Is primary comprehensive reconstruction or a staged approach best for an open globe injury involving the posterior segment?
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A staged approach is better in most cases
The optimal timing of vitreoretinal surgical intervention in open globe injuries involving the posterior segment remains controversial. Early intervention has the potential benefit of removing the scaffolding for fibrous proliferation that leads to tractional retinal detachment and proliferative vitreoretinopathy. Early intervention, however, can be more challenging for the surgeon due to leakage from fresh wounds, increased risk for uncontrollable bleeding and a higher risk for hemorrhagic choroidal detachment. Additionally, the cornea is often edematous or lacerated with an acute injury, and visualization is often poor. Finally, injuries often occur at night, when regular operating room staff are not available and finding technicians familiar with advanced retinal surgery is unlikely.
There are two instances in which surgery should be performed acutely. These are the presence of retinal detachment (usually visualized on B-scan ultrasound in these severely injured eyes that often harbor dense vitreous hemorrhage) and/or traumatic endophthalmitis. There is an increased risk for infection with Bacillus and Streptococcus species in trauma that can rapidly progress, and removal of the offending organisms with vitrectomy and injection of intravitreal antibiotics should be performed without delay.
In other instances, using a staged approach, closing the primary open globe injury and then proceeding with vitrectomy and secondary repair in 7 to 10 days, allows the eye some time to heal. Intensive topical steroid therapy can be instituted to help clear the cornea and anterior segment, possibly allowing the repair to proceed without a temporary keratoprosthesis. Also, if choroidal hemorrhagic detachment is present, waiting can allow for at least some liquefaction (complete liquefaction would not likely occur for 2 to 3 weeks) so that these can be partially drained at surgery. There is also potential for the posterior hyaloid in these young patients to be easier to separate from the retina after 7 to 10 days compared with an acute setting. Better separation of the posterior hyaloid will allow for a more complete vitrectomy and less chance of postoperative proliferation.
Robert A. Mittra, MD, is from VitreoRetinal Surgery, P.A., Minneapolis. Disclosure: Mittra reports no relevant financial disclosures.
Primary comprehensive reconstruction holds many advantages
The rationale for the traditional staged approach was based on three arguments, of which only one retains some validity today. The first argument was that delayed surgery would allow the cornea to recover from the edema and regain transparency. It is true that a wounded cornea immediately becomes edematous and, being a relatively dry tissue, loses transparency with water retention. When you suture the cornea and go 70% to 90% deep, as traditionally suggested, you do not incorporate in the suture the posterior cornea, where the water is collected, and as a result, the edema persists for several days. But if you close the wound with a suture that goes all the way through the cornea, in most cases the corneal edema completely disappears intraoperatively and there are no more visibility issues. The second argument theoretically in favor of delayed surgery is that time should be allowed for the posterior vitreous to spontaneously detach from the retina, which was believed to occur within 7 to 10 days. With the use of triamcinolone in the past few years, we have been able to see that the vitreous does not detach after a week or 10 days, particularly in young people, who are the majority of injury cases. Even months later, the vitreous is still attached to the retina. The third argument is the risk for choroidal hemorrhage during early surgery. This risk is real and can be very severe and difficult to manage, but it is still extremely rare; it might happen in one out of 100 cases. An experienced surgeon can deal with this complication and should not be discouraged from doing what I call primary comprehensive reconstruction.
Today, with the advanced instrumentation and techniques we have, there is no valid rationale to postpone the surgery. Early intervention has countless benefits. The most important is that many of the complications that would occur later can be prevented. Among them, proliferative vitreoretinopathy (PVR), which in a traumatized eye usually occurs fairly rapidly, is very severe and tends to recur, even after successful treatment. The two main causes of PVR are blood and inflammation, and if you do surgery very early, or at least within the first 4 days, you have a very good chance of preventing PVR. You also prevent retinal detachment, which can occur as early as a few hours after the injury, and you prevent infection if it is not present yet because you remove the vitreous that is the medium for the infection. You can remove any toxic material immediately. You cut down on costs and finally, and perhaps most importantly, you relieve the patients of the psychological burden of being twice on the operating table and waiting in between without knowing what the injury has caused to their eyes. This is an advantage that is not often discussed, but patients will be grateful to you for telling them early what the likely outcome might be.
Ferenc Kuhn, MD, PhD, is from the University of Alabama and Helen Keller Foundation for Research and Education, Birmingham, Alabama. Disclosure: Kuhn reports no relevant financial disclosures.