Feng and associates describe remarkable outcomes with reversal of no light perception (NLP) following vitrectomy in eyes that have sustained open-globe injury, with visual recovery better than light perception (LP) in 18 of 33 eyes ranging from LP to 20/40. The current standard in the United States is to perform primary closure of an open globe followed by careful assessment of vision and reevaluation prior to considering vitrectomy. If the eye has no potential for visual recovery, enucleation should be considered within the first 7 to 14 days to reduce the risk of sympathetic ophthalmia.

Results of this study can seriously impact current standards of care, patient expectations, and ethical and financial implications regarding performing vitrectomies on eyes with NLP vision. Therefore, this study, particularly its design, needs to be more closely scrutinized.

In this study, NLP vision was determined “by at least 2 senior trauma staff ophthalmologists after admission.” Visual acuity testing requires subjective input and is often unreliable following trauma. No objective finding, such as the presence of a relative afferent pupillary defect, was reported. Although the use of visual evoked potentials and electroretinograms are not practical in most cases following traumatic open-globe injuries, the authors report that exploratory surgery was performed between 3 and 52 days after injury, during which these objective tests of vision could also have been considered.

The authors state that “NLP vision was confirmed by the chief surgeon prior to exploratory surgery”—at the time of open-globe repair. However, re-determination or confirmation of NLP vision was not described (or performed) prior to subsequent vitrectomy.

Another point of confusion is the timing of vitreoretinal surgery. Tables 1 and 2 list “Time to PPV [pars plana vitrectomy] (days),” which ranges from 3 to 52 days. However, the authors later state that “the shortest and longest time interval between injury and exploratory surgery in these cases is 3 and 52 days, respectively.” If all cases underwent immediate vitrectomy following exploratory surgery, it is remarkable that all 33 open-globe injury cases received primary vitrectomy at the time of open-globe repair. Otherwise, if vitreoretinal surgery was performed in a staged manner, a visual acuity of NLP prior to vitreoretinal surgery was not confirmed/described prior to vitrectomy.

Given a lack of objective endpoints to support determination of NLP vision and unclear timing of visual acuity assessment prior to vitrectomy, we should hesitate before performing vitreoretinal surgery on eyes with NLP vision, which would change the current standard of care and have widespread medical, ethical, and financial implications.