Prognostic Indicators for No Light Perception after Open-Globe Injury




We read with interest the article by Feng and associates describing prognostic indications for patients who have no light perception after open-globe injury. The report provides valuable information on open-globe injury with no light perception. However, although the study was concise, we have some concerns regarding the presented findings.


First, ophthalmologists should keep in mind that light perception is a subjective measure. It is not a reliable test in the presence of severe media opacity, even when the bright light of an indirect ophthalmoscope is used. The absence of light perception may not reflect the need for enucleation, and the globe may be salvageable. Primary enucleation should be avoided because the occurrence of sympathetic ophthalmia is rare.


Second, timing of secondary posterior segment surgery is critical. Most authors advocate early vitreoretinal intervention to be performed between 2 and 14 days after open-globe injury. This difference is likely because of the formation of proliferative vitreoretinopathy. After posterior segment injury, proliferative vitreoretinopathy formation causes traction retinal detachment, extension of an existing detachment, and increased difficulty in achieving successful retinal reattachment. These challenges are especially true where closed-fold retinal detachment exists. Prompt removal of the proinflammatory mediators and repair of retinal detachment reduces the risk of formation of extensive proliferative vitreoretinopathy. Additionally, primary silicone oil tamponade is strongly recommended and may increase the anatomic success rate.


Third, when clinical management of severe open-globe injury is delayed, the result usually is phthisis bulbi change with hypotony and ciliary body damage. In these cases, eyes usually have a poor final visual outcome after a long follow-up period. Although the anatomic retina initially is attached successfully, ocular hypopyon is persistent or progressive because of ciliary body damage with hyposecretion of ocular fluid. As Feng and associates state, the removal of silicone oil may result in phthisis bulbi with or without subsequent retinal detachment.


Finally, Feng and associates concluded that severe intraocular hemorrhage is one of the factors associated with poor prognoses. Intraocular hemorrhage in eyes with open-globe injury may take the form of vitreous hemorrhage, subretinal hemorrhage, or suprachoroidal hemorrhage. In our clinical experience, patients with severe open-globe injury with no light perception almost always display severe intraocular hemorrhage at initial presentation. Severe intraocular hemorrhage, especially with dense hyphema, increases the possibility of corneal blood staining, which in turn decreases the visibility of the posterior segment during vitrectomy. However, vitreous hemorrhage does not often affect the final visual outcome. Subretinal hemorrhage, especially with blood clots, is associated with moderate vision loss. Combined with retinal detachment, massive suprachoroidal hemorrhage with choroidal laceration usually results in severe vision loss. We recently administered intravitreal or intracameral (aphakic patients) tissue plasminogen activator 1 to 2 days before vitreoretinal surgery. The activator accelerates the liquefaction of vitreous and subretinal blood clots and prevents iatrogenic retinal breaks during the vitrectomy. It is ineffective in suprachoroidal hemorrhage. In other cases, it helps remove the liquefied subretinal hemorrhage more rapidly, using perfluorocarbon liquid tamponade, and facilitates removal of subretinal blood clots.

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Jan 12, 2017 | Posted by in OPHTHALMOLOGY | Comments Off on Prognostic Indicators for No Light Perception after Open-Globe Injury

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