Prognostic Indicators for No Light Perception After Open-Globe Injury: Eye Injury Vitrectomy Study

KANG FENG, YUN TAO HU, AND ZHIZHONG MA To describe ocular characteristics, surgical interventions, and anatomic and visual outcomes of traumatized eyes with no light perception (NLP) following open-globe injury and to investigate prognostic predictors for NLP cases after open-globe injury. ● DESIGN: Interventional case series study. ● METHODS: Thirty-three traumatized eyes with NLP were selected from the Eye Injury Vitrectomy Study database, a hospital-based multicenter prospective cohort study. Inclusion criteria were NLP cases following openglobe injury with outcomes of anatomic restoration, phthisis bulbi, or enucleation. Exclusion criteria were cases with missing records, undergoing vitrectomy after injury at nonparticipating hospitals, direct optic head injury, endophthalmitis, and hypotonous or silicone oil– sustained eyes. All cases underwent vitreoretinal surgery or enucleation after exploratory surgery and were followed up for at least 6 months. Two outcomes were assessed: favorable outcome (anatomically restored eye globes with light perception [LP] or better vision) and unfavorable outcome (NLP, phthisis bulbi, or enucleation). ● RESULTS: The following 7 risk factors were significant between the 2 groups: rupture (P ‫ ؍‬.021); open globe III (P ‫ ؍‬.046); scleral wound >10 mm (P ‫ ؍‬.001); ciliary body damage (P < .001); severe intraocular hemorrhage (P ‫ ؍‬.005); closed funnel retinal detachment or retinal prolapse (P ‫ ؍‬.005); and choroidal damage (P ‫ ؍‬.001). ● CONCLUSIONS: These 7 risk factors are possible predictors of poor prognosis. Traumatized eyes with NLP can be anatomically restored with LP or better vision if vitreoretinal surgery is attempted, and a favorable anatomic and visual outcome is increased by having a decreased number of these risk factors. (Am J Ophthalmol 2011;152:654 – 662. © 2011 by Elsevier Inc. All rights reserved.)
● PURPOSE:

mia, many ophthalmologists usually select primary enucleation for traumatized eyes with NLP.7,8 With the advancement of vitreoretinal surgery, some traumatized eyes with NLP, which would have previously been enucleated, are now saved and recover light-perception (LP) or better vision. When performing exploratory surgery on traumatized NLP cases, clinicians can now make a choice between vitreoretinal surgery and enucleation according to the ocular findings. However, few published reports describe in detail the intraocular characteristics, surgical interventions, and outcomes of traumatized eyes with NLP following open-globe injury. Further, because of a lack of prognostic indicators, there are no decision-making guidelines that can be used during exploratory surgery in order to make an accurate assessment of prognosis. In this study, we described the ocular characteristics, surgical interventions, and the anatomic and visual outcomes of 33 traumatized NLP cases following open-globe injury and tracked the prognostic indicators for traumatized eyes with NLP vision.

METHODS
CASES IN THIS STUDY WERE SELECTED FROM THE EYE IN-

O
654

PEN-GLOBE INJURY IS ONE OF THE MOST COMMON

worldwide causes of monocular visual impairment and blindness.1– 4 Open-globe injury that causes no light perception (NLP) typically carries a dismal prognosis.5,6 Considering the risk of sympathetic ophthal-

Accepted for publication Apr 14, 2011. From the Peking University Eye Center, Peking University Third Hospital, Beijing, People’s Republic of China. Inquiries to Zhizhong Ma, Peking University Eye Center, Peking University Third Hospital, Huayuan North Street 49, Haidian, Beijing 100191, People’s Republic of China; e-mail: puh3_yk@bjmu.edu.cn

