Purpose
To describe ocular characteristics, surgical interventions, and anatomic and visual outcomes of traumatized eyes with no light perception (NLP) following open-globe injury and to investigate prognostic predictors for NLP cases after open-globe injury.
Design
Interventional case series study.
Methods
Thirty-three traumatized eyes with NLP were selected from the Eye Injury Vitrectomy Study database, a hospital-based multicenter prospective cohort study. Inclusion criteria were NLP cases following open-globe injury with outcomes of anatomic restoration, phthisis bulbi, or enucleation. Exclusion criteria were cases with missing records, undergoing vitrectomy after injury at nonparticipating hospitals, direct optic head injury, endophthalmitis, and hypotonous or silicone oil–sustained eyes. All cases underwent vitreoretinal surgery or enucleation after exploratory surgery and were followed up for at least 6 months. Two outcomes were assessed: favorable outcome (anatomically restored eye globes with light perception [LP] or better vision) and unfavorable outcome (NLP, phthisis bulbi, or enucleation).
Results
The following 7 risk factors were significant between the 2 groups: rupture ( P = .021); open globe III ( P = .046); scleral wound ≥10 mm ( P = .001); ciliary body damage ( P < .001); severe intraocular hemorrhage ( P = .005); closed funnel retinal detachment or retinal prolapse ( P = .005); and choroidal damage ( P = .001).
Conclusions
These 7 risk factors are possible predictors of poor prognosis. Traumatized eyes with NLP can be anatomically restored with LP or better vision if vitreoretinal surgery is attempted, and a favorable anatomic and visual outcome is increased by having a decreased number of these risk factors.
Open-globe injury is one of the most common worldwide causes of monocular visual impairment and blindness. Open-globe injury that causes no light perception (NLP) typically carries a dismal prognosis. Considering the risk of sympathetic ophthalmia, many ophthalmologists usually select primary enucleation for traumatized eyes with NLP. With the advancement of vitreoretinal surgery, some traumatized eyes with NLP, which would have previously been enucleated, are now saved and recover light-perception (LP) or better vision. When performing exploratory surgery on traumatized NLP cases, clinicians can now make a choice between vitreoretinal surgery and enucleation according to the ocular findings. However, few published reports describe in detail the intraocular characteristics, surgical interventions, and outcomes of traumatized eyes with NLP following open-globe injury. Further, because of a lack of prognostic indicators, there are no decision-making guidelines that can be used during exploratory surgery in order to make an accurate assessment of prognosis.
In this study, we described the ocular characteristics, surgical interventions, and the anatomic and visual outcomes of 33 traumatized NLP cases following open-globe injury and tracked the prognostic indicators for traumatized eyes with NLP vision.
Methods
Cases in this study were selected from the Eye Injury Vitrectomy Study database, which began in January 1997. The Eye Injury Vitrectomy Study is a hospital-based multicenter prospective cohort study whose purpose is to investigate the epidemiology, intervention of vitreoretinal surgery, and prognosis of severe eye injury. Six tertiary referral hospitals in China have successively participated in it. All injured patients in the database consented to enroll in the Eye Injury Vitrectomy Study. Its inclusion criteria were patients who suffered from severe eye injury and were treated with vitreoretinal surgery, enucleation, or evisceration. Exclusion criteria were patients with an eye injury who did not need vitreoretinal surgical intervention.
After patient demographics were obtained at admission, all initial ophthalmic examinations of the injured patients were conducted and reviewed by the chief of staff, and findings were confirmed by the chief surgeon before surgery. Information including patient age, sex, involved eye, best-corrected visual acuity (BCVA) after injury, and open-globe repair was recorded on a “Register of Eye Injury” form. Type and zone of injury conform to the recommendations of the United States Eye Injury Registry and the International Society of Ocular Trauma (Birmingham Eye Trauma Terminology [BETT ]) and “A System for Classifying Mechanical Injuries of the Eye.” Cornea, sclera, iris, lens, ciliary body, retina, choroid, intraocular foreign body (IOFB), intraocular hemorrhage, direct injury of optic nerve head, and endophthalmitis were examined and assessed during open-globe repair or exploratory surgery and recorded as baseline information on the “Register of Eye Injury” form by the chief surgeon. In addition, details of the vitreoretinal surgery and any subsequent surgical procedures and nonsurgical interventions were also recorded. Follow-up information, including the follow-up period, BCVA and intraocular pressure (IOP) at the last visit, tamponade of vitreous cavity, and anatomic outcome was recorded at outpatient follow-up after no less than 6 months.
