Purpose
To describe the long-term surgical course of patients with open globe injury.
Design
Retrospective case series.
Methods
Patients with open globe injuries (848 in total) treated surgically at the Massachusetts Eye and Ear Infirmary between 2000 and 2009 were retrospectively reviewed. Data from presentation, initial repair, and follow-up surgery were analyzed.
Results
Among 848 injuries, 1415 surgical procedures were performed. The mean follow-up time was 19.7 months, including 6017 visits. On average, patients required 1.7 surgeries and 7.1 follow-up visits. Factors predicting follow-up surgery included more severe ocular trauma score, worse prerepair visual acuity, retinal hemorrhage, anterior vitrectomy at primary repair, pars plana vitrectomy at primary repair, and lensectomy at primary repair. Patients with zone II injury, hemorrhagic choroidal detachment, and a history of previous ocular surgery tended to require follow-up surgery less frequently. Patients requiring a second surgery tended to have worse visual acuity at presentation and postrepair. Postoperative visual outcomes were worse for patients who underwent vitreoretinal follow-up surgery, likely because of mechanism of injury. Variables associated with inferior visual outcome were worse prerepair visual acuity, postoperative afferent pupillary defect (APD), old age, scleral laceration, and retinal detachment.
Conclusion
Open globe injuries require significant surgical follow-up. Patients requiring multiple operations tended to have worse postoperative visual acuity. Patients who underwent vitreoretinal surgery had overall worse visual outcomes. While the first year of surveillance appears to be pivotal in the course of an open globe injury, these patients can expect long-term care from comprehensive and subspecialty ophthalmologists.
Open globe injuries are a significant source of visual morbidity in the general population. While open globe injuries may result in abrupt vision loss in the acute setting by circumstances such as immediate traumatic forces or acute endophthalmitis, or even come to a finality by enucleation, visual outcomes may fluctuate with time and surgical interventions may be required over years. The considerable damage to the anterior segment and retina leads to a sustained need for close follow-up with an ophthalmologist, often necessitating further surgical procedures following the initial repair.
Much of the current literature focuses on prognostic factors at presentation. These studies demonstrate that better visual outcome was associated with higher ocular trauma scores, younger age, better initial visual acuity, corneal injuries, sharp mechanism of injury, shorter wounds, lack of lens damage, lack of retinal detachment, and male sex. However, there has been little research regarding the chronic management of these patients or factors predictive for further surgical intervention. The purpose of this study is to examine the long-term surgical rehabilitation of open globe injury patients at a large ophthalmic trauma referral center with a standardized treatment protocol.
Methods
A retrospective chart review was conducted on 846 patients comprising 848 open globe injuries at the Massachusetts Eye and Ear Infirmary (MEEI) between January 1, 2000 and April 30, 2009. An open globe injury was defined as a traumatic full-thickness break in the corneoscleral wall of the eye. The patients in this cohort represent consecutive patients treated by the ocular trauma service with either isolated open globe injuries or an open globe injury as part of a multisystem trauma. Demographic and clinical data from all patients were entered into a computerized database for review and analysis. The data included age, sex, information about the time and place of injury, mechanism of injury, initial examination, open globe repair surgical findings and techniques, and follow-up examinations, surgical procedures, and outcomes. The following data were entered for each surgery: zone of injury, uveal reposition, lensectomy, intraocular lens (IOL) insertion, intraocular foreign body (IOFB) removal, lid laceration repair, anterior chamber washout, disinsertion or reinsertion of rectus muscle, penetrating keratoplasty, cataract wound dehiscence repair, pars plana vitrectomy, anterior vitrectomy, Weck Cel vitrectomy, epiretinal membrane peel, scleral buckle, silicone oil placement, gas tamponade, laser therapy, cryotherapy, glaucoma operation (tube, shunt, or valve), or enucleation. The following data were entered for each follow-up clinic visit: corrected and uncorrected vision, intraocular pressure, corneal edema, cataract formation, choroidal detachment, endophthalmitis, glaucoma, hyphema, corneal scar, phthisis, retinal detachment, retinal scar, and vitreous hemorrhage. If a specific data field was not available for a patient, that patient was excluded from that particular analysis.
Patients are evaluated and treated for open globe injuries at the Massachusetts Eye and Ear Infirmary according to a previously published standardized protocol. Upon arrival to the emergency room a standard history and ocular examination is completed. A noncontrast computed tomography (CT) scan with thin cuts through the orbits is obtained, the patient’s tetanus is updated, and intravenous antibiotics are started. Repair of the open globe is completed within 24 hours when not prohibited by a late presentation or other active medical issues. After surgery, the patient is observed as an inpatient and continued on intravenous antibiotics for 48 hours. The Birmingham Eye Trauma Terminology (BETT) system was retrospectively applied. When possible, an ocular trauma score (OTS) was calculated based on the data available at presentation, as described by Kuhn and associates.
Following initial repair, patients are referred from the trauma service to subspecialty consult services as appropriate. In the majority of cases, patients did not have a local ophthalmologist able to care for the specific post-traumatic care and patients remained in the care of the trauma service or 1 or more of the subspecialty services at MEEI. Information regarding follow-up visits and surgical procedures from all specialties was captured. In cases where the patient received care elsewhere and referral notes were not received, these patients were excluded from the relevant portions of the analysis.
