Int. Ophthal. 1,2: 105-108, 1979
Guidelines in the management of penetrating ocular trauma with emphasis on the role and timing of pars plana vitrectomy* STEPHEN J. R Y A N , Los Angeles, USA
M.D.**
Keywords: Trauma, Vitrectomy, Retinal detachment Abstract The principles and guidelines in the management of penetrating ocular injury are detailed. In the absence of definitive clinical trial or an experimental model, the rationale for pars plana vitrectomy has been presented. In addition, our recommendations as to the appropriate role and timing of pars plana vitrectomy are included.
Introduction In a previous companion paper (9), the significance of penetrating ocular trauma and results of vitrectomy in selected cases of penetrating ocular injury were reviewed. The lack of definitive guidelines relates to the marked variability from patient to patient and injury to injury. When one couples this variability with the variety of ophthalmic surgeons and different philosophies of approach to penetrating injury, it is not surprising that there is such a wide divergence of opinion as to the appropriate management of such cases. Our results confirm the opinions expressed in the literature that injuries confined to the anterior segment do extremely well, whereas injuries involving the posterior segment, i.e., those involving the vit-
From the Department of Ophthalmology, University of Southern California School of Medicine, and the Estelle Doheny Eye Foundation, Los Angeles, California, U.S.A.
reous, retina, and choroid, are still a major and most significant problem. The mechanisms of blindness include severe hemorrhage, e.g., suprachoroidal and supraciliary body, and marked disruption of intraocular contents, for which our present-day surgical techniques are woefully deficient. However, there are a significant number of eyes lost via traction retinal detachments secondary to vitreous condensation, organization, and traction that might be prevented with the introduction of new techniques, such as pars plana vitrectomy. There is current controversy not only as to the role of pars plana vitrectomy, but also as to the optimum time for surgical intervention. There are those who favor immediate (within the first 48 hours) intervention (1) and others who favor waiting approximately two weeks. The purpose of this paper is to provide our own guidelines for the management of penetrating ocular trauma and to discuss the role and timing, as well as the rationale, for pars plana vitrectomy in penetrating ocular trauma.
* This study was supported in part by the National Institutes of Health grant EY 02061-01.
Guidelines and Principles in the Management of Penetrating Ocular infury
** Dr. Ryan is recipient of the Louis B. Mayer Scholar Award from Research to Prevent Blindness, Inc., New York, New York.
1. Thorough preoperative evaluation. 2. Prompt primary repair.
Stephen J. Ryan
106 3. Early vitreoretinal evaluation for definitive vitreous surgery. 4. Close follow up.
The Initial Preoperative Evaluation should include. 1. A pertinent history and clinical examination, which are appropriate and commensurate with the urgency of commencing the primary surgical repair. 2. Diagnostic tests, where appropriate. These are to include x-ray, ultrasound, electrophysiology, depending on the nature of the injury, i.e., if there is a history of foreign body. 3. Formulation of plan.
The Prompt Primary Surgical Repair Procedure should include 1. Thorough exploration. 2. Debridement. 3. Approach to ocular tissues. a. Cornea and sclera - microscopic reapproximation. b. Uvea (particularly the iris or ciliary body) abscission or reposition, depending on the duration of exposure, extent of the injury, technical limitations, etc. c. Lens - if unequivocally injured, a relatively atraumatic removal should be performed. d. Vitreous - avoid incarceration in the wound if at all possible. e. Retina - consider each case individually for buckling or cryotherapy or diathermy 4. Other aspects - see below. Preoperative and postoperative antibiotic coverage and approach to inflammation, glaucoma, and other associated problems should be incorporated in the therapeutic plan. Depending on the local availability of vitreous instrumentation and the vitreoretinal expertise, one can consider possible referral or consultation prior to the initial repair, or refer the patient shortly after the primary repair for the definitive operation, especially in cases of posterior penetrating injury. In any event, a thorough retinovitreal evaluation should be performed as soon as possible after the injury and primary surgical repair, so that vitreous surgery can be performed four to ten days after the initial injury when indicated.
After the primary repair, vitreoretinal evaluation should be performed w i t h i n four to seven days after injury, if possible. In addition to the clinical examination, diagnostic tests (particularly ultrasound, electroretinogram, and x-ray, where indicated) can and should be performed. A plan should be formulated with the pros and cons of early and late vitrect o m y as appropriate for the individual case in question (see below). The definitive vitreoretinal surgery should be performed as one operation, rather than staged vitreous and retinal surgery.
