POSTERIOR SEGMENT INJURIES IN OPERATION IRAQI FREEDOM AND OPERATION ENDURING FREEDOM: 2001 to 2011.

BACKGROUND/PURPOSE: To characterize the nature of posterior segment ocular injuries in combat trauma. METHODS: Eyes in the Walter Reed Ocular Trauma Database were evaluated for the presence of posterior segment injury. Final visual outcomes in open-globe versus closed-globe injuries and by zone of injury and the types of posterior segment injuries in open-globe versus closed-globe injuries were assessed. RESULTS: Four hundred fifty-two of 890 eyes (50.8%) had at least one posterior segment injury. The mechanism of injury was most commonly an improvised explosive device in 280 (62.0%) eyes. Sixty-one patients (13.5%) had a Zone I injury, 50 (11.1%) a Zone II injury, and 341 (75.4%) a Zone III injury. Patients with Zone I injuries were more likely to have a final visual acuity of 20/200 or better compared with patients with either a Zone II (P < 0.001) or Zone III injury (P = 0.007). Eyes with a closed-globe injury were more likely to have a final visual acuity of 20/200 or better compared with those with an open-globe injury (P < 0.001). Furthermore, closed-globe injury compared with open-globe injury had a lower risk of vitreous hemorrhage (odds ratio 0.32, P < 0.001), proliferative vitreoretinopathy (odds ratio 0.14, P < 0.001), and retinal detachment (odds ratio 0.18, P < 0.001) but a higher risk of chorioretinal rupture (odds ratio 2.82, P < 0.001) and macular hole (odds ratio 3.46, P = 0.004). CONCLUSION: Patients with combat ophthalmic trauma had similar posterior segment injury patterns to civilian trauma in open-globe versus closed-globe injuries. Zone II and III injuries were associated with a worse visual prognosis.

Clinical analysis of posterior segment injury in left-behind children in China.

BACKGROUND: We aimed to evaluate the severity and prognosis of posterior segment injury between left-behind children (LBC) and guarded children (NLBC). METHODS: A retrospective, controlled analysis of a case series was performed. Patients diagnosed with posterior segment injury in Department of vitreous and retinal, the Affiliated Ophthalmology and Otolaryngology Hospital of Fudan University were included in this study. Patients were divided into two groups, including LBC group (n = 48) and NLBC group (n = 44). All the children underwent 25G transconjunctival sutureless pars plana vitrectomy. RESULTS: Compared with NLBC, LBC had delayed treatment, worse baseline vision and visual prognosis, lower OTS rating, more times of vitrectomies, more complicated surgical procedures, and higher rate of lens removal and silicone oil tamponade. CONCLUSIONS: Due to lack of care and delayed treatment, posterior segment ocular trauma in the LBC was more severe, more common complicated with infectious endophthalmitis, and had worse visual prognosis. It was urgent to enforce the guardianship in LBC.

23-gauge transconjunctival vitrectomy for posterior segment intraocular foreign bodies.

BACKGROUND: This study is a report of the outcomes of 23-gauge (G) transconjunctival vitrectomy (TV) performed to treat a posterior segment intraocular foreign body (IOFB). METHODS: The data of 14 eyes of 14 patients who underwent 23-G TV for the removal of a posterior segment IOFB were reviewed in this study. Surgery was initiated with a 23-G system in each case and the posterior segment IOFB was removed through the enlarged sclerotomy site. All of the patients were male. The mean age of the patients was 36.6+-11.0 years. RESULTS: The foreign body (FB) was located in the vitreous in 11 eyes and in the retina in 3 eyes. Before the 23-G TV, complicated cataract was detected in 6 eyes, vitreous hemorrhage was detected in 5 eyes, and retinal detachment was detected in 1 eye. The size of the FB ranged from 3 mm to 7 mm; 12 of the FBs were metallic and 2 were glass. Silicone oil was used as a tamponade agent in 5 eyes and gas tamponade (C3F8) was used in 4 eyes. The mean follow-up time was 8.15+-2.9 months. At the last examination, of the 14 eyes included in the study, the visual acuity (VA) was 0.1 or better in 10 eyes and less than 0.1 in 4 eyes because 2 eyes had peri-macular scar, 1 eye had massive sub-epiretinal membrane and 1 eye had retinal re-detachment. CONCLUSION: 23-G TV is seen as an effective and minimally invasive technique to remove posterior segment IOFBs.

