Reasonableness of surgical interventions in eyes with no light perception after severe ocular trauma.

Dear Editor,

Ocular trauma (OT) is a common cause of monocular blindness or severe visual impairment amongst the young adults in working age. Eyes with no light perception (NLP) at initial presentation after injury tend to have a poor visual prognosis, and therefore, ophthalmologists commonly advocate primary enucleation or rather refrain from further surgical interventions (Matthews et al. 1998; Salehi‐Had et al.2009; Soni et al. 2013). In this case series, we present our results in patients with NLP regarding visual and anatomical outcome, as well as the necessity for further surgical interventions (Fig. 1).

Fig. 1

(A): Intraoperative imaging of surgical repair of a bulbus rupture resulting in NLP due to blunt contusion with a piece of wood (B): postoperative image.

This is a retrospective chart review performed at the Department of Ophthalmology, Medical University of Graz. The study was approved by the local ethics committee. We reviewed medical charts of patients who presented at our emergency department with confirmed NLP due to OT. Assessment of NLP was performed by two independent examiners using the bright illumination of an indirect ophthalmoscope. All patients received surgical primary repair within 24 hr. Continuous data were presented as mean ± standard deviation (range). To facilitate statistical analysis the visual acuity in Snellen and semiquantitative measurements were converted into logMAR. Accordingly, light perception (LP), hand motion (HM) and counting fingers (CF) were represented as 3 logMAR, 2.28 logMAR and 1.98 logMAR, respectively (Lange et al. 2009).

Overall, 19 eyes of 19 patients were enrolled. Of these, 6 were female and 13 were male. The patients´ age averaged 50.4 ± 26.7 years (9–86). All patients had NLP (>3 logMAR) at the initial presentation due to fall (n = 7), blunt injury (n = 5), sharp injury (n = 3) and fireworks (n = 4) resulting in open globe injuries. Ocular Trauma Score was 1 in 18 patients and 2 in 1 patient, predicting a final visual outcome of NLP in 74% and 27%, respectively (Kuhn et al. 2002). Overall, 2.7 ± 1.2 surgeries (1–6, in total 51), were necessary to establish the final outcome. All patients received detailed information about the prevalent findings and the potential prognosis, comprising multiple further surgical interventions and expressed their wish for a bulb preserving approach. In detail, apart from the primary wound closure including excision of prolapsed intraocular tissue and corneal or scleral suture 29 reconstructive surgeries of the posterior pole (24 vitrectomies including retinectomy and gas or silicone‐oil tamponade, 4 retinal laser coagulations—aside within vitrectomies, and 1 intravitreal injection), and 19 surgeries of the anterior segment (7 penetrating keratoplasties, 7 anterior chamber lavages, 3 iris reconstructions and 2 lensectomies with intraocular lens implantation) were performed, one eye had to be enucleated because of a second severe trauma 3 months after primary wound repair. Follow up accounted for a median of 10 months (6–48). The final visual acuity was NLP in 5 patients including the patient who underwent enucleation, and 2.68 ± 0.45 logMAR (3–1.8) in 14 patients. In detail 9 patients achieved LP, 3 HM, 1 CF and 1 1.52 logMAR. Bulb rupture was found to accompany with better visual outcome compared to penetrating injury caused by blunt trauma. Detached or nearly completely destroyed retina due to the trauma was the cause for NLP as final visual acuity. Therefore, 74% of patients regained a visual acuity of LP or better. This finding stands in contrast to the findings of Kuhn et al. predicting a visual acuity of NLP in 74% of cases (Kuhn et al. 2002). All patients 18, comprising these with NLP, were satisfied with their decision to choose a bulb preserving approach. None had to be enucleated because of pain or cosmetic unsatisfying outcome. The intraocular pressure was hypotonic (<10 mmHg) in 13 eyes, normotonic, defined as 11–20 mmHg, in 3 and hypertonic (>20 mmHg) in 2 patients. With surgical interventions following the primary wound closure, the retina could be attached in 8 patients. In 7 eyes, the retina detached in the follow‐up and in 3 eyes the retina was missing except for peripheral rests.

Our study shows that in eyes with NLP due to severe OT some visual function could generally be restored despite the primarily poor prognosis. In addition, a suitable anatomical outcome could be achieved and consequently, the psychological burden of the complete loss of the eye could be avoided. Although in some cases the individual decision of the surgeon, based on the extent of the injury or other circumstances, could favour primary enucleation, the mere absence of light perception at initial presentation should not be used as determining decision key.