jury Vitrectomy Study database, which began in January 1997. The Eye Injury Vitrectomy Study is a hospitalbased multicenter prospective cohort study whose purpose is to investigate the epidemiology, intervention of vitreoretinal surgery, and prognosis of severe eye injury. Six tertiary referral hospitals in China have successively participated in it. All injured patients in the database consented to enroll in the Eye Injury Vitrectomy Study. Its inclusion criteria were patients who suffered from severe eye injury and were treated with vitreoretinal surgery, enucleation, or evisceration. Exclusion criteria were patients with an eye injury who did not need vitreoretinal surgical intervention. After patient demographics were obtained at admission, all initial ophthalmic examinations of the injured patients were conducted and reviewed by the chief of staff, and findings were confirmed by the chief surgeon before surgery. Information including patient age, sex, involved eye, best-corrected visual acuity (BCVA) after injury, and open-globe repair was recorded on a “Register of Eye Injury” form. Type and zone of injury conform to the recommendations of the United States Eye Injury Registry
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the subretinal and suprachoroidal spaces connected with one another. ciliary body detachment. almost all of the vitreous was lost when the open-globe injury occurred. ones that underwent vitreoretinal surgery after injury at nonparticipating hospitals. open globe III. choroidal damage included choroidal laceration. All injured patients who had documented NLP in the emergency room or other nonparticipating hospitals were referred to and examined by at least 2 senior trauma staff ophthalmologists after admission. or enucleation. intraocular foreign body (IOFB).and the International Society of Ocular Trauma (Birmingham Eye Trauma Terminology [BETT9]) and “A System for Classifying Mechanical Injuries of the Eye. 33 traumatized eyes with NLP (33 patients) met the study’s outcome criteria of anatomically restored eyes. 655 Zone of injury. Intraocular hemorrhage. ciliary process atrophy. choroidal incarceration. especially following an eyeball rupture. Lens or iris is fully prolapsed out of the globe (missing or under the conjunctiva) at the time of injury. which was confirmed during exploratory surgery. and anatomic outcome was recorded at outpatient follow-up after no less than 6 months. sclera. and those with direct optic head injury. so the hemorrhage was actually accumulated within the 2 gaps. ● STUDY TERM DEFINITIONS: NLP. When the choroidal laceration occurred. direct injury of optic nerve head. which was confirmed during exploratory surgery. The prolapsed vitreous dragged the whole retinal incarceration into the wound tract. the data were excluded from this cohort. forming a closed funnel. Denmark). almost all the vitreous prolapsed because of a sudden drop of IOP. A cross-check for errors was conducted by 2 data entry clerks. Defined as a hemorrhage in the suprachoroidal space of sufficient volume to cause extrusion of the intraocular contents of the eye or to force the inner retinal surfaces into apposition due to a sharp drop of IOP after onset of the open-globe injury. Closed funnel retinal detachment. endophthalmitis. iris. Choroidal damage. In this study. Follow-up information. Severe intraocular hemorrhage was defined as a hemorrhage too dense to allow visualization of the optic disc and identification of the intraocular tissues. ciliary body defect. Large scleral wound. choroidal detachment. ciliary body damage included ciliary epithelium detachment. 4 PROGNOSTIC INDICATORS FOR OPEN-GLOBE INJURED EYES WITH NLP . which was examined during open-globe repair or exploratory surgery. Lens or iris extrusion. phthisis bulbi. forming a closed funnel.”10 Cornea. choroid. tamponade of vitreous cavity. Massive suprachoroidal hemorrhage. The baseline and follow-up sheets were collected and data were input in the Eye Injury Vitrectomy Study electronic database using Epidata (The EpiData Association. wound involvement is isolated to the cornea or corneoscleral limbus. ciliary body. an intraocular hemorrhage included a vitreous hemorrhage. In total. In this study. The exclusion criteria were hypotonous or silicone oil– sustained cases. BCVA and intraocular pressure (IOP) at the last visit. Ciliary body damage. VOL. and the hemorrhage accumulated in the subretinal space. In some patients. which was confirmed during open-globe repair or exploratory surgery. As a final step. NO. If a variable could not be identified or was missing in the record. full-thickness wound is posterior to open globe II. and choroidal defect. In this study. and a follow-up period of less than 6 months. In open-globe injured eyes. fullthickness wound involves the sclera no more posterior than 5 mm from the corneoscleral limbus. The zone of injury is defined by location of the most posterior full-thickness aspect of the globe opening according to The Ocular Trauma Classification Group:10 open globe I. 152. In addition. The prolapsed vitreous dragged the whole retinal incarceration into the wound tract. NLP vision was confirmed by the chief surgeon prior to exploratory surgery. NLP vision was determined by an examination using an indirect ophthalmoscope with the highest-intensity light while the fellow eye was fully occluded. In this study. 2009. retina. a subretinal hemorrhage. and formation of ciliary membrane. Hence. Closed funnel retinal detachment was diagnosed during exploratory surgery. there were 72 NLP eyes post open-globe injury in the Eye Injury Vitrectomy Study database. the inclusion criteria were NLP cases following open-globe injury. it was quite difficult to discern which types of hemorrhage were in an injured eye globe with severe intraocular tissue disorder. and a suprachoroidal hemorrhage. details of the vitreoretinal surgery and any subsequent surgical procedures and nonsurgical interventions were also recorded. we considered it more appropriate to refer to this as an “intraocular hemorrhage. open globe II. Odense. A large scleral wound was defined as a scleral wound length of 10 mm or more. intraocular hemorrhage. lens. These injured eyes did not include cases of missing records. As of December 31. choroidal rupture. including the follow-up period. and endophthalmitis were examined and assessed during open-globe repair or exploratory surgery and recorded as baseline information on the “Register of Eye Injury” form by the chief surgeon. Under such circumstances.” which was confirmed during globe exploration.