Enhanced Depth Imaging Optical Coherence Tomography of Posterior Globe Rupture.

Occult globe rupture is a rare but potentially devastating result of eye trauma. The authors present a case of a woman who sustained blunt trauma to the right eye resulting in a peripapillary circumferential posterior globe rupture. Clinically, the eye maintained good vision and normal intraocular pressure with a clear media, though subretinal fluid and retinal hemorrhage were present overlying the scleral defect. Enhanced depth imaging spectral-domain optical coherence tomography (EDI SD-OCT) revealed a sharp step-off of the sclera, choroid, and Bruch's membrane/retinal pigment epithelium, with overlying intact and contiguous inner retina, corresponding to a posterior globe rupture. Following conservative management, the subretinal fluid resolved and visual acuity improved to 20/20 over a month period, whereas the posterior globe step-off remained stable. This case demonstrates the potential for occult open globe injuries with preserved visual function in cases of blunt ocular trauma, and the first to document EDI SD-OCT findings of a posterior globe rupture. Multimodal imaging may help in the evaluation and diagnosis of suspected posterior segment globe rupture. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e171-e172.].

Prognostic value of ocular trauma score for open globe injuries associated with metallic intraocular foreign bodies.

BACKGROUND: The prognostic value of the ocular trauma score (OTS) in patients who underwent 23-gauge pars plana vitrectomy (23-G PPV) for surgical removal of posterior segment metallic intaocular foreign bodies (IOFB) was evaluated. METHODS: Patients who underwent 23-G PPV for surgical removal of retained metallic IOFBs were retrospectively analyzed. OTS score for each patient was calculated and raw scores were converted to their corresponding OTS categories. The final VAs in study patients were compared with their respective OTS categories. RESULTS: Twenty-five eyes from 25 patients were examined. Twenty-four (96%) of the patients were male, and the mean age was 34 ± 12 years. The time from injury to 23-G PPV was 9 ± 4 days. Fourteen (56%) patients had zone 1 trauma, eight (32%) patients had zone 2 trauma, and three (12%) patients had zone 3 trauma. Postoperative visual acuity was ≥ 20/200 in 14 (56%) of the patients and ≥ 20/40 in seven (28%) eyes. At the final visit, anatomical success was achieved in 86% of patients with retinal detachment at presentation. No statistically significant differences were found between our final VAs and OTS scores. CONCLUSION: OTS, which provides prognostic information after general ocular trauma, may also provide valuable prognostic information for patients who undergo 23-G PPV for the surgical removal of metallic posterior segment IOFBs.

Occult globe rupture: diagnostic and treatment challenge.

Occult globe rupture is a traumatic dehiscence of the sclera at or posterior to the rectus muscle insertions without a visible eye wall defect on slit lamp examination. Occult scleral ruptures are important because they can be difficult to diagnose, but normally require preoperative protection against external pressure to reduce risk of herniation of ocular contents through the rupture and then urgent surgical repair to restore eye wall structural integrity and achieve optimum prognosis. A deeper-than-normal anterior chamber with posteriorly retracted plateau iris seen immediately after acute ocular trauma is virtually pathognomonic of posterior globe dehiscence. Three additional less specific signs are helpful: extensive chemosis that is often hemorrhagic, relative hypotony, and vitreous hemorrhage. Although the diagnosis is normally clinical, made by history of direct severe ocular trauma and careful anterior-segment slit lamp examination, computed tomography and ultrasonography can be helpful when thorough slit lamp examination is not possible. Strong suspicion of occult rupture should engender surgical exploration. Vitreous hemorrhage, vitreous or retinal incarceration, and retinal tears or detachment may necessitate subsequent pars plana vitrectomy or other vitreoretinal surgery. When pars plana vitrectomy is indicated, special precautions are suggested if watertight closure of the globe rupture has not been possible.

Surgical Management and Outcome of Open Globe Injuries with Posterior Segment Complications: A 10-Year Review.