Discussion Eagling (5) has indicated that there has not been the improvement in perforating injuries involving I the posterior segment as has been the case in anterior segment trauma. When one considers that the main mechanisms for blindness include expulsive choroidal hemorrhage, retinal detachment, and cyclitic membrane formation, the poor prognosis for posterior segment injuries is not surprising. Eagling (5) describes the rapid development of cyclitic membrane formation with the retina being involved and incorporated in the cyclitic membrane. She cited vitreoretinal traction rather than retinal hole formation as the main mechanism for retinal detachment. It is remarkable that in all 17 of Eagling's (5) cases with posterior perforating injury but without vitreous hemorrhage, none developed vitreous organization, whereas, in those cases with vitreous hemorrhage and vitreous loss, only three out of sixteen did not develop vitreous organization. The stimulation of secondary fibrosis after incarceration of vitreous in the wound may explain the disproportionate degree of fibrosis in those patients with only localized vitreous hemorrhage (1,10). Eagling (5) emphasizes the importance of meticulous excision of the vitreous from the wound and excellent wound approximation to prevent vitreous incarceration leading to traction and seconary fibrosis of the vitreous. Coles and Haik (3) advocated extensive anterior vitrectomy after primary wound closure (ab externo incision) with prior extraction of the lens and anterior vitrectormy. It has been our argument that a complete, rather than anterior, vitrect o m y should be performed in penetrating wounds of
107
Management of Penetrating Ocular Trauma
the posterior segment because of the possibility of organization of the vitreous. In regards the question of appropriate timing of vitrectomy, the controversy of early versus late vitrectomy remains. Arguments in favor of early vitrectomy within the first 48 hours include p r o m p t removal of the damaged vitreous as a scaffold and matrix, as well as the hemorrhage as a stimulus to vitreous condensation, inflammation, development of cyclitic membranes, and traction retinal detachment (11). Earlier intervention might well decrease the inflammation. On the other hand, there may be further complications, chiefly of hemorrhage, and it may be more difficult to achieve control in the operating room. In addition, surgery within the first one or two days after injury possibly may not be performed with a posterior vitreous separation, a helpful finding at surgery. In favor of late surgery (ten to fourteen days after injury), one can follow the patient, charting the course and possibly avoiding surgery. If the eye is somewhat more quiet or less inflamed, then there may also be less bleeding at surgery and inflammation after surgery. In addition, there will be a posterior vitreous separation, which is of great advantage to the vitreous surgeon. On the other hand, by waiting more than seven days, there may be further vitreous organization and preretinal or retroretinal membrane formation. Retinal detachment can progress with membrane formation during the first seven days (10). Review of m y personal cases of vitrectomy for penetrating trauma was interesting in terms of evaluation of my own guidelines. I had initially advocated vitrect o m y not before 14 days after injury. This was, in part, related to insufficient experience with both the technique of vitrectomy and the understanding of the rapidity with which the process leading to traction retinal detachments can occur. Soon, my own inclinations were to operate earlier-within the first 48 hours, as advocated by Coleman (2), so as to avoid complications such as vitreous fibrosis. My experience and complications encountered, especially of uncontrolled bleeding, forced me to re-evaluate early surgery and led me to recommend a later time (ten to fourteen days after injury). Now, m y inclination is to operate four to ten days after injury for vitreoretinal surgery. My arguments reflect a desire to interrupt the process of cellular membrane formation by
removal of the vitreous matrix and scaffolding at the time of the least risk of complications. The two main reasons for early enucleation of the severely injured eyes, i.e., fear of sympathetic ophthalmia and skepticism as to any useful outcome, should be re-examined. The marked fall in the incidence of sympathetic ophthalmia with p r o m p t surgical closure of the wounds and postoperative management has decreased the weight of this argument (4,7). Although there are cases that cannot be salvaged, an attempt at salvage should be made at the primary repair rather than primary enucleation. Many eyes have been salvaged by vitrectomy that would have been almost certainly lost previously. Despite the few cases of sympathetic ophthalmia after vitrectomy for trauma (8), these salvaged eyes outweigh this argument in the author's opinion. Also, we have had occasion to examine eyes histopathologically that might well have profited from vitrectormy. A suggested approach to the management of penetrating ocular injuries has been proposed. In our experience, penetrating injuries of the anterior segment alone, i.e., up to and involving the lens but not involving the vitreous cavity, have achieved good results. The observations of Eagling (5) and Faulborn (6) support this observation. It is our current recommendation that thorough vitrectomy be performed at four to ten days after injury. The goals of vitrectomy are to clear the media of all opacities, to remove the damaged vitreous (and thus the potential scaffolding for organization), and to diminish the possibilities of flbroblastic proliferation. By removing the vitreous, we have a better view of the retina for the frequently necessary retinal surgery. In addition, removing the vitreous matrix may eliminate a source of traction for subsequent retinal detachment. Scleral buckling procedures are used in an adjunct fashion.
