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New approach to managing severe ocular injuries reduces PVR rate
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VIENNA — Proactively managing patients who sustain certain types of severe ocular injuries associated with scar-related complications can help avoid those complications and improve visual outcomes, according to a surgeon speaking here.
"Proactive management means early surgery, within 4 days, and prophylactic chorio-retinectomy to prevent retinal incarceration and consequently PVR (proliferative vitreoretinopathy) and retinal detachment," said Ferenc Kuhn, MD, at the joint meeting of the European Society of Ophthalmology and the American Academy of Ophthalmology.
Dr. Kuhn introduced the new treatment protocol for managing eyes that sustain perforating injuries, rupture injuries with a post-equatorial extension and deep-impact intraocular foreign body injuries. These injuries all have a high rate of scar-related complications, which lead to poor anatomical and functional outcomes, he said.
"Traditionally, with these types of injuries we would close the wound at day 1, do a vitrectomy around day 7 and then send the patient back and wait. In most cases, after about 2 months the ambulance brings back the patient with PVR and then we do surgery for PVR," Dr. Kuhn said.
This traditional management approach generally leads to an almost endless series of reoperations because "PVR recurs and then you repeatedly cut the retina until there is no retina left," he said.
In contrast, the proactive management approach proposed by Dr. Kuhn attempts to prevent rather than simply treat the complications caused by vitreous traction, vitreous hemorrhage and retinal incarceration.
The proactive management approach involves immediately closing the wound. A complete vitrectomy is then performed within 4 days. "Then, a deep diathermy is performed around the exit wound, along the rupture wound or around the intraocular foreign body impact site," Dr. Kuhn said.
In addition to preventing bleeding, the goal of diathermy is to destroy part of the choroid and retina and obtain a 1-mm ring of bare, retina/choroid-free sclera, which dramatically reduces PVR rates, he said.
In a study of 21 eyes with more than 6 months of follow-up, Dr. Kuhn found that this proactive management approach led to a PVR rate of less than 10%, with only two eyes developing PVR. In contrast, previous studies have found PVR rates around 60% using the traditional management approach.
An international prospective, multicenter study evaluating the new proactive management approach has been set up. Surgeons willing to participate can contact Dr. Kuhn at fkuhn@mindspring.com.