FP571 : Outcomes of Eye Injuries with Retained Iofb Managed By Pars Plana Vitrectomy (PPV)

To identify the predictive factors for anatomical and visual outcomes in posterior segment IOFB patients managed by pars plana vitrectomy (PPV).

INTRODUCTON :

  • Retained posterior segment intraocular foreign bodies (RIOFBs)in open globe ocular injuries account for 18-40% of allocular trauma cases.[1,2]
  • Among open globe injuriesclassified by Birmingham Eye TraumaTerminology, injury connected with sharp penetration had a better visual prognosis than that associated with blunt penetration, and intraocular foreign bodies (IOFBs) were reported as having better visual outcome when compared with other mechanisms.
  • Intraocular foreign body (IOFB) injuries are a relativelycommon form of ocular injury especially in young men.1,2In addition to the initial damage, infection, and mechanical andchemical reactions are known complications of IOFBs.
  • Recent advances in vitreoretinalsurgical techniques, has suggested to improve the outcome ofPPV in the management of posterior segment IOFBs.Management of RIOFBs still remains achallenge despite the advances in the surgical techniques.
  • In this study we analyze all the consecutive cases with open-globeinjuries and IOFBs that we treated by pars plana vitrectomy(PPV), in order to define the factors that affected thefinal visual acuity and globe survival.

AIMS AND OBJECTIVES :

  • The objectives of this study were to identify the predictive factors and evaluate

the visual outcomes in posterior segment IOFB patients managed by pars planavitrectomy (PPV).

  • We aim to present the clinical features and the algorithm according to which we manage the foreign bodies that are located in the posterior segment of the eye. 

MATERIALS AND METHODS : 

  • Ours was a clinical retrospective study.
  • A retrospective study including 72 patients, who had  PPV for IOFB removal.
  • Study period : From 2012 to 2015
  • We reviewed the medical records of all the cases with IOFBs  that we removed by PPV (2012–2015).
  • We extracted the following parameters: age, gender, mode of injury, wound anatomy, IOFB characteristics, ocular lesions, initial and final visual acuities, postoperative status of the retina and surgical complications of patients who attended the emergency/OPD eye care services at Shri Ganapati Netralaya, Jalna, Maharashtra.
  • Minimum 6 months follow up data.
  • The surgical technique was a standard three port pars plana approach with simultaneous pars planalensectomy or phacoemulsification when  considered necessary. IOFB was removed by forceps or an intraocular magnet. We used  liquid perfluorocarbon intraoperatively and sulfur hexafluoride (SF6) or silicone oil, as  intraocular tamponade, if required. Endolaser photocoagulation of the breaks and 360°photocoagulation of the retinal periphery were performed. 

RESULTS :

  • 51 males and 21 females with a mean age of34.6 years (Range – 16 to 64 yrs) were evaluated, with right eye injury seen in 40(55.55 %), left eye affected in 29(40.27 %) and bilateral injury seen in 03(4.17%) of the cases.
  • The mean interval between the time of injury and IOFB removal was 24 ± 43.1 days (range, 1 dayto 240 days).

Nature of the Foreign Body :

Material of IOFB Number
METAL 23%
WOOD 37%
STONE 30%
FIREWORK 5%
GLASS 5%

Clinical data of the patients :

               CLINICAL FEATURES NUMBER (%)
Penetrating site

Cornea

Sclera

Corneosclera

           56(77.78 %)

10(13.89%)

06(08.33%)

Hyphema            20(27.78%)
Iris injury             42(58.33%)
Lens injury             49(68.05%)
Vitreous hemorrhage              53(73.61%)
Endophthalmitis             06(08.33%)
Retinal detachment             07(9.72 %)

Preoperative and final visual acuity :

VISUAL ACUITY PRE-OP VA FINAL BCVA
≥ 20/40 9 (12.50%) 25(34.72)
< 20/40 – 20/200 13(18.05%) 13(18.05%)
< 20/200 50(69.4%) 34(47.22%)
TOTAL 72(100%) 72(100%)

IOFB LOCATION :

IOFB LOCATION NO. OF CASES
In the vitreous 49
In the retina 15
Perforating 8
TOTAL 72

 

COMPLICATIONS AND OUTCOMES OF INJURY :

  • Retinal detachment was seen in (9.72%) cases
  • Endophthalmitis occurred in 18 cases of which 6 cases presented to us with endophthalmitis and 12 developed it post operatively despite due care.(8.33%).
  • Evisceration was required in 08 (11.11%) due to risk of sympathetic ophthalmitis in fellow eye /badly mutilated globe which was not reparable or panophthalmitis.
  • Pthisis was the eventual outcome in 9 (12.5%) of cases.
  • The reason for poor visual acuity was corneal scar secondary to the primary injury in the majority of eyes (42 eyes) with or without retinal injury from IOFB.

