Program list

SYMPOSIUM: EVRS-ISOT Joint Session
Moderators: Claude Boscher, Silvia Bopp
Monday, September 15th, 2003 ;11:00 -18:00

SECONDARY INTERVENTIONS AFTER POSTERIOR SEGMENT TRAUMA
Silvia Bopp*, Klaus Lucke
Germany

Purpose: The present paper highlights the sequences of interventions that may follow primary trauma care and indicates on secondary complications, such as PVR, hypotony and sympathetic ophthalmia. Treatment modalities and the significance for the anatomic and functional outcome are presented.
Introduction: Despite of the advances in vitreoretinal techniques, visual prognosis in eyes with open globe injuries and posterior segment involvement is still uncertain. Vitreoretinal surgery today can salvage and restore vision in severely injured eyes that previously would have been enucleated. Functional prognosis depends to a large extent on the severeness of the mechanical trauma and its immediate tissue damage. Meticulous primary care is crucial to rescue eyes with a potential for useful vision. However, even in eyes with posterior segment structures preserved and initial appropriate treatment performed, secondary complications may threaten the final outcome.
Subsequent surgery:
Initial treatment in severely injured eyes may only allow closure of the wounds to restore the eye ball and prevent posttraumatic endophthalmitis. Subsequent surgery is frequently indicated to reconstruct the intraocular tissues and restore vision. Timing of vitreous surgery is a matter of debate: pros and cons of early vs. deferred vitrectomy include the difficulty and hazard of surgery in a recently damaged eye vs. the risk of already initiated PVR-reaction. Reconstructive vitreoretinal surgery is recommended on day 7-10, but no later than 2 weeks. Exceptions are posttraumatic endophthalmitis and retained intraocular foreign bodies that usually require immediate treatment. Later revision surgery:
Proliferative vitreoretinopathy is the most frequent cause of visual loss in eyes that otherwise have a favorable visual potential and have undergone successful initial trauma surgery. PVR-reaction occurs in up to 45% and is characterized by an aggressive, chronic course requiring repeated surgery. Visual prognosis decreases dramatically, once PVR is initiated. Treatment is similar to PVR after retinal detachment, but surgery often more extensive. Vascularization and scarring at the injury site necessitates debridement of the internal sclero-retino-choroidal wound. Relaxing retinotomies are often unavoidable. As a result of the chronic PVR-process, for most eyes a long-term tamponade with silicone oil is indicated. Anatomic success rates are reported in 60-80% and useful vision can be achieved in 50-80%. Causes for failures are situations in which PVR is technically inoperable or in which one cannot expect any visual function even after surgical control of PVR.
Hypotony:
Hypotony indicates ciliary body insuffiency, either caused by the primary trauma (ciliary body destruction) or secondary by the presence of cyclitic tractional membranes (fibrovascular scarring tissue or PVR-membranes). These eyes are at a high risk to develop phthisis, even if the retina is attached. Therapy is difficult with no effective long-term treatment available. Long-term silicone oil tamponade or repeated intravitreal injections of hyaluronic acid may prolong survival of hypotonous eyes. Meticulous cleansing of the vitreous base and removal of cyclitic membranes at the time of initial surgeries is of utmost importance to prevent hypotony in the long-term course.
Sympathetic ophthalmia (SO):
Today, SO has become an extremely rare event. It is defined by a bilateral chronic granulomatous uveitis that affects the injured eye and the healthy fellow-eye (sympathizing eye) after a variable time interval. It is still a matter of debate, if early enucleation of severely traumatized eyes prevents SO and - in case SO has developed - enucleation of the exciting eye allows better control of the uveitis. Prophylactic enucleation of eyes with functional loss or painless phthisis is no longer recommended, but patients should be informed about SO. With adequate systemic long-term steroid therapy, most sympathizing eyes retain useful vision.
Conclusions: Visual prognosis in eyes with ocular injuries affecting the posterior segment is serious. Primary microsurgical care is crucial to allow later reconstructive surgery. For prevention and treatment of complications, effective vitreoretinal techniques are available. However, irreversible trauma-related tissue damage and the eye's more or less extensive wound healing response limit the final outcome. In general, prognosis in eyes with simple penetrating injury and in eyes with intraocular metallic foreign body is better than after perforating injuries and globe ruptures. PVR is the major late complication: it can be controlled by (repeated) surgery, but it worsens the functional outcome significantly.
Take-home message: Eyes with open globe injuries involving the posterior segment often show an unpredictable course. Final functional outcome depends on both, the trauma-related damage and further complications. In case of adequate primary care and management of secondary complications, 2/3 of eyes retain useful vision.