HM ϭ hand movement. TSD. endolaser and perfluorocarbon were used in cases that required a retinal operation. UF. . MP ϭ membrane peeling. TKP ϭ temporary keratoprosthesis. PVR ϭ proliferative vitreoretinopathy. b All cases underwent 20-gauge PPV. C3F8 Rx.656 TABLE 1. Rx. SO MP. Zone II: full-thickness wound involves the sclera no more posteriorly than 5 mm from the corneoscleral limbus. SO ϭ silicone oil. RD ϭ retinal detachment. F/U ϭ period of follow-up. MP. and Visual Outcomes of Traumatized Eyes With No Light Perception After Open-Globe Injury in Favorable Outcome Group Time to PPV (days) Ciliary Body Damage No Age (years) Type of Injury Zonea Corneal/Scleral Wound (mm) Extrusion of Lens/Iris Retina PVR Choroidal Damage Severe IOH Main Surgical Interventionsb F/U (months) Final BCVA 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 39 19 41 37 26 8 35 27 37 28 36 46 49 37 21 41 41 30 Perforating Penetrating Rupture Rupture Rupture Perforating Perforating Rupture Penetrating Rupture Rupture Rupture Rupture Perforating IOFB Rupture Penetrating Rupture III II III II II II III III III III III III III II I III II III 3 3 3 3 4 5 5 10 10 11 12 14 27 30 30 42 45 52 Yes / Ͻ10 No / Ͻ10 Yes / Ͻ10 No / Ͻ10 No / Ͻ10 No / Ͻ10 Yes / Ն10 No / Ͻ10 No / Ն10 No / Ͻ10 No / Ն10 No / Ն10 No / Ն10 Yes / Ͻ10 Yes / No Yes / Ն10 Yes / Ͻ10 Yes / Ͻ10 Ϫ/Ϫ Ϫ/Ϫ Ϫ/Ϫ Ϫ/Ϫ Ϫ/Ϫ Ϫ/Ϫ Ϫ/Ϫ ϩ/Ϫ Ϫ/Ϫ Ϫ/Ϫ ϩ/ϩ Ϫ/Ϫ Ϫ/Ϫ Ϫ/Ϫ Ϫ/Ϫ Ϫ/Ϫ Ϫ/Ϫ Ϫ/Ϫ Ϫ Ϫ Ϫ Ϫ ϩ ϩ Ϫ ϩ Ϫ Ϫ ϩ Ϫ ϩ Ϫ Ϫ ϩ Ϫ Ϫ RD F-RD RD RD RD RD RD RD RD F-RD F-RD RD F-RD RD RD RD RD F-RD Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ ϩ Ϫ Ϫ Ϫ ϩ ϩ ϩ ϩ ϩ ϩ Ϫ Ϫ ϩ ϩ ϩ Ϫ Ϫ ϩ ϩ Ϫ ϩ ϩ ϩ Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ ϩ ϩ Ϫ ϩ Ϫ Ϫ Ϫ Ϫ ϩ Ϫ Ϫ Lx. Rx. C3F8 MP. UF. Rx. CF ϭ counting fingers. Ocular Characteristics. SO TKP. F-RD ϭ closed funnel retinal detachment. UF. Rx ϭ retinotomy or retinectomy. Lx ϭ lensectomy. C3F8 Lx. C3F8 Lx. LP ϭ light perception. Rx.5’ CF 0. C3F8 Rx. UF ϭ unfold closed funnel retinal detachment. SO MP. Surgical Interventions. TSD ϭ trans-scleral drainage. Rx. IOFB ϭ intraocular foreign body. a Zone I: wound involvement is isolated to the cornea or corneoscleral limbus. C3F8 C3F8 Lx. Rx. MP. SO 6 6 29 9 11 7 6 7 14 10 47 7 11 6 7 7 6 6 CF 1’ 20/160 LP CF 0. Rx. Rx.5’ 20/100 LP AMERICAN JOURNAL OF OPHTHALMOLOGY OCTOBER 2011 BCVA ϭ best-corrected visual acuity. IOH ϭ intraocular hemorrhage.2’ 20/500 HM 20/50 CF 0. UF.5’ CF 0.5’ 20/40 LP 20/160 LP 20/320 CF 0. SO MP. SO C3F8 Lx. SO MP. Zone III: full-thickness wound is posterior to zone II. PPV ϭ pars plana vitrectomy. C3F8 TSD. C3F8 Lx. C3F8 UF.

