Open globe injuries are one of the most sight-threatening eye “diseases” in ophthalmology. Prior to the acute diagnosis and treatment of an open globe injury, a brief medical history should be performed to provide valuable information about the underlying responsible mechanisms and structural damages that have to be expected[18].
The spectrum of open globe injuries ranges from isolated corneal cuts to complex severe traumas involving various ophthalmic structures. Consequently, the prognosis for visual acuity also ranges from very good, such as in cases with only peripheral corneal defects, to a significantly reduced vision in cases with severe ocular trauma involving the posterior segments of the eye. Often, perforations of the cornea also affect the iris, lens and/or ciliary body. Permanent consequences can be traumatic mydriasis, irido-dialysis or partial as well as total defects of the iris and secondary glaucoma. The primary aim of the surgical treatment in those cases is a watertight re-adaptation of the wound edges with fine monofilament sutures (usually 10.0 nylon sutures). If the lens capsule is damaged in the process, the consequence is usually a traumatic cataract with the necessity for a lens exchange. Because the traumatic cataract is not always visible pre- or intraoperatively, the IOL replacement is performed in a second surgery after the acute phase. In severe blunt ocular trauma, common locations for ruptures of the globe are very often the area around the limbus, the thinnest parts of the sclera directly behind the insertion of the rectus muscles or preformed incisions from earlier ocular interventions. The primary aim of the surgical treatment in those cases is a rapid wound closure (e.g. with 7.0 vicryl sutures). A retinal detachment can occur directly due to the trauma or secondarily because of proliferation and subsequent traction of fibro-vascular or vitreo-proliferative tissue. The aim of surgical treatment in cases of retinal detachment is re-attachment of the retina including ensured retinal holes or tears. This can be achieved with scleral buckling or with vitrectomy including the use of gas or, in some cases, silicone oil, see Fig. 3.
The appropriate antibiotic prophylaxis for cases of open-globe injuries without presenting infection is controversial. In our clinic, we support the use of topical as well as systemic antibiotics (Cefuroxime 3 × 500 mg/d). Despite of this precaution, we observed eight patients with posttraumatic endophthalmitis over the course of postoperative treatment and follow up observation[19].
The mean age of all included patients was 42.9 ± 22.2 years, the vast majority of the relatively young patients were male and in working age. Thus, long-term consequences such as the inability for three-dimensional vision due to significantly reduced visual acuity with consequent restrictions regarding certain types of work and workplaces has also significant economic impacts beyond the health care system alone.
Open globe injuries are a very heterogeneous group of patients. This leads to mostly individual, not standardized treatments and management of the traumas. The prognosis of visual acuity depends on the mechanism of the trauma, the location of the wound and the damaged ocular structures.
In our analysis, patients with open globe injuries affecting the posterior segment had a significantly worse BCVA outcome than patients suffering from injuries not involving the posterior segment. This difference in BCVA was reduced to a non-significant trend if the posterior segment involvement was only the vitreous. Our interpretation of the evaluated data is that damaged retina or the optic nerve in open globe injuries are associated with a significantly worse postoperative BCVA outcome.
One of the limitations is the retrospective character of our work which allows for careful but still solid interpretations and conclusions due to its relatively high number of included cases. Another aspect is the heterogeneity of the trauma patients with individualized surgical approaches with the difficulty to classify and subdivide into standardized subgroups. We tried to compensate for those limitations with a relatively large number of included patients over time and a simple classification into injuries with and without involvement of the posterior segment. Further analyses have to be done to evaluate the functional outcomes of those patients over longer time periods in order to better identify possible prognostic factors for a good visual outcome and/or following complications over time other than the initial involvement of the posterior segment.