Advocating for Early Vitrectomy in Open Globe Injuries

Lessons learned from managing complex trauma cases in low-income settings

Ocular trauma is unfortunately an all-too-common presentation at Kabgayi Eye Unit (KEU) in Rwanda, where I work as a consultant ophthalmologist and vitreoretinal surgeon. This article is a reflection of my experience managing such cases, focusing specifically on advocating for early vitrectomy. I will not delve into the techniques of primary repair, as they are beyond the scope of this discussion.

Initial challenges

When I first arrived at KEU, there had been no vitreoretinal (VR) surgeon for two years. This gap had left a tsunami of cases with post-traumatic complications, most notably closed funnel retinal detachment with phthisis, leading to a staggering 50 percent enucleation rate in these eyes. Unfortunately, these cases confirmed what I had already observed on my arrival: the absence of timely vitrectomy left these eyes vulnerable to irreversible damage. My approach to managing these cases, including the emphasis on early vitrectomy, was shaped by insights from a VR colleague in Rwanda, whose expertise has been invaluable.

The reasons for such poor outcomes are multifactorial:

• Vitreous incarceration into the wound with fibrovascular growth on the vitreous scaffold, as demonstrated by Cleary et al. (1). This has led to the development of proliferative vitreoretinopathy (PVR), which can develop within days leading to tractional retinal detachment. Posterior vitrectomy eliminates stimulating factors for PVR and removes the scaffold for proliferation, but this should be done within the first week after trauma.

• Another important factor – less known to many – is the contraction of the lens capsule if not removed during the initial lensectomy. So, if the lens including posterior capsule is damaged and violating the vitreous, I would advocate for complete removal of the lens, including the entire bag, as contraction of the capsule can cause traction on the ciliary body and ciliary processes, inevitably contributing to phthisis bulbi.

• Lens particles, vitreous, and blood together are the perfect “recipe’’ for anterior PVR, which can also cause traction on the ciliary body.

Existing studies support my observation, with one large series reporting a 29 percent risk of retinal detachment after open globe injury, with up to 70 percent of such eyes developing retinal detachment within a month if not addressed early (2). This evidence underscored my belief that early vitrectomy is not merely a therapeutic procedure but a prophylactic one, aiming to prevent retinal detachment before it occurs.

Additionally, Chauhan et al., in a retrospective analysis of 110 trauma patients undergoing PPV that sought to emphasize the time of surgical intervention, found that same-day vitrectomy yielded the best final VA and lowest rates of PVR and enucleation, regardless of aetiology (3).

Identifying occult scleral ruptures

Before exploring surgical techniques, I must stress the importance of maintaining a low threshold for suspecting occult scleral rupture. If the mechanism of injury involves equatorial distension – such as being struck by an object that compresses the globe – clinicians should carefully evaluate for the following signs:

• poor vision

• relative afferent pupillary defect (RAPD)

• severe subconjunctival haemorrhage

• vitreous haemorrhage

• a deep anterior chamber

• suprachoroidal haemorrhage on B-scan ultrasound

Secondary repair: key steps in surgery

To prevent the catastrophic complications of delayed intervention, I advocate booking patients for posterior vitrectomy (PPV) seven days after primary repair. This timeline allows for adequate wound healing, while also minimizing the risk of complications like fibrovascular proliferation or PVR.

1. Ensure a secure primary repair. If there is any doubt about the adequacy of the initial repair, re-exploration and additional suturing are essential.
   

2. Front-to-back surgical approach:
   
   Cornea: Achieving a sufficient view is usually possible, even in the presence of corneal oedema, allowing vitrectomy to proceed. Various techniques can help improve visualization, including removing the corneal epithelium, filling the anterior chamber with viscoelastic to avoid water influx into corneal stroma, and clearing fibrin or blood from the anterior chamber. Avoiding both excessively high and low intraocular pressures is also important, as is minimizing exposure to potentially toxic drops in the preoperative period. If visualization remains inadequate despite these measures, a temporary keratoprosthesis may be considered. However, this is not available in low-income settings and is one of our contraindications for surgery when required.
   
   Iris: Preparation of the iris diaphragm is crucial, especially for eyes requiring silicone oil tamponade. I often use McCannel sutures or Siepser's knots to repair iris defects. A peripheral iridectomy may also be necessary in aphakic eyes to prevent pupillary block.
   
   A silicone oil retention suture is indispensable in cases where iris is completely missing. There are a few important points to remember about this technique: First and foremost, you need a functioning ciliary body to keep silicone oil at the back of the eye as it fills the AC with aqueous humour. Properly sealing all anterior segment wounds is vital to prevent oil migration during or after surgery, as any drop in the anterior chamber pressure towards the end of surgery is likely to cause oil to migrate to the anterior chamber and will not go back.
   
   Lens and capsule: Complete removal of the lens, including the capsule, is of paramount importance. A good tip for this: I use bimanual technique with forceps to pull the capsule centrally and stretch the zonules, then use a vitreous cutter to sever the connection to the ciliary processes. This is particularly important in young patients, where traction from pulling zonules can lead to retinal tears.
   
   Ciliary body: Clearing fibrin, blood, or vitreous from the ciliary processes is essential to prevent chronic inflammation and traction. Perform scleral indentation to ensure that the ciliary processes are free of any residual capsule.
   
   Suprachoroidal hemorrhage: If detected on B-scan, I prefer draining it before initiating vitrectomy
   

3. Vitrectomy setup and execution:
   
   23-gauge, four-port pars plana vitrectomy (PPV) with a chandelier illumination system.
   
   I usually start with an anterior chamber maintainer, even in phakic eyes, as it is usually difficult to see the position of the infusion cannula at the start of the case.
   
   Start vitrectomy slightly superonasally, to avoid cutting into the temporal retina, where the macula is located. Carefully identify the retina to prevent inadvertent injury. Patience is critical in making the first opening in the posterior hyaloid, until I clear the view to proceed further.
   
   Triamcinolone staining helps visualize residual vitreous. I induce posterior vitreous detachment (PVD) as needed and ensure its complete removal. In my experience, this is done easily in the majority of cases.
   
   I perform a bimanual peripheral vitrectomy using the chandelier system-clearing peripheral vitreous with base shaving and ensuring ciliary processes are free.
   
   Generally speaking, these patients will usually have multiple oral breaks. I usually end up doing 360-degree laser retinopexy. I have a very low threshold of using silicone oil as a tamponade.

Managing large intraocular foreign bodies (IOFBs)

In Africa, large IOFBs are unfortunately common, meaning that conventional techniques often fall short. I once encountered a large stone inside the eye, which I successfully removed using a prolene suture loop with a sliding knot. A large scleral wound, similar to the incision for manual small-incision cataract surgery, is ideal for such cases, as it allows atraumatic removal and is self-sealing.

Retinal incarceration near IOFB sites is best left alone if the macula is unaffected and the retina is otherwise attached.

Certain cases are best left unoperated to avoid accelerating phthisis or causing unnecessary pain in patients. These include situations requiring temporary keratoprostheses, failed multiple surgeries, or chronic closed-funnel detachments of long duration.

Conclusion

The primary repair of open globe injuries is just the beginning. Ensuring meticulous primary repair, removing the lens entirely, and performing early pars plana vitrectomy can significantly improve outcomes and reduce the risk of enucleation. These interventions provide hope for patients facing otherwise devastating prognoses, and underscore the critical role of early pars plana vitrectomy in managing complex ocular trauma.