Rx. MP. UF. C3F8 TKP. C3F8 SB. AR ϭ anatomic restoration. UF. a Zone II: full-thickness wound involves the sclera no more posteriorly than 5 mm from the corneoscleral limbus. Rx ϭ retinotomy or retinectomy. PVR ϭ proliferative vitreoretinopathy. Lx ϭ lensectomy. b All cases underwent 20-gauge PPV except for cases 1. EN ϭ enucleation. C3F8 MP. SO ϭ silicone oil. TKP ϭ temporary keratoprosthesis. PPV ϭ pars plana vitrectomy. TSD. UF ϭ unfold closed funnel retinal detachment. and Anatomic Outcomes of Traumatized Eyes With No Light Perception After Open-Globe Injury in Unfavorable Outcome Group Time to PPV (days) Corneal / Scleral Wound (mm) Ciliary Body Damage Age (years) Type of Injury Zonea Extrusion of Lens / Iris Retina PVR Choroidal Damage Severe IOH Main Surgical Interventionsb F/U (months) Outcome 1 2 3 4 5 6 7 8 9 10 11 12 27 38 51 25 32 41 33 25 22 47 13 23 Rupture Rupture Penetrating Rupture Rupture Rupture Rupture Rupture Rupture Rupture Rupture Rupture III III III III III III III III III III III III 7 9 10 12 12 13 13 13 14 16 16 18 No / Ն10 No / Ն10 Yes / Ն10 No / Ն10 Yes / Ն10 No / Ն10 No / Ն10 Yes / Ն10 No / Ն10 No / Ն10 No / Ն10 Yes / Ն10 Ϫ/Ϫ Ϫ/Ϫ Ϫ/Ϫ ϩ/ϩ Ϫ/Ϫ ϩ/ϩ Ϫ/ϩ Ϫ/Ϫ ϩ/ϩ Ϫ/Ϫ Ϫ/Ϫ ϩ/Ϫ ϩ ϩ ϩ ϩ ϩ ϩ ϩ ϩ ϩ ϩ ϩ ϩ All-pro F-RD F-RD All-pro F-RD F-RD F-RD RD All-pro All-pro RD F-RD Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ ϩ ϩ ϩ ϩ ϩ ϩ ϩ ϩ ϩ ϩ ϩ ϩ ϩ ϩ ϩ Ϫ ϩ ϩ ϩ ϩ ϩ ϩ Ϫ ϩ Ϫ ϩ PROGNOSTIC INDICATORS FOR 13 10 Rupture III 19 Yes / Ն10 ϩ/Ϫ ϩ F-RD ϩ ϩ ϩ 14 15 13 21 Rupture Rupture III II 24 49 Yes / Ն10 Yes / Ͻ10 Ϫ/Ϫ Ϫ/Ϫ ϩ ϩ RD F-RD ϩ ϩ ϩ ϩ ϩ Ϫ Enucleation Lx. endolaser and perfluorocarbon were used in cases that required a retinal operation. Rx. UF. Surgical Interventions. F-RD ϭ closed funnel retinal detachment. NLP ϭ no light perception. 4 No TABLE 2. SO Enucleation TKP. C3F8 – 6 – 7 7 – 7 9 8 8 79 6 EN PB EN EN PB EN EN AR(NLP) EN PB PB EN OPEN-GLOBE INJURED EYES WITH NLP 657 5 EN 7 7 EN AR(NLP) All-pro ϭ all prolapsed. 152. and 6. 3. F/U ϭ period of follow-up. NO. SO SB. SO C3F8 Lx. RD ϭ retinal detachment. Rx.VOL. Zone III: full-thickness wound is posterior to zone II. MP. C3F8 MP. UF. IOH ϭ intraocular hemorrhage. C3F8 MP. Rx. Ocular Characteristics. UF. MP ϭ membrane peeling. SO Lx. PB ϭ phthisis bulbi. UF. SB ϭ scleral buckle. Rx. TSD ϭ trans-scleral drainage. SO Enucleation Lx. .

