Retinal detachment after open-globe injury

Early versus Delayed Timing of Primary Repair after Open-Globe Injury: A Systematic Review and Meta-analysis

TOPIC

The timing of primary repair of open-globe injury is variable in major trauma centers worldwide, and consensus on optimal timing is lacking.

CLINICAL RELEVANCE

Surgery is the mainstay of open-globe injury management, and appropriate timing of surgical repair may minimize the risk of potentially blinding complications such as endophthalmitis, thereby optimizing visual outcomes.

METHODS

A systematic literature review was performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines (International Prospective Register of Systematic Reviews identifier, CRD42023442972). The Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and ISRCTN registries and ClinicalTrials.gov were searched from inception through October 29, 2023. Prospective and retrospective nonrandomized studies of patients with open-globe injury with a minimum of 1 month of follow-up after primary repair were included. Primary outcomes included visual acuity at last follow-up and the proportion of patients with endophthalmitis. Certainty of the evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach.

RESULTS

Fifteen studies met inclusion criteria, reporting a total of 8497 eyes. The most common injury types were penetrating and intraocular foreign body (IOFB). Meta-analysis found that primary repair less than 24 hours after open-globe injury was associated with 0.30 odds of endophthalmitis compared with primary repair conducted more than 24 hours after trauma (odds ratio, 0.39; 95% confidence interval [CI], 0.19-0.79; I2 = 95%; P = 0.01). No significant difference was found in reported visual outcomes between patients whose open-globe injuries were repaired more than, compared with less than, 24 hours after trauma (odds ratio, 0.89; 95% CI, 0.61-1.29; I2 = 70%; P = 0.52). All included studies were retrospective and nonrandomized, demonstrating an overall low certainty of evidence on GRADE assessment.

DISCUSSION

Only retrospective data exist around the effect of timing of open-globe repair, resulting in low certainty of the available evidence. However, this review of current evidence, predominantly including penetrating and IOFB injuries, suggests that primary repair performed less than 24 hours after open-globe injury is associated with a reduced endophthalmitis rate compared with longer delays, consistent with delay to primary repair increasing endophthalmitis risk.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

EARLY RETINAL DETACHMENTS AFTER OPEN GLOBE REPAIR: Incidence and Risk Factors

PURPOSE

Risk factors for the development of rhegmatogenous retinal detachments (RRDs) in the early postoperative period after open globe repair are not well understood. RRDs are often diagnosed late after open globe injuries, which can negatively affect visual prognosis. The authors assessed the incidence and risk factors that predict the development of this complication.

METHODS

The authors conducted a retrospective case-control study of all open globe injuries at a single ocular trauma center from January 2016 to September 2021 where at baseline the retina was attached. Cases were defined as postoperative RRDs that developed within 90 days of open globe repair.

RESULTS

Of 96 eyes included, 40 (41.7%) subsequently developed RRD. Univariate analysis revealed initial visual acuity of light perception or worse (odds ratio 7.64; 95% CI, 3.03-19.22; P < 0.01), Zone 3 injuries (odds ratio 7.54; 95% CI, 2.64-21.54; P < 0.01), no view of the lens (odds ratio 4.26; 95% CI, 1.77-10.26; P < 0.01), and the presence of injuries external to the globe (odds ratio 5.33; 95% CI, 2.09-13.63; P < 0.01) to be associated with early RRD development. On multivariate analysis, presenting visual acuity of light perception ( P < 0.001), the presence of external injuries ( P = 0.001), and Zone 3 injuries ( P = 0.037) remained significant. Of the 40 patients with early retinal detachment, 34 (85%) remained attached after repair, with variable visual outcomes.

CONCLUSION

Presenting visual acuity of light perception, Zone 3 injuries, and external injuries to the globe confer increased risk of early postoperative RRD after open globe repair. The majority of RRDs can be successfully repaired.