References
1. Cleary, P.E. In preparation. 2. Coleman, D.J. Role of vitrectomy in trauma. IN Current Concepts of the Vitreous including Vitrectomy, Gitter, K.A. (ed.). C.V. Mosby Company, St. Louis, Missouri, pp. 236-243 (1976). 3. Coles, W.H. and Haik, G.M. Vitrectomy in intraoeular trauma: Its rationale and its indications and limitations. Arch Ophthalmol 87:621 (1972).
108
4. Eagling, E.M. Perforating injuries involving the posterior segment. Trans. Ophthalmol Soc U.K. 95:335 (1975). 5. Eagling, E.M. Perforating injuries of the eye. Brit J Ophthalmo160: 723 (1976). 6. Faulborn, J., Atkinson, A., and Olivier, D. Primary vitrectomy as a preventive surgical procedure in the treatment of severely injured eyes. Brit J Ophthalmol 61 : 202 (1977). 7. Johnston, S. Perforating eye injuries: A five-year survey. Trans Ophthalmol Soc U.K. 91:895 (1971). 8. Lewis, M.L., Gass, J.D.M., and Spencer, W.H. Sympathetic uveitis after trauma and vitrectomy. Arch Ophthalmo196:263 (1978). 9. Ryan, S.J. Results of pars plana vitrectomy in penetrating ocular trauma. International Ophthalmology. 1 : 5 - 8 (1978). 10. Winthrop, S.R. In preparation. 11. Witmer, R.Modern Problems in Ophthalmology 10:316 (1972). Author's address: Estelle Doheny Eye Foundation, 1355 San Pablo Street, Los Angeles, California 90033 U.S.A.
Stephen J. Ryan
Guidelines in the management of penetrating ocular trauma with emphasis on the role and timing of pars plana vitrectomy* STEPHEN J. R Y A N , Los Angeles, USA
M.D.**
Keywords: Trauma, Vitrectomy, Retinal detachment Abstract The principles and guidelines in the management of penetrating ocular injury are detailed. In the absence of definitive clinical trial or an experimental model, the rationale for pars plana vitrectomy has been presented. In addition, our recommendations as to the appropriate role and timing of pars plana vitrectomy are included.
Introduction In a previous companion paper (9), the significance of penetrating ocular trauma and results of vitrectomy in selected cases of penetrating ocular injury were reviewed. The lack of definitive guidelines relates to the marked variability from patient to patient and injury to injury. When one couples this variability with the variety of ophthalmic surgeons and different philosophies of approach to penetrating injury, it is not surprising that there is such a wide divergence of opinion as to the appropriate management of such cases. Our results confirm the opinions expressed in the literature that injuries confined to the anterior segment do extremely well, whereas injuries involving the posterior segment, i.e., those involving the vit-
From the Department of Ophthalmology, University of Southern California School of Medicine, and the Estelle Doheny Eye Foundation, Los Angeles, California, U.S.A.
reous, retina, and choroid, are still a major and most significant problem. The mechanisms of blindness include severe hemorrhage, e.g., suprachoroidal and supraciliary body, and marked disruption of intraocular contents, for which our present-day surgical techniques are woefully deficient. However, there are a significant number of eyes lost via traction retinal detachments secondary to vitreous condensation, organization, and traction that might be prevented with the introduction of new techniques, such as pars plana vitrectomy. There is current controversy not only as to the role of pars plana vitrectomy, but also as to the optimum time for surgical intervention. There are those who favor immediate (within the first 48 hours) intervention (1) and others who favor waiting approximately two weeks. The purpose of this paper is to provide our own guidelines for the management of penetrating ocular trauma and to discuss the role and timing, as well as the rationale, for pars plana vitrectomy in penetrating ocular trauma.
* This study was supported in part by the National Institutes of Health grant EY 02061-01.