IOFB IMPACTED IN RETINA                     STANDARD 3 PORT PARS PLANA
APPROACH

DISCUSSION :

  • Microsurgical and vitreoretinal instrumentation and techniques, allows managing the posterior segment injuries associated with IOFBs successfully. It has been shown that vitreoretinal surgery is able to reduce the rate of visual loss.3,4
  • Rationale for using PPV for IOFB removal :
  • Before the development of PPV, all the magnetic foreignbodies were extracted from the eye with theexternal magnet [5].
  • The drawback comes from the high risk of retinaldetachment in eyes that develop vitreous organizationand shortening of the pre-retinal fibrous bands.
  • The argument in favor of PPVin the management of IOFBs is that removing the damagedvitreous decreases the risk of retinal detachment.
  • The use of PPV dramatically decreased the risk ofretinal detachment in the period following IOFB extraction.Thus, in older studies, retinal detachment ratesafter primary surgery was up to 79 %, whereas in more recent ones, 11–23 % [6,7].
  • Our study reports the retinal detachment rate to be 72 %.
  • The incidence of infectious endophthalmitis after retainingan IOFB has been reported to be 0–13.5%.2 We had 18 cases of endophthalmitis associated with IOFB in our series (2%).
  • Several studies has shown that delayed removal of IOFB mayend with poor visual and anatomical outcomes includingthe development of infectious endophthalmitis and retinaldetachment.7,11,12
  • The limitations of our study include the retrospective natureand small sample size of the study, and short follow up periodin some eyes may preclude definite conclusion. Despite theselimitations, our results show that the anatomical outcome ofPPV for eyes with posterior segment IOFB in terms of retinalattachment is adequate; however, associated ocular injuries maylimit visual improvement.

CONCLUSION :

  • We identified two factors that were significantly associatedwith a worse outcome in our series: retinaldetachment upon presentation and wooden/organic IOFB compared to metallic IOFB’s.
  • Eye protection should play a major role in preventingthis disability affecting young people. Eyeprotection during risky work situations needs furtherpromotion and education.

REFERENCES :

  1. Shock JP, Adams D. Long term visual acuity results afterpenetrating and perforating ocular injuries. Am J Ophthalmol1985;100:714‑8.
  2. Thompson JT, Parver LM, Enger CL Mieler WF, Liggett PE.Infectious endophthalmitis after penetrating injury withretained intraocular foreign bodies. National Eye Trauma Study.Ophthalmology 1993;100:1468‑74.
  3.  Williams DF, Mieler WF, Abrams GW, Lewis H. Resultsand prognostic factors in penetrating ocular injurieswith retained intraocular foreign bodies. Ophthalmology1988:95:911-6.
  4.  Chow DR, Garretson BR, Kuczynski B, Williams GA, MargherioR, Cox MS, et al. External versus internal approach tothe removal of metallic intraocular foreign bodies. Retina2000;20:364-69.
  5. .Mittra RA, Mieler WF. Controversies in the Management of Open-GlobeInjuries Involving the Posterior Segment.SurvOphthalmol. 1999;44:215–25.
  6. Chiquet C, Zech J, Denis P, Adelin P, Trepsat C. Intraocular foreign bodies.Factors influencing final visual outcome. ActaOphthalmol Scand.1999;77:321–5.
  7. Soheilian M, Feghi M, Yazdani S, Anisian A, Ahmadieh H, DehghanMH, et al. Surgical management of nonmetallic and nonmagneticmetallic intraocular foreign bodies. Ophthalmic Surg Lasers Imaging.2005;36:189–96.
FP925 : More Than What Meets the Eye: Delayed Presentation of Orbital Foreign Body - a Case Report

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