Traumatic retinal detachment: A contemporary update

Retinal detachment following ocular trauma (TrRD) is one of the leading causes of blindness and visual impairment worldwide. In the absence of a standardized definition, the diagnosis of traumatic retinal detachment relies on identifying a history of trauma that precedes the detachment. There is an increasing pool of data regarding the etiology and epidemiology of TrRD.Various causes of TrRD mentioned in the literature include work-related eye trauma in construction and manufacturing industries, sports injuries, explosive eye injuries, road traffic accidents, and intraocular foreign bodies. Although there is extensive literature on post-trauma retinal detachments, a comprehensive discussion of its pathogenesis, management, outcomes, and complications is lacking. We offer an in-depth review of the epidemiology, risk factors, pathogenesis, diagnosis, management, and outcomes of TrRD based on the current literature.

Outcomes of Open-Globe Injuries With Associated Retinal Detachment: Experience at an Ocular Trauma Center

Purpose: To characterize the clinical features and outcomes of open-globe injuries with associated retinal detachment (RD). Methods: A retrospective review was performed. Results: Thirty-six patients with open-globe injuries and subsequent rhegmatogenous RD were analyzed between January 2016 and September 2021. The median time to diagnosis and to the initial vitrectomy repair was 2.5 days and 20 days, respectively. Six months postoperatively, the median Snellen best-corrected visual acuity (BCVA) improved from light perception to hand motions. The logMAR BCVAs were significantly higher (worse) for patients who had more than 20 days between their injury and the initial vitrectomy repair (P = .01) and if their retinal detachment after open-globe injury score was higher than 5 (P = .03). The number of days between the open-globe injury and the initial vitrectomy repair was directly correlated with the final logMAR BCVA (P = .03). On multivariate analysis, a duration of more than 20 days between the open-globe injury and the initial vitrectomy repair was statistically significant for predicting the 6-month logMAR BCVA (P = .02). Conclusions: The final visual outcome for cases of RD associated with open-globe injury may be improved by minimizing the time between the injury and the initial vitrectomy repair.

Outcomes of Retinal Detachment after Open-Globe Injury, and Independent Validation of the Retinal Detachment after Open-Globe Injury Scoring System

PURPOSE

To independently validate the Retinal Detachment after Open-Globe Injury (RD-OGI) scoring system as a clinical prediction model for estimating the risk of retinal detachment (RD) after open-globe injury (OGI), and to characterize outcomes of RD stratified by RD-OGI risk category.

DESIGN

Retrospective, multi-institutional cohort study.

PARTICIPANTS

A validation cohort of 236 eyes with OGI managed at 2 academic institutions from 2017 through 2021 was compared with the predictions of the RD-OGI score model and to the derivation cohort of 893 eyes with OGI used to develop it.

METHODS

RD-OGI scores were calculated, and patients were stratified into 3 risk groups (low, moderate, and high). The incidence of RD in the validation cohort was used to calculate performance metrics to evaluate predictive accuracy of the RD-OGI score.

MAIN OUTCOME MEASURES

Area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and accuracy of the RD-OGI score; anatomic success (retina attached or detached); and best-corrected visual acuity (BCVA) at last follow-up.

RESULTS

In the validation cohort, 92 of 236 eyes (39%) demonstrated RD after OGI. The RD incidence predicted by the RD-OGI score was correlated strongly with actual RD incidence in the validation cohort (Spearman ρ = 0.92; P < 0.001). The RD-OGI score demonstrated high discrimination with the validation cohort (AUC, 0.84; 95% confidence interval [CI], 0.79-0.89). An RD-OGI score of 2.5 was found to have 73% accuracy, 93% sensitivity, and 60% specificity for predicting no RD (RD-OGI score < 2.5) versus RD (RD-OGI score ≥ 2.5). Median BCVA at last follow-up for successfully reattached eyes was comparable for high-risk eyes (approximately 20/380) and moderate-risk eyes (approximately 20/300; P > 0.99), but both were significantly worse compared with low-risk eyes (approximately 20/25; P = 0.010).