Guidelines and Principles in the Management of Penetrating Ocular infury
** Dr. Ryan is recipient of the Louis B. Mayer Scholar Award from Research to Prevent Blindness, Inc., New York, New York.
1. Thorough preoperative evaluation. 2. Prompt primary repair.
Stephen J. Ryan
106 3. Early vitreoretinal evaluation for definitive vitreous surgery. 4. Close follow up.
The Initial Preoperative Evaluation should include. 1. A pertinent history and clinical examination, which are appropriate and commensurate with the urgency of commencing the primary surgical repair. 2. Diagnostic tests, where appropriate. These are to include x-ray, ultrasound, electrophysiology, depending on the nature of the injury, i.e., if there is a history of foreign body. 3. Formulation of plan.
The Prompt Primary Surgical Repair Procedure should include 1. Thorough exploration. 2. Debridement. 3. Approach to ocular tissues. a. Cornea and sclera - microscopic reapproximation. b. Uvea (particularly the iris or ciliary body) abscission or reposition, depending on the duration of exposure, extent of the injury, technical limitations, etc. c. Lens - if unequivocally injured, a relatively atraumatic removal should be performed. d. Vitreous - avoid incarceration in the wound if at all possible. e. Retina - consider each case individually for buckling or cryotherapy or diathermy 4. Other aspects - see below. Preoperative and postoperative antibiotic coverage and approach to inflammation, glaucoma, and other associated problems should be incorporated in the therapeutic plan. Depending on the local availability of vitreous instrumentation and the vitreoretinal expertise, one can consider possible referral or consultation prior to the initial repair, or refer the patient shortly after the primary repair for the definitive operation, especially in cases of posterior penetrating injury. In any event, a thorough retinovitreal evaluation should be performed as soon as possible after the injury and primary surgical repair, so that vitreous surgery can be performed four to ten days after the initial injury when indicated.
After the primary repair, vitreoretinal evaluation should be performed w i t h i n four to seven days after injury, if possible. In addition to the clinical examination, diagnostic tests (particularly ultrasound, electroretinogram, and x-ray, where indicated) can and should be performed. A plan should be formulated with the pros and cons of early and late vitrect o m y as appropriate for the individual case in question (see below). The definitive vitreoretinal surgery should be performed as one operation, rather than staged vitreous and retinal surgery.
Discussion Eagling (5) has indicated that there has not been the improvement in perforating injuries involving I the posterior segment as has been the case in anterior segment trauma. When one considers that the main mechanisms for blindness include expulsive choroidal hemorrhage, retinal detachment, and cyclitic membrane formation, the poor prognosis for posterior segment injuries is not surprising. Eagling (5) describes the rapid development of cyclitic membrane formation with the retina being involved and incorporated in the cyclitic membrane. She cited vitreoretinal traction rather than retinal hole formation as the main mechanism for retinal detachment. It is remarkable that in all 17 of Eagling's (5) cases with posterior perforating injury but without vitreous hemorrhage, none developed vitreous organization, whereas, in those cases with vitreous hemorrhage and vitreous loss, only three out of sixteen did not develop vitreous organization. The stimulation of secondary fibrosis after incarceration of vitreous in the wound may explain the disproportionate degree of fibrosis in those patients with only localized vitreous hemorrhage (1,10). Eagling (5) emphasizes the importance of meticulous excision of the vitreous from the wound and excellent wound approximation to prevent vitreous incarceration leading to traction and seconary fibrosis of the vitreous. Coles and Haik (3) advocated extensive anterior vitrectomy after primary wound closure (ab externo incision) with prior extraction of the lens and anterior vitrectormy. It has been our argument that a complete, rather than anterior, vitrect o m y should be performed in penetrating wounds of
107
Management of Penetrating Ocular Trauma