Statistical analysis was performed using an unpaired t test to compare means between groups, a Mann-Whitney test for nonparametric data, or a 2-tailed Fisher exact test to compare categorical data. Stepwise multiple linear regression was performed using SPSS version 17.0 software (SPSS, Inc, Chicago, Illinois, USA). A P value <.05 was considered statistically significant. Kaplan-Meier curves were generated for time to postrepair surgery and time to enucleation using GraphPad Prism version 5.0 (Graphpad Software, La Jolla, California, USA).
Results
The 848 open globe injuries required a total of 1415 ophthalmic surgeries at MEEI, including primary open globe repair or enucleation. The most common mechanisms of injury were: projectile (168/848; 21%), fall (129/848; 16%), blunt (126/848; 16%), nail (106/848; 13%), wood (52/848; 6%), glass (36/848; 5%), motor vehicle collision (30/848; 4%), wire (26/848; 3%), blade (23/848; 3%), assault (22/848; 3%), and BB/pellet gun (15/848; 2%). The majority of injuries were considered penetrating (511/848; 60%), with intraocular foreign bodies identified in 15% of patients (123/848). The remaining injuries were classified as ruptured globes (332/848; 39%) and perforated globes (5/848; 0.6%). The average number of operations per patient, including open globe repair, was 1.7. The mean follow-up time was 19.7 months (range 1 day to 131 months). There were a total of 6017 follow-up visits, averaging 7.1 per patient. The longest time between initial injury and last follow-up surgery was 73 months. The total number of procedures and the total number of patients receiving each operation is presented in Table 1 . Other than open globe repair, the most common procedures performed were lensectomy (300/848; 35% of cases) and vitrectomy (239/848; 28% of cases). When limiting the patient population to patients with at least 6 months of follow-up, the average number of surgeries per open globe injury patient was 2.0.
| Procedure | Total # Procedures | Patients, N (%) |
|---|---|---|
| Anterior chamber washout | 119 | 115 (14) |
| Anterior vitrectomy | 152 | 137 (16) |
| Lensectomy | 324 | 300 (35) |
| IOL insertion | 118 | 113 (13) |
| Penetrating keratoplasty | 30 | 29 (3) |
| Vitrectomy | 333 | 239 (28) |
| Gas | 72 | 64 (8) |
| Oil | 81 | 72 (8) |
| Laser | 158 | 130 (15) |
| Cryo | 24 | 23 (3) |
| Scleral buckle | 92 | 89 (10) |
| Membrane peel | 115 | 99 (12) |
| Tube/shunt/trabeculectomy | 10 | 8 (1) |
| Enucleation | 74 | 74 (9) |
| Primary enucleation | 14 | 14 (2) |
| Secondary enucleation | 60 | 60 (7) |
The majority of cases (466/848; 55%) underwent only open globe repair, while the remaining (382/848) 45% required follow-up surgeries. A significant number of patients (262/848; 31%) had 1 additional surgery performed after the primary repair, and the remaining 14% (120/848) needed at least 2 additional operations after their open globe repair. The maximum number of surgeries performed on a single patient was 9. A comparison of visual outcome data by number of surgeries required is shown in Table 2 . The patients requiring multiple surgeries tended to be younger (mean age 38.4 years vs 44.1 years; P = .0005). While both groups were predominantly male, the multiple surgery group had a lower percentage of female patients than the single surgery group ( P = .0188). The median visual acuity at presentation was worse (hand motions) in the multiple surgery group than in the single surgery group (count fingers; P < .0001). Similarly, the median best postoperative vision in the multiple surgeries group (20/100) was worse than in the single surgery group (20/30; P < .0001). Several open globe repair characteristics were statistically correlated with the need for a follow-up surgery: more severe ocular trauma score ( P < .0001), anterior vitrectomy at primary repair ( P = .0309), pars plana vitrectomy at primary repair ( P = .0094), and lensectomy at primary repair ( P = .0340). Zone II injuries (defined as the region extending from the limbus to 5 mm posterior to the limbus) were associated with fewer follow-up surgeries ( P = .0053).
| Single Surgery | Multiple Surgeries | P Value | |
|---|---|---|---|
| Total injuries | 466 | 382 | |
| Age (y), mean (range) | 44.1 (1 to 97) | 38.4 (<1 to 94) | .0005 |
| Male (%) | 351 (75) | 315 (82) | .0188 |
| Female (%) | 115 (25) | 67 (18) | .0188 |
| Median preoperative VA | Count fingers | Hand motions | <.0001 |
| Median best postoperative VA | 20/30 | 20/100 | <.0001 |
Nearly one-third of patients (245/848; 29%) required vitreoretinal surgery ( Table 3 ). There was no age difference between the groups that did or did not undergo vitreoretinal surgery ( P = .1426). There was a higher percentage of male patients in the group requiring vitreoretinal surgery (207/245; 84.5%) than in the group that did not undergo vitreoretinal surgery (459/603, 76.1%; P = .0074). Patients requiring vitreoretinal surgery were much more likely to have had an injury involving an IOFB (76/245; 31.0%) than those who did not require vitreoretinal surgery (48/603, 8.0%; P < .0001). The median initial visual acuity was hand motions in both the group requiring follow-up retina surgery and the group that did not. However, the median vision at final follow-up in the group requiring vitreoretinal surgery (20/400) was worse than in the group not requiring vitreoretinal surgery (20/40; P = .0002).