The baseline and follow-up sheets were collected and data were input in the Eye Injury Vitrectomy Study electronic database using Epidata (The EpiData Association, Odense, Denmark). A cross-check for errors was conducted by 2 data entry clerks. If a variable could not be identified or was missing in the record, the data were excluded from this cohort.
In this study, the inclusion criteria were NLP cases following open-globe injury. As of December 31, 2009, there were 72 NLP eyes post open-globe injury in the Eye Injury Vitrectomy Study database. These injured eyes did not include cases of missing records, ones that underwent vitreoretinal surgery after injury at nonparticipating hospitals, and those with direct optic head injury, endophthalmitis, and a follow-up period of less than 6 months. The exclusion criteria were hypotonous or silicone oil–sustained cases. In total, 33 traumatized eyes with NLP (33 patients) met the study’s outcome criteria of anatomically restored eyes, phthisis bulbi, or enucleation.
Study Term Definitions
NLP
NLP vision was determined by an examination using an indirect ophthalmoscope with the highest-intensity light while the fellow eye was fully occluded. All injured patients who had documented NLP in the emergency room or other nonparticipating hospitals were referred to and examined by at least 2 senior trauma staff ophthalmologists after admission. As a final step, NLP vision was confirmed by the chief surgeon prior to exploratory surgery.
Zone of injury
The zone of injury is defined by location of the most posterior full-thickness aspect of the globe opening according to The Ocular Trauma Classification Group: open globe I, wound involvement is isolated to the cornea or corneoscleral limbus; open globe II, full-thickness wound involves the sclera no more posterior than 5 mm from the corneoscleral limbus; open globe III, full-thickness wound is posterior to open globe II.
Lens or iris extrusion
Lens or iris is fully prolapsed out of the globe (missing or under the conjunctiva) at the time of injury, which was confirmed during open-globe repair or exploratory surgery.
Intraocular hemorrhage
In some patients, almost all of the vitreous was lost when the open-globe injury occurred, especially following an eyeball rupture. The prolapsed vitreous dragged the whole retinal incarceration into the wound tract, forming a closed funnel, and the hemorrhage accumulated in the subretinal space. When the choroidal laceration occurred, the subretinal and suprachoroidal spaces connected with one another, so the hemorrhage was actually accumulated within the 2 gaps. Under such circumstances, it was quite difficult to discern which types of hemorrhage were in an injured eye globe with severe intraocular tissue disorder. Hence, we considered it more appropriate to refer to this as an “intraocular hemorrhage,” which was confirmed during globe exploration. In this study, an intraocular hemorrhage included a vitreous hemorrhage, a subretinal hemorrhage, and a suprachoroidal hemorrhage. Severe intraocular hemorrhage was defined as a hemorrhage too dense to allow visualization of the optic disc and identification of the intraocular tissues.
Large scleral wound
A large scleral wound was defined as a scleral wound length of 10 mm or more, which was examined during open-globe repair or exploratory surgery.
Ciliary body damage
In this study, ciliary body damage included ciliary epithelium detachment, ciliary body detachment, ciliary body defect, ciliary process atrophy, and formation of ciliary membrane, which was confirmed during exploratory surgery.
Closed funnel retinal detachment
In open-globe injured eyes, almost all the vitreous prolapsed because of a sudden drop of IOP. The prolapsed vitreous dragged the whole retinal incarceration into the wound tract, forming a closed funnel. Closed funnel retinal detachment was diagnosed during exploratory surgery.
Choroidal damage
In this study, choroidal damage included choroidal laceration, choroidal detachment, choroidal rupture, choroidal incarceration, and choroidal defect, which was confirmed during exploratory surgery.
Massive suprachoroidal hemorrhage
Defined as a hemorrhage in the suprachoroidal space of sufficient volume to cause extrusion of the intraocular contents of the eye or to force the inner retinal surfaces into apposition due to a sharp drop of IOP after onset of the open-globe injury.
Anatomically restored eyes
Determined after a period of follow-up no less than 6 months, IOP ≥ 8 mm Hg, vitreous cavity filled with aqueous humor, retinal attachment, or only local detachment that does not require surgery.