the posterior segment because of the possibility of organization of the vitreous. In regards the question of appropriate timing of vitrectomy, the controversy of early versus late vitrectomy remains. Arguments in favor of early vitrectomy within the first 48 hours include p r o m p t removal of the damaged vitreous as a scaffold and matrix, as well as the hemorrhage as a stimulus to vitreous condensation, inflammation, development of cyclitic membranes, and traction retinal detachment (11). Earlier intervention might well decrease the inflammation. On the other hand, there may be further complications, chiefly of hemorrhage, and it may be more difficult to achieve control in the operating room. In addition, surgery within the first one or two days after injury possibly may not be performed with a posterior vitreous separation, a helpful finding at surgery. In favor of late surgery (ten to fourteen days after injury), one can follow the patient, charting the course and possibly avoiding surgery. If the eye is somewhat more quiet or less inflamed, then there may also be less bleeding at surgery and inflammation after surgery. In addition, there will be a posterior vitreous separation, which is of great advantage to the vitreous surgeon. On the other hand, by waiting more than seven days, there may be further vitreous organization and preretinal or retroretinal membrane formation. Retinal detachment can progress with membrane formation during the first seven days (10). Review of m y personal cases of vitrectomy for penetrating trauma was interesting in terms of evaluation of my own guidelines. I had initially advocated vitrect o m y not before 14 days after injury. This was, in part, related to insufficient experience with both the technique of vitrectomy and the understanding of the rapidity with which the process leading to traction retinal detachments can occur. Soon, my own inclinations were to operate earlier-within the first 48 hours, as advocated by Coleman (2), so as to avoid complications such as vitreous fibrosis. My experience and complications encountered, especially of uncontrolled bleeding, forced me to re-evaluate early surgery and led me to recommend a later time (ten to fourteen days after injury). Now, m y inclination is to operate four to ten days after injury for vitreoretinal surgery. My arguments reflect a desire to interrupt the process of cellular membrane formation by
removal of the vitreous matrix and scaffolding at the time of the least risk of complications. The two main reasons for early enucleation of the severely injured eyes, i.e., fear of sympathetic ophthalmia and skepticism as to any useful outcome, should be re-examined. The marked fall in the incidence of sympathetic ophthalmia with p r o m p t surgical closure of the wounds and postoperative management has decreased the weight of this argument (4,7). Although there are cases that cannot be salvaged, an attempt at salvage should be made at the primary repair rather than primary enucleation. Many eyes have been salvaged by vitrectomy that would have been almost certainly lost previously. Despite the few cases of sympathetic ophthalmia after vitrectomy for trauma (8), these salvaged eyes outweigh this argument in the author's opinion. Also, we have had occasion to examine eyes histopathologically that might well have profited from vitrectormy. A suggested approach to the management of penetrating ocular injuries has been proposed. In our experience, penetrating injuries of the anterior segment alone, i.e., up to and involving the lens but not involving the vitreous cavity, have achieved good results. The observations of Eagling (5) and Faulborn (6) support this observation. It is our current recommendation that thorough vitrectomy be performed at four to ten days after injury. The goals of vitrectomy are to clear the media of all opacities, to remove the damaged vitreous (and thus the potential scaffolding for organization), and to diminish the possibilities of flbroblastic proliferation. By removing the vitreous, we have a better view of the retina for the frequently necessary retinal surgery. In addition, removing the vitreous matrix may eliminate a source of traction for subsequent retinal detachment. Scleral buckling procedures are used in an adjunct fashion.
References
1. Cleary, P.E. In preparation. 2. Coleman, D.J. Role of vitrectomy in trauma. IN Current Concepts of the Vitreous including Vitrectomy, Gitter, K.A. (ed.). C.V. Mosby Company, St. Louis, Missouri, pp. 236-243 (1976). 3. Coles, W.H. and Haik, G.M. Vitrectomy in intraoeular trauma: Its rationale and its indications and limitations. Arch Ophthalmol 87:621 (1972).
108
4. Eagling, E.M. Perforating injuries involving the posterior segment. Trans. Ophthalmol Soc U.K. 95:335 (1975). 5. Eagling, E.M. Perforating injuries of the eye. Brit J Ophthalmo160: 723 (1976). 6. Faulborn, J., Atkinson, A., and Olivier, D. Primary vitrectomy as a preventive surgical procedure in the treatment of severely injured eyes. Brit J Ophthalmol 61 : 202 (1977). 7. Johnston, S. Perforating eye injuries: A five-year survey. Trans Ophthalmol Soc U.K. 91:895 (1971). 8. Lewis, M.L., Gass, J.D.M., and Spencer, W.H. Sympathetic uveitis after trauma and vitrectomy. Arch Ophthalmo196:263 (1978). 9. Ryan, S.J. Results of pars plana vitrectomy in penetrating ocular trauma. International Ophthalmology. 1 : 5 - 8 (1978). 10. Winthrop, S.R. In preparation. 11. Witmer, R.Modern Problems in Ophthalmology 10:316 (1972). Author's address: Estelle Doheny Eye Foundation, 1355 San Pablo Street, Los Angeles, California 90033 U.S.A.
Stephen J. Ryan