CONCLUSIONS

The RD-OGI score reliably predicts the risk of developing RD after OGI. In eyes that develop RD, a higher RD-OGI score is correlated strongly with a greater risk for poor functional and anatomic outcomes. An RD-OGI score of 2.5 or more identifies eyes at substantial risk of RD and adverse outcomes and may serve as a useful cutoff for guiding referral to a vitreoretinal surgeon after primary globe closure.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Effect of time to operative repair within twenty-four hours on visual acuity outcomes for open globe injuries

PURPOSE

Convention is to perform open globe injury (OGI) repair within 24 h to minimize risk of endophthalmitis. However, there are limited data assessing how time to operative repair (OR) within 24 h impacts postoperative visual acuity (VA).

METHODS

Manual retrospective chart review of 633 eyes at Massachusetts Eye and Ear (MEE) with a diagnosis of OGI between 2012 and 2022. Inclusion criteria were primary repair ≤ 24 h after injury and ≥1 month follow-up. Multivariate regression analysis was conducted with postoperative VA as primary outcome.

RESULTS

Of the subjects, 489 (77.3%) were male and 496 (78.4%) were white. Demographics of OGI wounds included 320 (50.6%) rupture and 313 (49.4%) laceration; 126 (19.9%) with rAPD, 189 (29.9%) zone 3 injuries, 449 (71.2%) uveal prolapse, and 110 (17.4%) intraocular foreign body. Final postoperative LogMAR VAs consisted of 31% with a VA < 1.7, 9% with a VA of 1.9, 18% with a VA of 2.3, 27% with a VA of 2.7, and 11% with a VA of 3.0. Multivariate analysis showed no significant correlation between time to OR and postoperative VA (p = 0.800) [95%CI: -0.01,0.01]. Older age (p < 0.001) [95%CI: 0.00,0.01], worse presenting VA (p < 0.001) [95%CI: 0.17,0.32], rAPD (p < 0.001) [95%CI: 0.65,1.0], mechanism of rupture (p < 0.001) [95%CI: 0.19,0.54], higher zone of injury (p < 0.001) [95%CI: 0.25,0.45], and uveal prolapse (p = 0.003) [95%CI: 0.09,0.42] were significantly associated with worse final VA.

CONCLUSIONS

Time to repair of OGIs within 24 h does not influence final VA. Optimization of surgical and patient factors may contribute more significantly to final VA than prioritizing more rapid time to OR.

Epiretinal Amniotic Membrane in Complicated Retinal Detachment: a Clinical and In Vitro Safety Assessment

INTRODUCTION

Amniotic membrane (AM) is a popular treatment for external ocular diseases. First intraocular implantations in other diseases reported promising results. Here, we review three cases of intravitreal epiretinal human AM (iehAM) transplantation as an adjunct treatment for complicated retinal detachment and analyze clinical safety. Possible cellular rejection reactions against the explanted iehAM were evaluated and its influence was assessed on three retinal cell lines in vitro.

METHODS

Three patients with complicated retinal detachment and implanted iehAM during pars plana vitrectomy are retrospectively presented. After removal of the iehAM at subsequent surgery, tissue-specific cellular responses were studied by light microscopy and immunohistochemical staining. We investigated the influence of AM in vitro on retinal pigment epithelial cells (ARPE-19), Müller cells (Mio-M1), and differentiated retinal neuroblasts (661W) . An anti-histone DNA ELISA for cell apoptosis, a BrdU ELISA for cell proliferation, a WST-1 assay for cell viability, and a live/dead assay for cell death were performed.

RESULTS

Despite the severity of the retinal detachment, stable clinical outcomes were obtained in all three cases. Immunostaining of the explanted iehAM showed no evidence of cellular immunological rejection. In vitro, there was no statistical significant change in cell death or cell viability nor were proliferative effects detected on ARPE-19, Müller cells, and retinal neuroblasts exposed to AM.

CONCLUSION

iehAM was a viable adjuvant with many potential benefits for treatment of complicated retinal detachment. Our investigations could not detect any signs of rejection reactions or toxicity. Further studies are needed to evaluate this potential in more detail.