Hypotonous eyes
Determined after a period of follow-up no less than 6 months, IOP < 8 mm Hg, vitreous cavity filled with aqueous humor that exhibits the Tyndall effect owing to the presence of damage to the blood-ocular barrier.
Silicone oil–sustained eyes
Silicone oil–sustained eyes refers to eyes injected with silicone oil because of an incomplete treatment, lower IOP (<8 mm Hg), unrecovered retinal detachment, or inoperable retinal detachment.
Favorable outcome
Favorable outcome is defined as anatomically restored eyes whose final BCVA is LP or better after 6 months of follow-up.
Unfavorable outcome
Unfavorable outcome is defined as cases of phthisis bulbi or cases that underwent enucleation. Anatomically restored eyes whose final BCVA is NLP after 6 months of follow-up are also considered as an unfavorable outcome.
Statistical Analysis
Because the number of cases was less than 40, the Fisher exact test was used to evaluate the variables including interval of time between injury and vitrectomy, type and zone of injury, corneal and scleral wound, extrusion of iris or lens, ciliary body damage, severe intraocular hemorrhage, closed funnel retinal detachment or retinal prolapse, proliferative vitreoretinopathy (PVR), and choroidal damage according to 2 main outcomes: favorable and unfavorable.
The statistical level of significance was preset at .05 and all the eligible data were analyzed using SPSS version 17.0 statistical software (SPSS Inc, Chicago, Illinois, USA).
Results
Demographics of Cases
A total of 72 cases with NLP after open-globe injury were reviewed during this study period, and 33 injured eyes (33 patients) met the criteria for the evaluation of prognostic indicators. The number of eyes in the favorable outcome group and the unfavorable outcome group was 18 and 15 respectively.
The mean patient age was 33.2 years in the favorable outcome group; the youngest patient and the oldest patient were 8 and 49 years old respectively. The mean patient age was 28.1 years in the unfavorable outcome group; the youngest and the oldest were 10 and 51 years old respectively.
The average follow-up period of the favorable outcome group was 11.2 months (ranging from 6 to 47.4 months). The average follow-up period of the unfavorable outcome group was 12.9 months, except for 3 cases that underwent primary enucleation after globe exploration. The shortest follow-up period was 5.4 months for 1 case that was enucleated at a subsequent surgical procedure after a period of follow-up. The longest follow-up time was 78.9 months ( Tables 1 and 2 ).
| No | Age (years) | Type of Injury | Zone a | Time to PPV (days) | Corneal/Scleral Wound (mm) | Extrusion of Lens/Iris | Ciliary Body Damage | Retina | PVR | Choroidal Damage | Severe IOH | Main Surgical Interventions b | F/U (months) | Final BCVA |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 39 | Perforating | III | 3 | Yes / <10 | − / − | − | RD | − | − | − | Lx, C3F8 | 6 | CF 1′ |
| 2 | 19 | Penetrating | II | 3 | No / <10 | − / − | − | F-RD | − | − | − | Lx, UF, C3F8 | 6 | 20/160 |
| 3 | 41 | Rupture | III | 3 | Yes / <10 | − / − | − | RD | − | + | − | Lx, Rx, C3F8 | 29 | LP |
| 4 | 37 | Rupture | II | 3 | No / <10 | − / − | − | RD | − | + | − | TSD, C3F8 | 9 | CF 0.2′ |
| 5 | 26 | Rupture | II | 4 | No / <10 | − / − | + | RD | − | + | − | Rx, C3F8 | 11 | 20/500 |
| 6 | 8 | Perforating | II | 5 | No / <10 | − / − | + | RD | − | − | − | C3F8 | 7 | HM |