PURPOSE: To describe the characteristics, management, and outcomes of open globe injured (OGI) eyes that underwent pars plana vitrectomy (PPV) for posterior segment complications. METHODS: Retrospective chart review of cases that underwent PPV for posterior segment complications associated with OGI between 2003-2012 at University Hospital, Newark, NJ. RESULTS: 120 eyes were identified and classified as follows: "early retinal detachment (RD)" (within 30 days of OGI), 64 (53%) eyes; "delayed RD" (≥30 days after OGI), 30 (25%) eyes; and "no RD," 26 (22%) eyes. Injuries included penetrating (39 (33%) eyes), rupture (60 (50%) eyes), and penetrating wounds with retained intraocular foreign body (21 (17%) eyes). Injuries in Zones I, II, and III were seen in 40 (35%) eyes), 38 (34%) eyes, and 35 (31%) eyes, respectively, with statistically different ocular trauma scores (p<0.01) associated with each zone of injury. Mean presenting and final logMAR VA were 2.20± 0.63 and 1.87 ±0.60, respectively (p<0.01), with a mean follow-up of 3.2 years. Final overall anatomic success after surgeries was 98% for early RD and 95% for delayed RD. CONCLUSION: Despite a high anatomic success rate, the overall functional success rate for eyes with posterior segment trauma that undergo PPV is poor and comparable to other studies.

Clinical characteristics and visual outcome, prognostic factor, visual acuity and globe survival in posterior segment intraocular foreign body at Tilganga Institute of Ophthalmology.

PURPOSE: To evaluate clinical characteristics, visual outcomes and globe survival after intraocular foreign body removal from posterior segment via pars plana approach. METHODS: A hospital based retrospective study. All the patients of penetrating eye injury with intraocular foreign body in posterior segment as detected by computed tomography were enrolled from 2012 to 2014. RESULTS: Thirty patients of 30 eyes were included. The mean age was 27.7 years. (2-52). Twenty-four (80%) were male. Out of 30 eyes 19 (63.3%) eyes had injury at Zone 1 and 11 (36.7%) eyes had injury at Zone 2. The mean time spent between primary repair following surgery and intra ocular foreign body removal, was 15.47 days. Retinal detachment and endophthalmitis prior to intraocular foreign body removal was present in 9/30 of eyes. We looked for correlation between post operative Phthisis bulbi with zone of injury and pre operative endophthalmitis and preoperative retinal detachment. However, p value for the above correlation was more than 0.552 and 0.815 respectively, which was statistically not significant. CONCLUSIONS: The eyes with posterior segment intraocular foreign bodies showing clinical features of preoperative endophthalmitis, retinal detachment and the zone of injury also did not have any direct significance with globe survival.

Retinectomy vs vitrectomy combined with scleral buckling in repair of posterior segment open-globe injuries with retinal incarceration.

PurposeTo evaluate the anatomic and functional outcome of pars plana vitrectomy (PPV) combined with scleral buckling (SB) vs retinectomy in treating posterior segment open-globe injuries with retinal incarceration.MethodsPatients (38 eyes) with posterior segment open-globe injuries and retinal incarceration were identified, and they underwent either PPV combined with SB (PPV+SB, n=19) or retinectomy (n=19). The two groups were matched in the following categories: the severity of injury (including wound length), the location of the incarceration site and the presence of retinal detachment. Anatomic reattachment of the retina and best-corrected visual acuity (BCVA) were measured at the time of 12 months after operation.ResultsAt 12 months after operation, the PPV+SB group demonstrated a better anatomic retinal attachment rate (84.2% vs 68.4%, P=0.252) and BCVA (73.7% vs 47.4%, P=0.247) compared with the retinectomy group, however, the differences failed to reach statistical significance. Compared with the PPV+SB group, the rectinectomy group had significantly higher rates of hemorrhage (47.4% vs 15.8%, P=0.036), inflammation (42.1% vs 10.5%, P=0.027), and a lower intraocular pressure (IOP, 9.8±3.1 vs 13.6±4.1 mmHg, P=0.002) after silicone oil (SO) removal.ConclusionsFor patients with posterior segment open-globe injuries and retinal incarceration, PPV and SB treatments resulted in a better anatomic and functional outcome and less post-operation complications compared with the retinectomy.

Open Globe Injuries Presenting With Normal or High Intraocular Pressure.