or cases that underwent enucleation. ciliary body damage. IOP Ͻ 8 mm Hg. The statistical level of significance was preset at .2 years in the favorable outcome group.3) 14 (77. type and zone of injury. ciliary body damage. 658 AMERICAN JOURNAL OF Because the number of cases was less than 40. Zone II: full-thickness wound involves the sclera no more posteriorly than 5 mm from the corneoscleral limbus.2) 1 (6. Favorable outcome is defined as anatomically restored eyes whose final BCVA is LP or better after 6 months of follow-up. The number of eyes in the favorable outcome group and the unfavorable outcome group was 18 and 15 respectively. and choroidal damage according to 2 main outcomes: favorable and unfavorable. closed funnel retinal detachment or retinal prolapse.7) 14 (93. Silicone oil–sustained eyes. the OPHTHALMOLOGY OCTOBER 2011 .0 100. b Others include penetrating. c Zone I: wound involvement is isolated to the cornea or corneoscleral limbus. corneal and scleral wound.3) 12 (66.7 11. closed funnel retinal detachment or retinal prolapse. perforating.046 0 1 2 3 4 5 6 7 3 3 2 4 2 2 1 1 100.1) 12 (66.9) 11 (61.7) 14 (93. Favorable outcome. Hypotonous eyes.0 100. or only local detachment that does not require surgery. and 33 injured eyes (33 patients) met the criteria for the evaluation of prognostic indicators.7 16. c Anatomically restored eyes with final vision of no light perception.4) 3 (20.7) 6 (33. Unfavorable outcome is defined as cases of phthisis bulbi or cases that underwent enucleation. ● STATISTICAL ANALYSIS: Anatomically restored eyes. the youngest patient and the oldest patient were 8 and 49 years old respectively.3) .005 13 (72.0 33.3) 1 (6. or inoperable retinal detachment. Zone III: full-thickness wound is posterior to zone II.0 66.0 statistical software (SPSS Inc. open globe III. Determined after a period of follow-up no less than 6 months.05 and all the eligible data were analyzed using SPSS version 17.0) .7) 14 (93. and choroidal damage.7 66. Silicone oil–sustained eyes refers to eyes injected with silicone oil because of an incomplete treatment. vitreous cavity filled with aqueous humor.7) 11 (73.1 0 0 0 0 1 1 5 8 .0) 15 (100. scleral wound Ն10 mm.7) 6 (33.TABLE 3. severe intraocular hemorrhage.0 .3 83. the Fisher exact test was used to evaluate the variables including interval of time between injury and vitrectomy.005 .8) 10 (55. Outcomes of Open-Globe Injured Eyes With No Light Perception by Assorted Risk Factors Favorable Outcomeb Risk Factors a Unfavorable Outcomec Count Row (%) Count Row (%) Pa Type of injury Othersb Rupture Zone of injuryc Zone I / Zone II Zone III Scleral wound (mm) None / Ͻ10 Ն10 Ciliary body Normal Damage Intraocular hemorrhage Mild / Moderate Severe Closed funnel RD or retinal prolapse No Yes Choroid Normal Damage 8 (44.4) 10 (55. IOP Ն 8 mm Hg. extrusion of iris or lens. intraocular foreign body. The mean patient age was 28.001 a Risk factors include rupture.0 .0) 15 (100.3 88.2) 5 (27.3 33. retinal attachment. Unfavorable outcome.9 .0 .0) 0 (.001 RD ϭ retinal detachment. USA).3) 1 (6. vitreous cavity filled with aqueous humor that exhibits the Tyndall effect owing to the presence of damage to the blood-ocular barrier.8) 4 (22.3) 0 (. proliferative vitreoretinopathy (PVR). Determined after a period of follow-up no less than 6 months.0 100.6) 8 (44.1 years in the unfavorable outcome group. Seven Prognostic Factors for Outcomes of Open-Globe Injured Eyes With No Light Perception Count (Column %) Favorable Outcome Unfavorable Outcome TABLE 4. Chicago. a P values calculated with Fisher exact test.001 .021 . severe intraocular hemorrhage. Ͻ. lower IOP (Ͻ8 mm Hg). The mean patient age was 33. b Anatomically restored eyes with final vision of light perception or better.6) 7 (38. Anatomically restored eyes whose final BCVA is NLP after 6 months of follow-up are also considered as an unfavorable outcome. RESULTS ● DEMOGRAPHICS OF CASES: A total of 72 cases with NLP after open-globe injury were reviewed during this study period. Illinois.0) 4 (26. phthisis bulbi.0) 12 (80. unrecovered retinal detachment.