The clinical features and the factors affecting visual prognosis in pediatric open-globe ınjuries

PURPOSE

To investigate clinical features and factors affecting visual prognosis after pediatric open-globe injuries.

METHODS

Retrospective study of 223 children with open-globe injury was conducted. Children with final logMAR visual acuity (LVA) > 0.70 were determined as poor-vision group (group 1, n = 108) and those with final LVA ≤ 0.70 as good-vision group (group 2, n = 115). Demographic characteristics (age, gender, and damaged eye), time between trauma and surgery, ocular trauma score (OTS), follow-up time, injury size, initial and final visual acuity levels, injury type (penetrating injury, globe rupture, perforating injury, and intraocular foreign body injury), injury localization (zone 1 = within the corneal and/or limbal area, zone 2 = within the scleral area extending 5 mm back from the limbus, and zone 3 = within the area posterior to zone 2), injury cause [metal objects (fork, knife, needle), broken glass, blunt objects (ball, punch), pen-pencil, and unidentified objects], and accompanying ocular findings of the groups were detected, and comparisons were done. Additionally, effects of age, time between trauma and surgery, OTS, injury size, follow-up time, initial LVA, injury type, and injury zone on final LVA were analyzed in both groups.

RESULTS

Mean age was 9.1 ± 2.0 years. There were 151 males and 72 females. Compared to group 1, group 2 had better initial and final visions (1.21 ± 0.26 vs 0.60 ± 0.28, p < 0.001 for initial LVA; 1.00 ± 0.32 vs 0.30 ± 0.13, p < 0.001 for final LVA), greater OTS (1.72 ± 0.53 vs 3.73 ± 0.61, p = 0.025), and smaller injury size (10.4 ± 3.5 vs 5.8 ± 2.4 mm, p = 0.002). Globe rupture (p = 0.015) and relative afferent pupillary defect (RAPD) (p = 0.037) were higher in group 1, while penetrating injury (p = 0.044), zone 1 involvement (p = 0.038), and metal object injury (p = 0.041) were higher in group 2. Based on multivariate analysis, the presences of globe rupture (p = 0.024) and RAPD (p = 0.035), the involvement without zone 1 (p = 0.042), and the injury without metal object (fork, knife, needle) (p = 0.046) were associated with poor final vision. Final LVA (for group 1 and group 2) was negatively correlated with OTS (r =  - 0.398, p = 0.037; r =  - 0.369, p = 0.040), while positively correlated with injury size (r = 0.412, p = 0.031; r = 0.318, p = 0.046) and initial LVA (r = 0.335, p = 0.043; r = 0.402, p = 0.034).

CONCLUSION

In our study, poor prognostic factors affecting final vision were low OTS, poor initial vision, the presences of globe rupture and RAPD, the large injury size, the involvement without zone 1, and the injury without metal object (fork, knife, needle).

Validation of the Retinal Detachment after Open Globe Injury (RD-OGI) Score as an Effective Tool for Predicting Retinal Detachment

PURPOSE

The Retinal Detachment after Open Globe Injury (RD-OGI) Score is a clinical prediction model that was developed at the Massachusetts Eye and Ear Infirmary to predict the risk of retinal detachment (RD) after open globe injury (OGI). This study sought to validate the RD-OGI Score in an independent cohort of patients.

DESIGN

Retrospective cohort study.

PARTICIPANTS

The predictive value of the RD-OGI Score was evaluated by comparing the original RD-OGI Scores of 893 eyes with OGI that presented between 1999 and 2011 (the derivation cohort) with 184 eyes with OGI that presented from January 1, 2012, to January 31, 2014 (the validation cohort).

METHODS

Three risk classes (low, moderate, and high) were created and logistic regression was undertaken to evaluate the optimal predictive value of the RD-OGI Score. A Kaplan-Meier survival analysis evaluated survival experience between the risk classes.

MAIN OUTCOME MEASURES

Time to RD.

