Open globe trauma often presents a dilemma: enucleate an eye that has lost light perception, or risk losing the other eye to sympathetic ophthalmia. While rare, sympathetic ophthalmia has historically been a significant concern when weighing the risks and benefits of enucleation vs. posterior segment repair following a traumatic injury. Indeed, the possibility of losing the “good” eye to this potentially blinding, immune-mediated, inflammatory condition months or years later was enough to dissuade surgeons from attempting to repair the injured eye.
But times have changed, and ophthalmologists are becoming more aggressive in saving vision in eyes that were once thought to be irreparable.
“Traditionally, ophthalmologists who assessed the eye using the absence of light perception as a guidepost were more rushed to choose enucleation to reduce the risk of sympathetic ophthalmia in the fellow eye,” noted Dante J. Pieramici, MD, a vitreoretinal specialist with California Retina Consultants in Santa Barbara. “Yet today, no light perception (NLP) should not be an absolute contraindication to secondary repair.” In fact, there are many cases recorded in the United States Eye Injury Registry (www.useironline.org) that show trauma patients regaining some level of vision after posterior segment repair. They were able to maintain the eye and did not develop sympathetic ophthalmia.
Challenging Old Assumptions
Ferenc Kuhn, MD, PhD, a retina specialist who divides his time in clinical trauma management between Alabama and Hungary, placed the historical rush to enucleate in perspective.
“For most ophthalmologists, instead of viewing open globe injuries like other eye problems that could possibly benefit through timely intervention, if the eye lost light perception, it signaled the end of the world—the point of no return,” explained Dr. Kuhn. “Thus, it became a self-fulfilling prophecy. Since there was no hope in the first place, there was no need to even attempt to repair the eye. And since no repair took place, vision was inevitably lost.”
Dr. Kuhn and his colleagues found in their research that the loss of light perception did not necessarily signal hopelessness and that, in some cases, it was not a permanent state but rather a temporary one.
They injected several bovine eyes with blood and then captured the light distribution by placing a camera behind a window cut into the back of the eye. The researchers found that 97 percent of the incoming light did not reach the back of the eye; the light was partially absorbed and partially scattered by the hemorrhage.
“This told us that if you remove the blood, you may be able to remove a big portion of the problem,” Dr. Kuhn said. So he started to suggest to ocular trauma patients that there is a decent chance for some improvement. He informed patients about possible vision restoration with posterior segment repair, as well as their risk of sympathetic ophthalmia if they kept the eye. “I haven’t met too many patients who opted for enucleation—even with this risk—when there was a possibility their vision could possibly be enhanced.”
Advocate for Posterior Segment Repair
Dr. Kuhn argued that it is worthwhile to invest in posterior segment repair even if the ophthalmologist is simply trying to reverse NLP. “Going from no light to light perception is viewed as a small improvement,” he said, “but that only holds true for someone with 20/20 vision. In patients with very poor vision to begin with, just a minor improvement means a lot. It is literally a day and night difference.”
He added that “Murphy’s Law” should also be taken into consideration. If a traumatic event should happen to the good eye two years later, the second eye cannot be considered a backup if it has been enucleated. Just having light perception in the injured eye may be vital if the good eye loses vision.
“Thus, we have been recommending enucleation only if it is physically impossible to salvage the globe. And we can always do enucleation later,” Dr. Kuhn said. “However, we are trying to keep the eyeball and preserve as much function as possible with an early reconstructive surgery.”
Dr. Kuhn noted that choosing posterior segment repair often means a lot of work for an outcome that may or may not prove positive. “Realistically, you are fighting a lot for very little,” he said. “The patient often must undergo multiple surgeries and endure great pain, and it puts a lot of stress on the patient and family. On the other hand, there is only a short window of opportunity to do the actual repair or the chance is gone forever.”
To illustrate this point, Dr. Kuhn cited the case of a 65-year-old man whose wife punched him during an altercation. She landed a blow to his eye that was so severe the eye required enucleation. Nine years later, the wife hit the man again, this time in the good eye. The patient presented with a significantly damaged eye and no light perception.
“This is one of those rare, truly amazing success stories where we repaired the bad eye, and the patient actually eventually achieved reading vision. While this is not a typical success story, it is possible. But it wouldn’t be possible if we simply said, ‘Forget it’ and didn’t try,” Dr. Kuhn said.
In the Trenches
This trend toward posterior segment repair can be seen in trauma centers such as The New York Eye and Ear Infirmary, which treats the greatest number of eye injuries in New York City. Ronald C. Gentile, MD, a vitreoretinal specialist and codirector of the trauma service at NYEE noted that most ocular trauma patients are young men with injuries related to sports, work or violence.
“If restoring some vision is possible, we will do a posterior repair before an enucleation,” Dr. Gentile said. “Most cases of open globe injuries—involving rupture and laceration—require that the initial closure be done immediately.
“We prefer that the posterior segment surgery be performed three to 10 days later to allow the cornea to be clear, the vitreous hyaloid to be easier to remove and the choroid to be less congested. Also, waiting during this time period decreases the chances of intraocular hemorrhages.”
The exception to this strategy is when the patient has an intraocular foreign body, has a suspected infection or is at high risk of infection—for example, from being poked in the eye with a dirty stick or fish hook. In those cases, the posterior segment repair should be done immediately, although subsequent surgeries may be necessary.
Likewise, Dr. Kuhn advocated delaying the secondary posterior segment repair, noting that “going in earlier doesn’t bring you any substantial benefit in serious injuries, and also the likelihood of a huge intraoperative hemorrhage is higher the sooner you operate. In addition, you can talk to the patients and explore diagnostic methods to see exactly what will be necessary in terms of surgery.”
Excellent Resource: Online Registry
For Dr. Pieramici, the chance to restore vision in patients with ocular trauma is a challenge worth taking. He cited the case of a mountain climber who fell 60 feet into a ravine, smashing his face. His eye burst open, detaching the retina. Dr. Pieramici and his team, through advanced posterior segment repair procedures, were able to restore the man’s vision to 20/100.
“Examples like this run contrary to the traditional teaching that restoring vision in ocular trauma is hopeless,” he said. “And there are many more examples in the United States Eye Injury Registry, which has data on 10,000 eye injuries. This registry is an exciting resource, especially since we now have online reporting. Any ophthalmologist can get online and report a case on his or her patient, the initial prescription and then a six-month follow-up report.”
For Dr. Kuhn, the main message coming from the registry is that surgeons should not just give up because the patient does not have light perception. “Removing the eye is psychologically traumatizing to the patient. If there is a chance to put the eye back together, even if there is limited vision, it is worthwhile to do so. And it buys the patients some time to comprehend, digest and accept the loss. Enucleation can be done at some future point, but it certainly is worthwhile to try to save these eyes.”
Drs. Pieramici and Kuhn coauthored a book titled Ocular Trauma: Principles and Practice (New York: Thieme Medical Publishers, 2002). It focuses on developing individualized treatment strategies for ocular trauma.