P ϭ . The average follow-up period of the unfavorable outcome group was 12. 28 had vision worse than 20/400. which implied no further therapeutic intervention previously. The proportion of eyes with favorable outcome and useful vision (better than 20/200) in the entire series of 72 cases was 25% (18/72) and 6. The longest follow-up time was 78. 152. open globe III (P ϭ . As to visual outcome. the Fisher exact test showed that a rupture (P ϭ . especially patients from remote and rural areas.021). which mainly depended on the referral time of patients to the participating hospitals. These hospitals treat a large number of referred ocular injury patients from north and south China each year. large scleral wound (P ϭ . however. is still a challenge for ophthalmologists. 1 eye retained vision of 20/320 (severe visual impairment). 4 eyes became phthisical after 6 to 79 months. In this study. there were 38 silicone oil– sustained eyes and 1 hypotonous eye.932. Rupture. In some cases. severe intraocular hemorrhage (P ϭ . closed funnel retinal detachment or retinal prolapse (P ϭ . NO. many clinicians advocate primary enucleation for traumatized eyes with NLP.001). The average follow-up period of the favorable outcome group was 11. 20 eyes were anatomically restored with follow-up visual acuity (VA) ranging from NLP to 20/40. In the 39 excluded cases. silicone oil cannot be evacuated in some silicone oil–sustained eyes because the detached retina does not reattach due to extensive fibrosis or scarring of the retina.001) (Table 4). there is an uneven distribution of medical resources and a poor level of basic hospital treatment in rural areas. 6 eyes were enucleated at a subsequent surgical procedure after follow-up period of 5 to 8 months. it has been shown that the occurrence of sympathetic ophthalmia is very small. 4 PROGNOSTIC INDICATORS FOR indicators for the NLP eyes after open-globe injury.001) predicted an unfavorable anatomic and visual outcome for traumatized eyes with NLP (Table 3).001). The shortest follow-up period was 5.9% (5/72) respectively. and 3 eyes were enucleated after exploratory surgery. except for 3 cases that underwent primary enucleation after globe exploration.2. and 15 eyes had NLP. There was a significant correlation between the probability of a favorable outcome and the number of risk factors when the Spearman rank correlation test was employed (correlation coefficient ϭ Ϫ0. Based on the clinical observation and authors’ experience. it might become phthisical or restore intraocular pressure of 8 mm Hg or more after a long period of follow-up. we have identified 33 cases with verified NLP following open-globe injury that achieved their final outcomes. Silicone oil–sustained eyes or hypotonous eyes were excluded for the following reasons: Under normal circumstances.9 months. During exploratory surgery. and some patients are reluctant to seek medical treatment until the status of their injured eyes is unbearable. silicone oil was evacuated 3 months after vitreoretinal surgery. the hypotonous eye’s status is unstable. 12 eyes had vision worse than 20/400 (profound visual impairment). contralateral sympathetic ophthalmia did not occur in any of the patients during the follow-up period. the retina did not attach after 3 months or onset of PVR. 5 eyes recovered vision better than 20/200 (visual impairment). and 9 had NLP (including 1 hypotonous eye). and investigated the factors that significantly predicted prognosis. a refill of silicone oil into the eye globe is necessary for reattaching the retina after membrane peeling and photocoagulation. The exclusion of patients is based on both their preoperative characteristics and their postoperative stable outcomes. Considering the poor prognosis and probability of sympathetic ophthalmia. Therefore. Six tertiary referral hospitals participated in this study. Some scholars11 believe. According to Moshfeghi’s standards. enucleation. Based on current published reports. that injured eyes with NLP can be repaired and have a functional outcome.4 months). ● ANATOMIC AND VISUAL OUTCOMES OF EYES WITH NLP: Of the 33 cases. and large scleral laceration (Ն10 659 OPEN-GLOBE INJURED EYES WITH NLP . that is. Vitreoretinal surgery can enable injured patients to retain their own eye globes even if LP or better vision cannot be restored. In China. One eye recovered vision better than 20/200.046). open globe III.9 months (Tables 1 and 2). clinicians should make a rational choice of surgical interventions according to the ocular characteristics of traumatized NLP cases. In addition. or phthisis.005). In this study. so eyes with NLP can sustain long-term follow-up and be observed without the implementation of enucleation or evisceration. ● PROGNOSTIC INDICATORS: DISCUSSION TREATING TRAUMATIZED EYES WITH NLP VISION AFTER open-globe injury.005).12–15 In our study. 1 retained vision of 20/250. and choroidal damage (P ϭ .8 open-globe injury with NLP vision is the indication for enucleation. The main points of this study are evaluation of whether LP or better vision can be restored and whether anatomic restoration can be achieved in injured eyes with NLP.youngest and the oldest were 10 and 51 years old respectively.2 months (ranging from 6 to 47. This study shows there are 7 ocular characteristics that correlate with the final anatomic and visual outcomes. there are no accepted prognostic VOL. Furthermore. ciliary body damage (P Ͻ . The delays were almost all attributable to the limitation of economic conditions and medical resources.4 months for 1 case that was enucleated at a subsequent surgical procedure after a period of follow-up. however. The shortest and longest time interval between injury and exploratory surgery in these cases is 3 and 52 days respectively.

