Predictive factors for final outcome of severely traumatized eyes with no light perception

BMC Ophthalmology Predictive factors for final outcome of severely traumatized eyes with no light perception Rupesh Agrawal 0 Ho Sue Wei 1 Stephen Teoh 0 0 Department of Ophthalmology, Tan Tock Seng Hospital , 11 Jalan, Tan Tock Seng 308433 , Singapore 1 Ministry of Health Holdings, Singapore , Singapore Background: An eye injury that causes no light perception (NLP) typically carries an unfavorable prognosis, and NLP because of trauma is a common indication for enucleation. With advances in vitreoretinal surgical techniques, however, the indication for enucleation is no longer determined by posttrauma NLP vision alone. There are limited studies in the literature to analyse the outcome of NLP eyes following open globe injury. The current study was aimed to evaluate the outcome of surgical repair of severely traumatized eyes with no light perception vision as preoperative visual acuity. Secondary objective was to possibly predict the factors affecting the final vision outcome in this eyes. Methods: Retrospective case analysis of patients with surgical repair of open globe injury over last ten years at a tertiary referral eye care centre in Singapore. Results: Out of one hundred and seventy two eyes with open globe injury 27 (15.7%) eyes had no light perception (NLP). After surgical repair, final visual acuity remained NLP in 18 (66.7%) eyes. Final vision improved to Light perception/ Hand movement (LP/HM) in 2(7.4%) eyes, 1/200 to 19/200(11.1%) in 3 eyes and 20/50-20/200(14.8%) in 4 eyes. The median follow up was 18.9 months (range: 4-60 months). The factors contributing to poor postoperative outcome were presence of RAPD (p = 0.014), wound extending into zone III (p = 0.023) and associated vitreoretinal trauma (p = 0.008). Conclusions: One third of eyes had ambulatory vision or better though two third of eyes still remained NLP. Preoperative visual acuity of NLP should not be an indication for primary enucleation or evisceration for severely traumatized eyes. Presence of afferent papillary defect, wound extending posterior to rectus insertion and associated vitreoretinal trauma can adversely affect the outcome in severely traumatized eyes with NLP. Timely intervention and state of art surgery may restore useful vision in severely traumatized eyes. Open globe injury; RAPD; No light perception (NLP); Zone III injury; Vitroretinal trauma - Background Ocular trauma can result in a wide spectrum of injury to the eye resulting in mild to severe ocular morbidity. Mechanical injuries to the eye can be classified into open globe injury and closed globe injury [1]. Open globe injury, defined as a full-thickness wound of the eye wall are usually not vision-threatening [1]. There have been numerous variables identified to affect final outcome in patients with open globe injury [2,3]. Those that have been found to correlate significantly with vision outcome include age, type or mechanism of injury, initial visual acuity, presence of a relative afferent pupillary defect (RAPD), extent of wound and size of open-globe injury, location of open globe wound, lens damage, hyphema, vitreous hemorrhage, retinal detachment, and presence of intraocular foreign body [2,3]. An eye injury that causes NLP typically carries an unfavorable prognosis, and NLP because of trauma is a common indication for enucleation [4]. Very few studies have analyzed outcome of severely traumatized eyes with no light perception (NLP). The United States Eye Injury Registry (USEIR) had reported improvement of vision in 16% of eyes with NLP at initial vision [1]. With advances in vitreoretinal surgical techniques, however, the indication for enucleation is no longer determined by posttrauma NLP vision alone. The current study was aimed to assess the outcome of surgical repair of severely traumatized eyes with no light perception as initial visual acuity following open globe injury. The secondary objective of the study was to possibly predict the preoperative variables affecting the final vision outcome in same group of patients. After obtaining Institutional review board consent to conduct the study, retrospective review of medical records of all the patients with surgical repair following open globe injury were retrieved and analyzed. Methods The medical records of 172 patients with consecutive open globe injuries seen at a single tertiary eye centre over 10 year period between 2000 till 2009 were retrospectively reviewed after institutional review board consent. Medical records of all this 172 patients were analyzed in detail. Out of this 172 patients, case records of 27 (15.7%) patients with NLP vision as initial preoperative visual acuity after severe ocular trauma were analyzed in detail for this study. Local Domain Specific Research Board (DSRB) approval was obtained for conducting this retrospective study. Detailed analysis of the case records included patient demographics, visual acuity at presentation ( in this series it was NLP in all patients), mode of injury, time since injury, ocular tissue/s involved and presence or absence of RAPD, details of operation, number of operations, extent of scleral involvement and final anatomical and visual outcome. All the patients were either local or immigrants in Singapore and industrial accidents or work place related eye injuries was the commonest setting in which eye injury happened. All patients were consulted within six hours of injury due to quite advance healthcare system in developed country like Singapore. Extent of the wound was classified into zone I, II or III. By definition, zone I injury is corneal wound with wound not extending beyond limbus, zone II injury extend up to 5 mm posterior to limbus into sclera and any injury involving beyond zone II injury i.e., extend of wound beyond 5 mm of sclera from limbus falls into zone III category [1]. Further all the eyes were classified based on international ocular trauma classification system. The parameters which were taken into consideration for classification were mode of injury ( Type B - Blunt or Type APenetrating), preoperative visual acuity ( NLP in this series in all patients, Grade 5 as per international classification of open globe injury), presence or absence of relative afferent papillary defect { RAPD P (positive) or N-(negative)} and zone of injury [1]. Ocular trauma score was also computed for all the patients to predict the possible outcome. Table 1 give detailed distribution of all the 27 patients into different groups based on international ocular trauma classification system and also ocular trauma score at presentation. Surgical technique All the patients underwent primary repair of open globe injuries under general anesthesia. Preoperative consent of very guarded visual prognosis was taken for all the patients. Consent also involved risk of sympathetic ophthalmia, multiple surgeries if required, and risk for enucleation or evisceration of the globe in case of unsalvageable eye. (...truncated)