We appreciate the opportunity to further discuss no light perception (NLP) following open-globe injury, in particular to respond to the comments from Chan and associates on our article regarding prognostic indicators for NLP after open-globe injury.

Although great progress in vitreoretinal surgical techniques has been made in recent years, enucleation is still applied to the open-globe injured eyes with NLP vision by most ophthalmologists. Per our experience and clinical observation, the indication for enucleation should not be determined by post-trauma NLP vision, but by the assessment during the exploratory surgery.

Chan and associates point out that enucleation should be considered within the first 7 to 14 days if the open-globe injured eye has no potential for visual recovery. In order to identify the potential for visual recovery of an open globe with NLP vision following injury, we developed the exploratory surgery, which is right before the vitreoretinal surgery or enucleation in the same surgical process but not included in the primary wound repair surgery.

The application of exploratory surgery to traumatized NLP cases can make clinicians ascertain which intraocular tissues are damaged and which interventions should be used during the surgery process. Our study demonstrated that a quarter of traumatized NLP eye globes, which would have been enucleated, can be saved and even recover light perception or better vision through globe exploration followed by vitreoretinal surgery.

During primary wound repair, clinicians can only explore the type and zone of injury and the length of sclera wound. But the damage to the crucial tissues, such as ciliary body, retina, and choroid, cannot be evaluated during the process of primary wound repair. And these damages were indicated as the main risk factors for developing NLP vision post-trauma and poor outcomes. Therefore, a judgment regarding the viability of injured eyes is insufficient at the time of primary wound repair.

In the Eye Injury Vitrectomy Study, NLP vision of all the traumatized patients was strictly tested by at least 2 senior ophthalmologists 3 times after admission. And the time to exploratory surgery was 3 days or more in all 33 cases in this study, so the patients can make correct judgments on visual acuity testing without subjective impact.

The long interval between injury and vitrectomy is primarily dependent on the referral time of patients to the participating hospitals. Relative afferent pupillary defect (RAPD) presented in all cases in this study, which was not listed in our paper because the traumatized NLP cases, based on our experience, usually presented with RAPD.

Based on the results of our study, the application of exploratory surgery just before the vitrectomy is a milestone for salvaging traumatized NLP eyes and should be widely extended to treatments for severely injured eyes.