In addition. There are not many published articles on this factor. the greater the probability of a no-vision outcome. ciliary body damage occurred in all the unfavorable outcome group cases. There were 2 cases (11. Wounds located posterior to the equator and blunt injury in open globes predict a poor final visual outcome. The difference between a massive suprachoroidal hemorrhage caused by trauma and one that occurs during corneal transplant surgery or neovascular glaucoma is that there is a choroidal laceration in open-globe severe eye injuries. 1 injured eye was enucleated after exploratory surgery.4%. the occurrence of closed funnel retinal detachment is often accompanied by choroidal damage and extensive ciliary body damage in eyes with NLP following openglobe injury. and ciliary body. So it appears that ciliary body damage after injury is destructive to both visual outcome and anatomic outcome. all cases had direct choroidal damage after open-globe injury except 1 case that had a choroidal rupture following blunt injury (rupture. closed funnel retinal detachment or a prolapsed retina is statistically significant (P ϭ . Articles have been published about suprachoroidal hemorrhage during cataract surgery. Rahman and associates16 reported that a blunt mechanism of open-globe injury (rupture) on presentation was a significant risk factor that was associated with eventual enucleation. ciliary body damage. which includes severe intraocular tissue injury. choroidal damage. Research by Matthews and associates7 also indicates that significant predictive factors for final visual outcome include the location of the wound and the mechanism of injury. and it did not occur in cases with 3 or fewer risk factors. 2/18) in the favorable outcome group and 8 cases (53.3%) of the favorable outcome group (P Ͻ . traumatized eye globes with open globe III usually present serious ocular injury characteristics. severe intraocular hemorrhage. however. 660 AMERICAN JOURNAL OF In this study. for it is usually followed by a massive suprachoroidal hemorrhage.3%. In our study. The eyes in these 4 cases were more severely injured than the others.21–23 glaucoma surgery.31 The authors consider that the choroidal hemorrhage is the main source of dense intraocular hemorrhage in severely injured eyes. Moreover. In open-globe injured eyes with choroidal lacerations. severe intraocular hemorrhage is also a risk factor of unfavorable outcome. It has been reported that choroidal hemorrhages are primarily caused by the vortex vein tears. Multivariate analysis in Rofail and associates’ report3 shows injured eyes with a large laceration (Ͼ10 mm) and rupture are prone to obtain an unfavorable final visual acuity. but also a reflection of the seriousness of the ocular damage. closed funnel retinal detachment or retinal prolapse. choroidal damage occurred in all cases of the unfavorable group and 8 cases (44. retina. and a large scleral wound are strong predictors of an eventual unfavorable outcome. surgical reattachment of the choroid is very difficult because the choroidal tissue and blood vessels contain abundant collagen and elastic fibers.27 There are also publications about choroidal ruptures.020). a rupture is often accompanied by a large scleral laceration and a prolapse of the intraocular contents following sudden drop of intraocular pressure. According to the authors’ clinical observation and experience. and an injured eye globe could not be anatomically restored if the ciliary body was seriously damaged. In this study. which constrict and make the choroidal wound shorter.20 pars plana vitrectomy. which can lead to phthisis bulbi.005) between the favorable and unfavorable outcome groups. and choroidal damage are all possible predictors of OPHTHALMOLOGY OCTOBER 2011 . scleral wound Ն10 mm. These data indicate that choroidal damage is the main risk factor for an unfavorable outcome as well as the main source for a dense intraocular hemorrhage of injured eyes. Ciliary body dysfunction attributable to trauma is usually responsible for prolonged or progressive hypotony that could result in irreversible structural and functional changes in the globe. which present difficulties on wound closure and severely damage the retina and choroid. To summarize.001). open globe III. There were 4 cases of retinal prolapse in the unfavorable outcome group: 1 phthisis bulbi occurred after 8 months. so these ocular characteristics are useful in patient counseling and in clinical decision making regarding further therapeutic interventions. Schepens32 considered that persistent choroidal detachment may also be an important factor of hypotony after vitrectomy. Articles documenting poor prognosis attributable to vitreous hemorrhage are numerous.17 Furthermore. This study shows that a rupture.25 penetrating keratoplasty. open globe II). In this study. Thus. and ciliary body damage (P ϭ . 8/18) of the favorable group (P ϭ .mm) are significant factors in both the favorable and unfavorable groups. and 2 eyes were enucleated after 7 and 8 months respectively. such as to the choroid and retina.26 and massive spontaneous choroidal hemorrhage. The mechanism of a rupture is also an important predictor of outcome in Schmidt and associates’ classification and regression tree model.19 In our study. Based on clinical observation. Few published articles. the type and zone of injury and scleral laceration can be examined during open-globe repair. and the prognosis for injured eyes is much worse when they occur simultaneously. while it occurred in 6 cases (33. the more posterior the wound extends. 8/15) in the unfavorable outcome group that simultaneously had closed funnel retinal detachment.28 –30 which are mainly attributable to blunt closed-globe injury.18 A functional ciliary body is essential for retaining the eye globe.001). The authors consider that severe intraocular hemorrhage is not only a predictor of an unfavorable outcome. a condition where the globe is permanently shrunken and dysfunctional and vision is lost. document the outcome of direct damage to the choroid following open-globe injury. a rupture. open globe III.1%. severe intraocular hemorrhage usually occurs following severe damage of the intraocular contents such as the choroid. and all 4 cases were complicated by choroidal and ciliary body damage.24.

