Performing phaco-vitrectomy with silicone oil in severe ocular injuries

Introduction

Thomas John

Traumatic injury to the eye is an ocular emergency and may often require surgical intervention to repair and preserve the globe and to retain or improve the visual acuity. The injury can cause anterior and/or posterior segment tissue damage, and the surgical correction has always aimed at re-establishing the normal globe anatomic architecture. However, the question arises as to when the posterior segment surgery should be performed — namely, at the time of initial repair or in a two-stage repair, in which the primary procedure is to close all tissue disruptions, such as corneal and scleral lacerations, while procedures such as posterior vitrectomy are carried out at a later date.

Here, Dr. Ahmad Mansour describes his approach of immediate phaco-vitrectomy with the use of silicone oil in severe ocular injury, thus doing all ocular repair at the time of initial surgery and avoiding a two-stage procedure.

– Thomas John, MD
OSN Surgical Maneuvers Editor

Severe injuries of the posterior segment are managed by repair of the ocular wound, and posterior segment pathologies are tackled 1 to 2 weeks later, in order to allow time for some forms of posterior vitreous detachment to develop and thereby facilitate vitreous surgery, to achieve better hemostasis, and to avoid intraoperative choroidal hemorrhage. However, serious concerns arise from leaving the traumatized eye with hyphema, choroidal hemorrhage, vitreous hemorrhage and hypotony for 1 to 2 weeks after suturing the lacerations. We present a small case series of ocular injuries managed by extensive, immediate, vitreoretinal surgery in the hope of rapid rehabilitation of vision.

Surgical techniques

Patients presenting to the emergency department between 2004 and 2009 with severe ocular injuries underwent primary repair of ocular lacerations by one surgeon with immediate vitrectomy within hours of the ocular trauma. Ocular lacerations were sutured (Figures 1 to 6).

Figure 1. Suturing of cornea and scleral lacerations in an eye with hyphema, lens perforation, vitreous hemorrhage, choroidal hemorrhage and intravitreal foreign bodies.

Figure 2. Hyphema cleanup. Images: Mansour A

Figure 3. Phacoemulsification with IOL implantation in the ciliary sulcus in case of lens rupture.

Figure 4. Bimanual vitrectomy is hampered by uncontrolled bleeding and poor visualization. Hemostasis is achieved by vitrectomy under air infusion.

Figure 5. Perfluoro-octane flattens the retina and displaces choroidal hemorrhage anteriorly, thereby aspirating it via the vitrector or draining it via anterior sclerotomies.

Figure 6. Maximal silicone oil exchange for perfluoropropane with endolaser around retinal tears.

Anterior segment pathologies were managed, including evacuation of the hyphema, filling of the anterior chamber with viscoelastic substance to prevent recurrent hyphema, removal of a ruptured or cataractous lens, and IOL insertion. We attempted to preserve the lens capsule and maintain compartmentalization by keeping the anterior chamber separated from the vitreous cavity to avoid silicone oil keratopathy or silicone oil glaucoma.

Vitreous in the anterior chamber was cut and removed with a vitrector. Phacoemulsification (or lens aspiration) was performed using side-port illumination to view the anterior capsule (because of absent red reflex secondary to vitreous hemorrhage). Low infusion/aspiration settings were used with repeated filling of the anterior chamber with viscoelastic substance to avoid vitreous ingress into the anterior chamber. In case of ruptured lens, care was taken to leave maximal capsular support.

When the lens rupture was large and centrally located, the vitrector was used to clear the pupillary area leaving peripheral cortical cleanup till after the completion of the vitrectomy when a good light reflex could be obtained. A foldable IOL implant was then inserted in the ciliary sulcus with the haptics placed in the meridian of maximal capsular remnant and intact zonules (Figure 3).

Suprachoroidal hemorrhage was drained at the site of the sclerotomy 3 mm from the limbus by injecting balanced salt solution into the anterior segment and then massaging around the sclerotomy site. A 6-mm infusion cannula was secured tightly to the sclera with 6-0 Vicryl sutures. A wide-angle viewing system was used, starting vitrectomy anteriorly and proceeding posteriorly.

The infusion pressure was set at 50 mm Hg. Aspiration was set at low levels to decrease turbulence and re-bleeding. When the bleeding inside the vitreous cavity was uncontrollable, vitrectomy was continued under air infusion set at 50 mm Hg. When the posterior vitreous was reached, perfluoro-octane was injected, allowing release of additional subretinal blood.

Small intraocular foreign bodies were removed via the sclerotomies, while larger intraocular foreign bodies were removed via a self-sealing corneoscleral tunnel in case of a large central lens rupture or via enlarging the sclerotomy in eyes with an intact lens. More thorough cleanup of vitreous was done at the vitreous base and at the posterior pole. Special care was taken to excise completely the vitreous from the circumference of the exit wound. Perfluoro-octane was exchanged directly with 1,000 centistokes silicone oil, or heavy silicone oil, in case of complex inferior retinal pathology. Endolaser was applied around retinal tears. Maximal filling of the vitreous cavity with silicone oil was attempted.

Eight eyes of eight consecutive patients had severe posterior segment injuries: zone 1 (four eyes), zone 2 (two eyes), and zone 3 (two eyes). Median best corrected visual acuity improved from baseline of light perception to final 20/800, with median follow-up of 21 months. Final anatomic success was achieved in seven eyes. Three patients developed proliferative vitreoretinopathy. The initial postoperative BCVA in two patients deteriorated from counting fingers at 3 m and 6/120, to counting fingers at 30 cm and hand motion, respectively. Vitrectomy removed the scaffold of the injury tract (vitreous hemorrhage, intraocular foreign bodies, ruptured lens-vitreous admixture) and flattened the retina by removing subretinal hemorrhage and tamponading retinal holes.

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• Thomas John, MD, is a clinical associate professor at Loyola University at Chicago and is in private practice in Tinley Park and Oak Lawn, Ill. He can be reached at 708-429-2223; fax: 708-429-2226; e-mail: tjcornea@gmail.com.
• Ahmad Mansour, MD, can be reached at Department of Ophthalmology, American University of Beirut, and Rafic Hariri University Hospital, Beirut, Lebanon; e-mail: ammansourmd@gmail.com.