RESULTS

At 1 year after OGI, 255 eyes (29%) in the derivation cohort and 66 eyes (36%) in the validation cohort were diagnosed with an RD. At 1 year, the low risk class (RD-OGI Scores 0-2) had a 3% detachment rate in the derivation cohort and a 0% detachment rate in the validation cohort, the moderate risk class (RD-OGI Scores 2.5-4.5) had a 29% detachment rate in the derivation cohort and a 35% detachment rate in the validation cohort, and the high risk class (RD-OGI scores 5-7.5) had a 73% detachment rate in the derivation cohort and an 86% detachment rate in the validation cohort. Regression modeling revealed the RD-OGI to be highly discriminative, especially 30 days after injury, with an area under the receiver operating characteristic curve of 0.939 in the validation cohort. Survival experience was significantly different depending upon the risk class (P < 0.0001, log-rank chi-square).

CONCLUSIONS

The RD-OGI Score can reliably predict the future risk of developing an RD based on clinical variables that are present at the time of the initial evaluation after OGI.

Successful Management in a Case of Traumatic Retinal Detachment due to Open Globe Injury Using Microincisional Vitrectomy

Background

Retinal detachment (RD) following ocular trauma often results in guarded visual prognosis and sometimes leads to loss of the eye. With the advent of microincisional vitrectomy surgery and the development of surgical techniques, the management of ocular trauma has been transformed.

Case Presentation

A 34-year-old man sustained an open globe injury from fragmented glass at work. He received primary repair and another follow-up surgery 9 days later, including vitrectomy, silicone oil tamponade, and lensectomy for RD and traumatic cataract at another medical center. However, his retina was totally detached and completely curled up in a roll with choroid on display when he was seen by us 1 month later. He was managed with vigilant and patient peeling and unfolding of the retina using a 23-gauge forceps and silicone oil tamponade, and achieved anatomical success and preservation of his eye at 6-month follow-up.

Conclusions

This report demonstrates that even in cases which appear to be hopeless at presentation, the surgeon's perseverance and surgical technique can salvage an eye that may otherwise be phthisical. It also encourages retinal surgeons to use microincisional vitrectomy to manage severe traumatic RD.

OUTCOMES OF RETINAL DETACHMENT REPAIR AFTER POSTERIOR OPEN GLOBE INJURY

PURPOSE

To report outcomes of retinal detachment (RD) repair following posterior open globe injury.

METHODS

This retrospective, consecutive case series examined patients who underwent RD repair following Zone II and/or III open globe injury repair between January 1, 2007 and October 31, 2013. Patients with <3 months of follow-up since their last vitreoretinal surgery, and those who underwent pars plana vitrectomy (e.g., for intraocular foreign body) during their initial open globe injury repair were excluded.

RESULTS

Of 30 patients who met inclusion criteria, reattachment of the retina was achieved in 25 (83%) during the first vitreoretinal surgical procedure and 5 (17%) were deemed inoperable intraoperatively. Ten patients (30%) developed recurrent RD, and 8 underwent additional surgery. At last follow-up, reattachment was observed in 4 of these 8. The overall rate of final reattachment was 63% (19 patients). The mean number of surgeries for RD was 1.5 (range, 1-3). Fifteen patients (50%) achieved final visual acuity of counting fingers or better. Mean follow-up from the last vitreoretinal surgery was 23 months (range, 3-52).

CONCLUSION

Although RD following posterior open globe injury confers a grave prognosis, successful anatomic reattachment of the retina was achieved in the majority of patients in this series, with half achieving ambulatory vision.

Traumatic retinal detachment--the difficulty and importance of correct diagnosis

Accurate characterization of a retinal detachment as traumatic is often difficult, but is important because it may instigate a careful search for occult coexistent traumatic pathology, affect the prognosis and the treatment of both eyes, influence insurance coverage benefits and medical-legal determinations, and is essential for epidemiologic studies. We review the epidemiology and pathophysiology of traumatic retinal detachment, common obstacles to correct diagnosis, diagnostic guidelines, and outline categories of traumatic causal relationships. Because there is no generally accepted definition of traumatic retinal detachment, we offer a practical one. Categorization as traumatic should be based on the particular history and physical examination rather than epidemiologic criteria.