Damage control surgery in ocular traumatology.. In 4 cases (66.Z. Vitreoretinal surgery or enucleation should be carefully determined after a comprehensive assessment of the injured ocular tissues during exploratory surgery and review of the 7 risk factors for poor prognosis developed from this study. Management of the opaque media eye with no light perception. This study was approved by the review board/ethics committee of the Peking University Third Hospital. Ophthalmology 2008.34(8): 783–786. Das A. for there is possible interaction between the risk factors. A historical review of sympathetic ophthalmia and its epidemiology. 247(4):477– 483. 1999:113–124. Schmidt GW. Gurdal C. Sobaci G. 4 PROGNOSTIC INDICATORS FOR OPEN-GLOBE INJURED EYES WITH NLP 661 . all cases that had no more than 3 of the above risk factors were saved and obtained LP or better vision. Larque-Daza AB.6 Traumatized eyes with NLP. Coleman DJ.F. 211 Evidence-Based Medicine Discipline Groups. we excluded the 39 eyes (54. analysis and interpretation of the data (K.44(4):277–301. et al. Motala MI. Graefes Arch Clin Exp Ophthalmol 1996.M.T.). The funding organization had no role in the design or conduct of this research. A system for classifying mechanical injuries of the eye (globe).129(1):47–53. Orhan M. Hence. the wound of ruptured eyes often extends to open III zone. Incidence of sympathetic ophthalmia after penetrating eye injury and choice of treatment. In addition.Z. Y. Rahman I. 3. The probability of a favorable outcome was increased following a decreased number of risk factors (correlation coefficient ϭ -0.. Slezakb Z. Matthews GP. Moshfeghi AA. Kuhn F. Surv Ophthalmol 1989. A standardized classification of ocular trauma. Clin Experiment Ophthalmol 2002.34(1):1–14. 5. O’Rourke P. Brown S. Morris R. Casson RJ. In this study. 7. The Ocular Trauma Classification Group. Moreover. Mutlu FM.). Morris R. Eur J Ophthalmol 2010. A multivariate model may be developed with larger patient numbers. Treister G. Am J Ophthalmol 1997.123(6):820 – 831. 18. Visual outcome and ocular survival in patients with retinal detachments secondary to open. Hindman HB. collection of the data (Z. to ensure the accurate results of prognostic indicators. For example. Injury 2004. Andreoli CM. are not beyond repair. Applying such analysis may indicate a lack of independently statistical significance of variables in prognosis.). these eyes obtained a favorable outcome through vitreoretinal surgery. conduct of the study (K.). Visual outcomes of vitreoretinal surgery in eyes with severe open-globe injury presenting with no-lightperception vision. Kuhn F. Du Toit N.15(4):312–318. Newland HS. Murray AD.001) (Table 4). Clin Experiment Ophthalmol 2006.30(1):15–18. Erdener U.932. Aaberg TM Sr. the number of some independent variables is zero under a certain condition of the dependent variable. Enucleation for open globe injury. Rofail M. Am J Ophthalmol 2009. Maitra S. Richards J. One of the primary limitations to this study is that our data are not adaptable to multivariate analysis. Devadason D.234(6):399 – 403. The authors indicate no financial conflict of interest. Lee GA.an unfavorable outcome.F. Kuhn F. Vitreoretinal Surgery of Injured Eye. 13. Leatherbarrow B. Z. In: Alfaro DV III..7%.T. Prognostic indicators for open globe injury. as demonstrated by the acceptable outcomes of NLP cases in this study. P ϭ .F..M.20(3):578 –583. Andreoli MT.147(4): 595– 600. and review and approval of the manuscript (Z. The sample pool of 33 cases is too small with respect to the 7 independent variables.20(12):1336 –1341. Savar A. and that they might be the reason for a higher enucleation rate in traumatized eyes with NLP than injured eyes with LP or better vision. Mukai S. Beijing. 6. Four-year review of open eye injuries at the Royal Adelaide Hospital. Ophthalmic Surg Lasers 1998.Z. 15. NO.Z. Y. Involved in design of the study (Z. Cases 11 and 13).92(1):61– 63. Based on the results of this study. VOL. Yildirim E. Deadly weapon-related open-globe injuries: outcome assessment by the ocular trauma classification system. Andreoli CM. Br J Ophthalmol 2008.2%) that may become phthisical or anatomically restored after a long period. Bayer A. Maino A. 9. Heimann K. Kloek CE. 4.03-9-02).M. Diaz-Rohena R. REFERENCES 1. Surv Ophthalmol 2000. we report our results based on the entire series of 72 cases. Enucleation. Grant MP. Walker JC. Irkec M. 4/6) of injured eyes that had 4 or 5 of the aforementioned risk factors. which is relevant and much more realistic. However. K. 11. the authors recommend that every effort be made to salvage traumatized eyes with NLP. Andreoli MT. PUBLICATION OF THIS ARTICLE WAS FUNDED BY A GRANT FROM THE PEKING UNIVERSITY HEALTH SCIENCE CENTER. eds. 8. Karagul S. Am J Ophthalmol 2000. Peralta-Calvo J.115(1):202–209. 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and neuro-ophthalmology.Biosketch Kang Feng. 152. NO. VOL. clinical trials. epidemiology. 4 PROGNOSTIC INDICATORS FOR OPEN-GLOBE INJURED EYES WITH NLP 662. MD. Dr Feng completed his ophthalmology residency at General Hospital of People’s Liberation Army in Beijing.e1 . evidence-based medicine. he has been engaged in the clinical study of ocular trauma and surgical technique at Peking University Third Hospital’s Department of Ophthalmology. Beijing. China. Feng’s research and clinical interests involve ocular trauma. is currently the Attending Physician of Peking University Third Hospital’s Department of Ophthalmology. Following residency. diabetic eye disease.

He serves on the editorial boards of the Ocular Surgery News Asia-Pacific Edition and American Journal of Ophthalmology-Chinese Edition. MD. Ma’s research and clinical interests involve ocular trauma. clinical trials. 662. Currently Dr Ma is Chair of the Chinese Committee of Ocular Trauma. and the China Representative of International Society of Ocular Trauma. and diabetic retinopathy. Beijing. is currently the Professor of Ophthalmology and Chairman of Peking University Third Hospital’s Department of Ophthalmology. China.Biosketch Zhizhong Ma.e2 AMERICAN JOURNAL OF OPHTHALMOLOGY OCTOBER 2011 .

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