Prospective eye injury study
Management protocol
Management protocol
Prospective study
prophylactic chorioretinectomy
in eyes seriously injured eyes at high risk for
proliferative vitreoretinopathy (PVR)
General description
The goal of the study is to evaluate a new treatment method (prophylactic chorioretinectomy)
for the treatment of eyes at high risk for PVR following severe trauma. These injuries have a
poor anatomical and functional outcome once PVR has started. In this prospective study we
intend to compare the results achieved with this proactive method to those published in the
literature using traditional methods of treatment. The goal is to perform prophylactic
chorioretinectomy within the first 100 after the injury.
Injury types included (see BETT for definitions)
• perforating injuries
• intraoular foreign body (IOFB
choroid
• rupture
exit wound
injury with a deep impact (involving the choroid
and possibly the sclera
or penetrating wounds extending posterior to
muscle insertion.
Cases to be excluded
Infection (endophthalmitis) at any time during the treatment/follow-up period.
Endpoints
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Prospective eye injury study
Primary:
Management protocol
Occurrence of proliferation (proliferation occurring at any point during the
follow-up period):
• PVR;
• full- or partial thickness retinal folds.
A distinction is to be made whether the PVR originates at where prophylactic
chorioretinectomy has been performed or elsewhere in the eye.
Secondary
• Anatomical failure (enucleation, evisceration, phthisis);
• visual acuity;
• lens status;
• retinal attachment;
• silicone oil in eye;
• intraocular pressure (IOP).
Management protocol
The intended plan is either to perform
1) primary surgery as soon as possible; this is followed by postoperative care and then
secondary vitrectomy with prophylactic chorioretinectomy, preferably no later than 100 hours
postinjury or
2) primary comprehensive surgery (wound closure + vitrectomy with prophylactic
chorioretinectomy.
(It is conceivable that no primary surgery is necessary - e.g., the wound is too small to
require closure and no anterior segment pathology requiring surgical intervention is
present -; strictly speaking, in such cases the secondary surgery is the primary surgery, but
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Prospective eye injury study
Management protocol
for data entry and analysis purposes, such intervention remains to be called secondary
surgery. It is also possible that the second surgery is performed >100 hours after the injury.
Although it is not preferable, this does NOT disqualify the case, just indicate this fact on the
sheet.)
Primary (emergency) surgery
• close wound
it can reasonabl
reached) as soon as possible;
• clear anterior opacity
as necessary
surgeon’s
decision
• in eyes with a perforating injury, it is preferred although not mandatory to perform
limited indirect ophthalmoscopic vitrectomy with without anterior chamber infusion
to cut intravitreal traction pathway; no indirect ophthalmoscopic vitrectomy in the
other two injury types;
• in eyes with an IOFB, it is the surgeon’s
decision whether the IOFB is removed
now delayed until the secondary surgery
• do not use scleral buckle.
If patient is referred with the primary surgery already performed elsewhere, skip to
“postoperative case” section.
Postoperative care
• heavy topical steroids (systemic corticosteroids: surgeon’s
surgeon’s
• intravenous/intravitreal antibiotics
Secondary surgery
surgeon’s
following
decision);
decision
decision
or referral
Must be performed no later than 100 hours postinjury.
• Pars plana vitrectomy: complete removal of all vitreous, including posterior
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Prospective eye injury study
Management protocol
cortical vitreous and vitreous base:
• use triamcinolone to stain posterior cortical vitreous;
• use scleral indentation to assure complete removal of peripheral vitreous;
• remove lens, even if clear, if this is felt necessary to get access to
vitreous base;
• pay close attention to cut/remove incarcerated vitreous around wounds/IOFB
impact site;
• removal of the IOFB if still present.
• Judicious retinectomy around
or
wound
impact site:
• deep diathermy (involving choroid, not just retina; use the highest power of
the diathermy machine);
• destroy retina and choroid so that a 1 mm “ring” of bare sclera around the
incarceration site remains;
• if wound is too close to fovea, appropriately reduce the width of the
ring juxtafoveally but keep it 1 mm elsewhere;
• no need to trim proliferative tissue plugging the exit/rupture wound;
• use forceps to gently lift remaining retina, verifying that remaining retinal
edge is free of any tissue connection;
• perform laser cerclage around
and in periphery;
• use silicone oil or gas for tamponade;
• inject 4 mg
intravitreally at
the
end of surgery, unless contraidicated (glaucoma).
• Do not use scleral buckle.
• If lens was removed
surgeon’s decision whether the posterior
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Prospective eye injury study
Management protocol
capsule
• IOL
implantation
surgeon’s decision; delayed implantation is preferred.
Postoperative care
• heavy topical steroids; systemic corticosteroids: surgeon’s
surgeon’s
• intravenous/intravitreal antibiotics
surgeon’s
decision;
decision
decision
Primary comprehensive surgery
All elements/steps described above apply, but all done in a single surgical setting.
Follow-up
Length: Minimal follow up of
months
whether or not oil removed.
One year follow up preferred.
V
Surgeon’s decision; visits at 1 month and 3 months post
secondary surgery preferred.
Documentation
• Video
of the surgeries requested.
• Copy of surgery description requested, with schematic drawing of wound/s.
• Photographs
• Macular OCT at final visit (6 months) requested.
Data entry to database
• fill out initial report form no later than 1 week after injury;
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Prospective eye injury study
Management protocol
• submit interim and final reports within 2 weeks after then examination.
All requested details must be reported on.
Literature to use if necessary
Kuhn, F., Teixeira, S., Pelayes, D. Late versus prophylactic chorioretinectomy for the
prevention of trauma-related proliferative chorioretinectomy.
Ophthalmic Research 48 S1:331-37, 2012
Kuhn, F., Mester, V., Morris, R. A proactive treatment approach for eyes with perforating
injury.
Klinische Monatsblatter für Augenheilkunde 221: 622-628, 2004
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