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Severe eye injury requires proactive management to prevent PVR
Early surgery and prophylactic retinectomy help prevent scar-related complications, lessen PVR.
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VIENNA — Proactively managing certain types of severe ocular injuries can effectively avoid complications and lead to better visual outcomes, according to one surgeon.
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“Proactive management means early surgery, within 4 days, and prophylactic chorioretinectomy to prevent retinal incarceration and, consequently, proliferative vitreoretinopathy (PVR) and retinal detachment,” said Ferenc Kuhn, MD, at the joint meeting of the European Society of Ophthalmology and the American Academy of Ophthalmology.
This type of approach was introduced by Dr. Kuhn for the treatment of perforating injuries, rupture injuries with a post-equatorial extension and deep impact intraocular foreign body injuries.
What these injuries have in common, he explained, is a high rate of scar-related complications, leading to poor anatomical and functional outcomes. Inflammation and scar tissue formation occur in response to the injury, and the scar incarcerates the retina. Retinal incarceration, in turn, leads to PVR, retinal detachment or retinal folds.
“Traditionally, with these type of injuries we would close the wound at day 1, do vitrectomy around day 7 and then send the patient back and wait. In most cases, after about 2 months, the ambulance would bring back the patient with PVR, and then we’d do surgery for PVR,” Dr. Kuhn said.
This approach generally leads to an almost endless series of reoperations because “PVR recurs and then you repeatedly cut the retina,” he said.
Visual outcome is generally poor. The results of large series of eyes with perforating injuries demonstrated that 80% of the eyes end up with less than 20/200 vision and only 11% achieve 20/40 or better. The PVR rate is 43% to 60%.
The proactive management approach aims at preventing the complications caused by vitreous traction, hemorrhage and retinal incarceration. Final results with this approach are substantially different, Dr. Kuhn said.
Early surgery, deep diathermy
If the problem is approached in a rational way, with severe posterior wounds there is no point in delaying vitrectomy to day 7 or day 10, Dr. Kuhn said. The wound can start to close after a few hours, and if the IOP is closely monitored during pars plana vitrectomy, the risk of losing the retina is low.
Early intervention, within 4 days, will leave no time for the inflammation and scarring processes to start and cause complications, Dr. Kuhn said.
Another difference from traditional management is in the type of surgery.
“We are not doing a vitrectomy and then adopting a ‘wait and see’ approach. We perform a deep diathermy around the exit wound, along the rupture wound or around the intraocular foreign body impact site,” Dr. Kuhn said.
Diathermy is aimed at not just preventing bleeding, but at destroying the pigment epithelium at the wound site, obtaining a 1 mm ring of bare, retina/choroid-free sclera. This idea, he said, came from the observation of eyes treated for choroidal melanoma, where destruction of the choroid, and therefore of the retinal pigment epithelium layer, is performed along with the vitrectomy procedure. In these eyes, PVR rate is low.
“By preventing the migration of retinal pigment epithelium cells into the vitreous chamber, the cascade of events that lead to PVR is stopped at the origin,” Dr. Kuhn said.
Step-by-step management
Dr. Kuhn suggested a two-step management of these cases. The first step is doing the primary emergency maneuvers, such as closing the wound as soon as possible, clearing anterior segment opacities such as hyphema and cataract if necessary, and removing intraocular foreign bodies when feasible.
In eyes with a perforating or intraocular foreign body injury, it is preferred to perform limited indirect ophthalmoscopic vitrectomy to cut the intravitreal traction pathway.
The second step is the reconstructive surgery, which should be performed between 48 and 96 hours after the injury.
At this stage, pars plana vitrectomy for complete removal of the vitreous is performed.
“Triamcinolone can be used to help in the detection and removal of the posterior cortical vitreous and vitreous base, and scleral indentation can be used to assure complete removal of peripheral vitreous,” Dr. Kuhn said.
Close attention should be given to cutting and removing incarcerated vitreous around wounds or at the intraocular foreign body impact site, he recommended.
Intraoperative IOP should be monitored closely to avoid IOP elevation that would lead to retinal extrusion into the orbit through the posterior wound.
Deep diathermy is then performed in the exit wound, rupture wound or intraocular foreign body impact site.
“Deep diathermy must involve the choroid, not just the retina. A ring of approximately 1 mm of bare sclera must be left around the wound site. If the wound is too close to the fovea, the width of the ring will be appropriately reduced,” Dr. Kuhn said.
By using forceps, the remaining retina is then lifted to verify that the retinal edge is free of any tissue bridge to the developing scar.
A laser cerclage is performed around the retinectomy and in the periphery. Finally, silicone oil or gas is injected to fill the vitreous cavity.
Postoperative care includes heavy topical steroids in all cases, and systemic steroids, antibiotics and other systemic medications if needed.
For more information:
- Ferenc Kuhn, MD, can be reached at 1201 11th Ave. South, Suite 300, Birmingham, AL 35202, U.S.A.; +1-205-558-2588; fax: +1-205-933-1341; e-mail: fkuhn@mindspring.com.
- Michela Cimberle is an OSN Correspondent based in Treviso, Italy, who covers all aspects of ophthalmology. She focuses geographically on Europe.