OBJECTIVES: To determine the frequency, clinical characteristics, and visual outcomes of patients who present with high or normal intraocular pressure (IOP) and open globe injuries. DESIGN: Retrospective chart review. SETTING: University of Maryland Medical Center, a level 1 trauma center. PATIENT OR STUDY POPULATION: All cases of open globe injury presenting to The University of Maryland Medical Center from July 2005 to January 2014. OBSERVATION: Demographics, initial physical examination, computed tomography findings, IOP of the affected and unaffected eyes, and follow-up evaluations. MAIN OUTCOME MEASURES: (1) IOP 10 mm Hg or greater and (2) visual acuity. RESULTS: Of 132 eyes presenting with open globe injury, IOP was recorded in 38 (28%). Mean IOP for the affected and unaffected eyes was 14±10.3 mm Hg and 16.6±4.1 mm Hg, respectively. Twenty-three (59.4%) eyes had IOP greater than 10 mm Hg. Six eyes (16.2%) had IOP greater than 21 mm Hg. Using bivariate analysis, IOP greater than 10 mm Hg was associated with posterior open globe injury (P=0.01), posterior hemorrhage (P=0.04), and intraconal retrobulbar hemorrhage (P=0.05). Adjusting for age, sex, and race, IOP greater than 10 mm Hg was associated with the presence of posterior open globe injury on clinical examination (P=0.04). Higher presenting IOP was found to predict light perception or worse vision (P=0.01). Multivariate analysis showed that poor presenting vision was the best predictor of poor final vision (P<0.01). CONCLUSIONS: High IOP does not exclude open globe injury. It is a frequent finding in patients with open globe injuries and may be associated with posterior injury and poor visual prognosis.

The outcomes of primary scleral buckling during repair of posterior segment open-globe injuries.

OBJECTIVE: To compare visual outcomes of eyes which underwent primary scleral buckling (PSB) treatment during posterior segment open-globe injury (OGI) repair with eyes not treated with PSB. METHODS: We retrospectively reviewed 38 eyes which underwent a posterior segment OGI repair with no preoperative evidence of retinal detachment (RD) at Soroka University Medical Center (1995-2010). 19 (50%) underwent scleral repair alone (control group) and the other 19 eyes were treated with PSB also (PSB group). We compared visual outcomes in these two groups and rates of subsequent postoperative complications. RESULTS: Baseline characteristics of the groups were similar. Compared with the control group, the PSB group had statistically significant lower rates of proliferative vitreoretinopathy (PVR) (5.3% versus 38.4%, P < 0.05) and a trend towards lower rates of RD (15.8% versus 41.1%, P = 0.1). PSB group eyes had a statistically significant improvement of their best distance visual acuity (BDVA) with lower means of final BDVA-grade (P < 0.05) and logMAR vision (P < 0.05). Eyes in the control group had no improvement in these parameters. CONCLUSION: PSB procedure during posterior segment OGI repair may decrease the risk of subsequent retinal complications and improve final visual outcome.

Occult wooden posterior segment intraocular foreign body.

BACKGROUND AND OBJECTIVE: To evaluate B-scan and computed tomographic appearance of a wooden intraocular foreign body within the posterior segment. MATERIALS AND METHODS: The authors report a case of a patient with an occult retained foreign body. To identify why the object was elusive, an in vitro study was conducted using computed tomography (CT) and B-scan on five human cadaveric eyes with known foreign bodies implanted into the vitreous cavity. RESULTS: Posterior segment metal and glass produced comet tail artifacts on B-scan, whereas stone, wood, and plastic produced shadowing artifacts. There was difficulty in identifying wood within the posterior chamber via CT. However, stone and plastic were easily detectable but difficult to identify without Hounsfield units. CONCLUSION: CT provides quick imaging of suspected posterior segment foreign bodies; however, B-scan ultrasonography may prove more useful than CT in detecting wooden foreign bodies.

Phacoemulsification with posterior chamber intraocular lens versus extracapsular cataract extraction (ECCE) with posterior chamber intraocular lens for age-related cataract.

