases (17.1%) in the range of Z22 to