| 7 | 35 | Perforating | III | 5 | Yes / ≥10 | − / − | − | RD | − | − | − | Lx, C3F8 | 6 | 20/50 |
| 8 | 27 | Rupture | III | 10 | No / <10 | + / − | + | RD | − | + | + | Rx, SO | 7 | CF 0.5′ |
| 9 | 37 | Penetrating | III | 10 | No / ≥10 | − / − | − | RD | + | + | + | MP, Rx, C3F8 | 14 | CF 0.5′ |
| 10 | 28 | Rupture | III | 11 | No / <10 | − / − | − | F-RD | − | − | − | Lx, UF, C3F8 | 10 | 20/40 |
| 11 | 36 | Rupture | III | 12 | No / ≥10 | + / + | + | F-RD | − | + | + | UF, TSD, SO | 47 | LP |
| 12 | 46 | Rupture | III | 14 | No / ≥10 | − / − | − | RD | − | + | − | C3F8 | 7 | 20/160 |
| 13 | 49 | Rupture | III | 27 | No / ≥10 | − / − | + | F-RD | + | + | − | Lx, MP, Rx, UF, SO | 11 | LP |
| 14 | 37 | Perforating | II | 30 | Yes / <10 | − / − | − | RD | + | − | − | MP, Rx, SO | 6 | 20/320 |
| 15 | 21 | IOFB | I | 30 | Yes / No | − / − | − | RD | + | − | − | MP, Rx, SO | 7 | CF 0.5′ |
| 16 | 41 | Rupture | III | 42 | Yes / ≥10 | − / − | + | RD | + | − | + | TKP, MP, Rx, C3F8 | 7 | CF 0.5′ |
| 17 | 41 | Penetrating | II | 45 | Yes / <10 | − / − | − | RD | + | − | − | MP, Rx, SO | 6 | 20/100 |
| 18 | 30 | Rupture | III | 52 | Yes / <10 | − / − | − | F-RD | + | − | − | MP, Rx, UF, SO | 6 | LP |
a Zone I: wound involvement is isolated to the cornea or corneoscleral limbus; Zone II: full-thickness wound involves the sclera no more posteriorly than 5 mm from the corneoscleral limbus; Zone III: full-thickness wound is posterior to zone II.
b All cases underwent 20-gauge PPV; endolaser and perfluorocarbon were used in cases that required a retinal operation.
| No | Age (years) | Type of Injury | Zone a | Time to PPV (days) | Corneal / Scleral Wound (mm) | Extrusion of Lens / Iris | Ciliary Body Damage | Retina | PVR | Choroidal Damage | Severe IOH | Main Surgical Interventions b | F/U (months) | Outcome |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 27 | Rupture | III | 7 | No / ≥10 | − / − | + | All-pro | − | + | + | Enucleation | – | EN |
| 2 | 38 | Rupture | III | 9 | No / ≥10 | − / − | + | F-RD | − | + | − | Lx, UF, SO | 6 | PB |
| 3 | 51 | Penetrating | III | 10 | Yes / ≥10 | − / − | + | F-RD | − | + | + | Enucleation | – | EN |
| 4 | 25 | Rupture | III | 12 | No / ≥10 | + / + | + | All-pro | − | + | + | TKP, SO | 7 | EN |
| 5 | 32 | Rupture | III | 12 | Yes / ≥10 | − / − | + | F-RD | − | + | + | Lx, UF, SO | 7 | PB |
| 6 | 41 | Rupture | III | 13 | No / ≥10 | + / + | + | F-RD | − | + | + | Enucleation | – | EN |
| 7 | 33 | Rupture | III | 13 | No / ≥10 | − / + | + | F-RD | − | + | + | Lx, UF, Rx, SO | 7 | EN |
| 8 | 25 | Rupture | III | 13 | Yes / ≥10 | − / − | + | RD | − | + | + | SB, TSD, C3F8 | 9 | AR(NLP) |
| 9 | 22 | Rupture | III | 14 | No / ≥10 | + / + | + | All-pro | − | + | − | MP, SO | 8 | EN |
| 10 | 47 | Rupture | III | 16 | No / ≥10 | − / − | + | All-pro | − | + | + | C3F8 | 8 | PB |
| 11 | 13 | Rupture | III | 16 | No / ≥10 | − / − | + | RD | + | + | − | Lx, MP, C3F8 | 79 | PB |
| 12 | 23 | Rupture | III | 18 | Yes / ≥10 | + / − | + | F-RD | + | + | + | SB, UF, MP, Rx, C3F8 | 6 | EN |
| 13 | 10 | Rupture | III | 19 | Yes / ≥10 | + / − | + | F-RD | + | + | + | MP, UF, Rx, C3F8 | 5 | EN |
| 14 | 13 | Rupture | III | 24 | Yes / ≥10 | − / − | + | RD | + | + | + | TKP, Rx, C3F8 | 7 | EN |
| 15 | 21 | Rupture | II | 49 | Yes / <10 | − / − | + | F-RD | + | + | − | MP, Rx, UF, C3F8 | 7 | AR(NLP) |
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