BACKGROUND: Age-related cataract is one of the leading causes of blindness worldwide. Therefore, it is important to establish the most effective surgical technique for cataract surgery. OBJECTIVES: The aim of this review is to examine the effects of two types of cataract surgery for age-related cataract: phacoemulsification and extracapsular cataract extraction (ECCE). SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2013, Issue 4), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to May 2013), EMBASE (January 1980 to May 2013), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to May 2013), Web of Science Conference Proceedings Citation Index - Science (CPCI-S) (January 1970 to May 2013), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 13 May 2013. SELECTION CRITERIA: We included randomised controlled trials of phacoemulsification compared to ECCE for age-related cataract. DATA COLLECTION AND ANALYSIS: Two authors independently selected and assessed all studies. We defined two primary outcomes: 'good functional vision' (presenting visual acuity of 6/12 or better) and 'poor visual outcome' (best corrected visual acuity of less than 6/60) at three and 12 months after surgery. We also collected data on intra and postoperative complications, and the cost of the procedures. MAIN RESULTS: We included 11 trials in this review with a total of 1228 participants, ranging from age 45 to 94. The studies were generally at unclear risk of bias due to poorly reported trial methods. No study reported presenting visual acuity, so we report both uncorrected (UCVA) and best corrected visual acuity (BCVA). Studies varied in visual acuity assessment methods and time frames at which outcomes were reported. Participants in the phacoemulsification group were more likely to achieve UCVA of 6/12 or more at three months (risk ratio (RR) 1.81, 95% confidence interval (CI) 1.36 to 2.41, two studies, 492 participants) and one year (RR 1.99, 95% CI 1.45 to 2.73, one study, 439 participants). People in the phacoemulsification group were also more likely to achieve BCVA of 6/12 or more at three months (RR 1.12, 95% CI 1.03 to 1.22, four studies, 645 participants) and one year (RR 1.06, 95% CI 0.99 to 1.14, one study, 439 participants), but the difference between the two groups was smaller. No trials reported BCVA less than 6/60 but three trials reported BCVA worse than 6/9 and 6/18: there were fewer events of this outcome in the phacoemulsification group than the ECCE group at both the three-month (RR 0.33, 95% CI 0.20 to 0.55, three studies, 604 participants) and 12-month time points (RR 0.62, 95% CI 0.36 to 1.05, one study, 439 participants). Three trials reported posterior capsule rupture: this occurred more commonly in the ECCE group than the phacoemulsification group but small numbers of events mean the true effect is uncertain (Peto odds ratio (OR) 0.56, 95% CI 0.26 to 1.22, three studies, 688 participants). Iris prolapse, cystoid macular oedema and posterior capsular opacification were also higher in the ECCE group than the phacoemulsification group. Phacoemulsification surgical costs were higher than ECCE in two studies. A third study reported similar costs for phacoemulsification and ECCE up to six weeks postoperatively, but following this time point ECCE incurred additional costs due to additional visits, spectacles and laser treatment to achieve a similar outcome. AUTHORS' CONCLUSIONS: Removing cataract by phacoemulsification may result in a better visual acuity compared to ECCE, with a lower complication rate. The review is currently underpowered to detect differences for rarer outcomes, including poor visual outcome. The lower cost of ECCE may justify its use in a patient population where high-volume surgery is a priority, however, there are a lack of data comparing phacoemulsification and ECCE in lower-income settings.

Vitrectomy for posterior segment intraocular foreign bodies, visual and anatomical outcomes.

PURPOSE: To evaluate the visual and anatomic results and determine the prognostic factors after pars plana vitrectomy and posterior segment intraocular foreign body (IOFB) removal. MATERIALS AND METHODS: This retrospective study reviews the patients' charts of 48 consecutive patients with posterior segment IOFB who underwent pars plana vitrectomy and IOFB removal over a 4-year period, recently. Association between visual outcome and various preoperative, operative, and postoperative variables was statistically analyzed. Data were analyzed with the paired t-test and the chi square test. Statistical significance was indicated by P < 0.05. RESULTS: The mean interval between the time of injury and IOFB removal was 24 ± 43.1 days and 27 (53%) eyes underwent IOFB removal within 7 days of the injury. Nine (19.1%) patients achieved a visual acuity of 20/40 or better. An improvement of visual acuity of at least three lines occurred in 21 (44.6%) eyes and the vision remained unchanged in 15 (31.9%) eyes. Postoperative retinal detachment occurred in five (10.6%) eyes. Visual improvement was more likely to occur in eyes with lower levels of presenting visual acuity (P = 0.2). Visual improvement was not associated with an entry site and IOFB location, lens injury, time to surgery, and pre- and post-operative retinal detachment. At the end of follow up, anatomical success was achieved in 97.9% of eyes. CONCLUSIONS: High anatomical success could be achieved after the removal of posterior segment IOFBs by vitrectomy, despite a delay in surgery. Poor visual outcome may be mainly due to the initial ocular injury.

Ultrasound of penetrating ocular injury in a combat environment.

Penetrating eye injuries are uncommon in a civilian environment, but unfortunately, very common in a military emergency department. Ultrasound of the eye is quick, reliable, accurate, and easy to learn. This review aims to demonstrate normal anatomy and penetrating injuries of the anterior and posterior compartments of the eye.