Open Globe Management

Alessandro A. Castellarin, MD; Dante J. Pieramici, MD

Disclosures

Compr Ophthalmol Update. 2007;8(5):111-124. 

In This Article

Initial Management and Perioperative Considerations

Surgical reconstruction of a severely traumatized globe is typically a complex procedure. If, for whatever reason, an ophthalmologist cannot appropriately address all treatable lesions that require acute management, it is usually preferable not to perform any surgery but to refer the patient.[8]

The incidence of endophthalmitis following penetrating injuries is 5% to 14% as reported in different studies.[9,10] In the USEIR, the incidence is 2.6%, and is more common in males than in females. The incidence of endophthalmitis is higher in patients whose trauma occurs in a rural setting (30%) or involves an IOFB (10% to 15%).[11]

Infections with more than one organism are common (up to 48%), and they are usually caused by a specific range of microorganisms, of which Bacillus species and coagulasenegative staphylococcus are the most prevalent. Risk factors for infection include 1) retained IOFB, 2) a rural injury setting, 3) delay in primary wound closure, and 4) disruption of the crystalline lens. Early symptoms include photophobia, pain out of proportion to the clinical findings, and visual loss worse than media opacities. Among clinical signs of endophthalmitis, hypopyon, vitritis, and retinal periphlebitis are more specific. Fungal endophthalmitis is more common in the settings of IOFB (if vegetable matter) and of soil contamination. Systemic, topical, periocular, and intraocular antibiotics may reduce the incidence of endophthalmitis.[12]

Antibiotics with adequate intraocular penetration along broad coverage for the most common pathogens of traumatic endophthalmitis should be chosen. Intravenous vancomycin has good intraocular penetration and is effective against Bacillus, streptococcus and staphylococcus.[13] Intravenous ceftazidime provides adequate coverage for gram-negative and has good intravitreal penetration.[14,15] Oral gatifloxacin, moxifloxacin, and ciprofloxacin have good intraocular penetration and can be a viable alternative if the patient is discharged home after surgical repair.[16,17] We currently use oral moxifloxacin (Avelox®, Bayer HealthCare Pharmaceuticals, Wayne, NJ) or ciprofloxacin for 7 days as prophylaxis against infection.

In addition to systemic antibiotics, topical antibiotics (gatifloxacin or moxifloxacin) and subconjunctival antibiotics (vancomycin and ceftazidime) are generally used. Unfortunately, all of these ways of administration may still be inadequate for prophylaxis. Therefore, in selected cases of open globe injuries suspected at high risk for developing endophthalmitis, intravitreal injection of vancomycin (1 mg/0.1 ml) and ceftazidime (2 mg/0.1 ml) should be considered immediately after primary repair.

Just recently, the results of a multicenter, randomized, doublemasked controlled study to evaluate the efficacy of intraocular gentamicin sulfate and clindamycin in the prevention of acute post-traumatic bacterial endophthalmitis following penetrating eye injuries were published. Following primary repair, eyes were randomized to intracameral or intravitreal injection of 40 micrograms of gentamicin sulfate and 45 micrograms of clindamycin (cases) versus balanced salt solution (controls). Endophthalmitis occurred in eight (2.3%) of 167 eyes in the control group and in only one (0.3%) of 179 eyes in the case group (P = .04). In eyes with an IOFB, endophthalmitis developed in seven of 25 control eyes and in none of 27 eyes receiving antibiotics. The study also found that intravitreal injection was superior to intracameral injection in preventing endophthalmitis.[18]

In the absence of signs of clinical infection, the use of prophylactic intravitreal antibiotics is controversial, but some consider it in cases at particular risk for infection (e.g., rural injury). Current intravitreal antibiotics, such as vancomycin and ceftazidime, are generally well-tolerated. We recommend considering intravitreal injection only when the posterior pole can be visualized or evaluated with B-scan ultrasonography. Antifungal prophylaxis for open globe injuries is not recommended.

Timing of repair varies according to the specific details of the injury. Rarely, wounds require immediate closure, and it may be advantageous to wait a few hours until appropriate equipment or personnel are available. The risk of endophthalmitis does not significantly increase in the first 24 or 36 hours.[9,19] Urgent repair should be considered for high-risk IOFB and endophthalmitis. Eye injuries with IOFB and open wounds should be performed within 24 hours. Repair of retinal detachment, if present, can be delayed by several days, especially if secondary reconstruction is necessary.

General anesthesia is usually preferred, as it does not require retrobulbar/peribulbar injections, which could worsen tissue extrusion. Local anesthesia (peribulbar or retrobulbar) can also be employed if a patient cannot tolerate general anesthesia; some investigators have reported successful closure of open globe injuries using local anesthesia.[20,21]

Management of ocular trauma is complex and varies for each individual and each trauma. It is accepted practice to primarily repair the wound (close the eye) and then delay the secondary reconstruction for days to weeks. The advantages of primary wound closure are the following:

1) Most surgically trained ophthalmologists should be able toperform the procedure.

2) Primary wound closure reduces the risk of intraoperative bleeding, allowing time for the primary wound to heal and the corneal opacities to clear, when present.

3)Primary wound closure might allow time for the development of vitreous separation that would facilitate vitrectomy.

4)Primary wound closure allows a better evaluation of the eye’s condition postoperatively; this evaluation can be done using ultrasonography.

5)Primary wound closure allows the ophthalmologist the opportunity to consult experts with subspecialty training; such consultations may be necessary for secondary repair.

Conversly, the advantages of comprehensive management of the traumatized eye are:

1)Comprehensive management is less expensive.

2)Comprehensive management offers potential prevention of endophthalmitis by removing the inoculated media.

3)Comprehensive management offers the potential reduction of post-injury inflammation and the prevention of scar tissue formation, such as proliferative vitreoretinopathy (PVR), again by removing stimulating factors (cytokines) present in the vitreous cavity.

4)Comprehensive management offers earlier visual rehabilitation.

Initial comprehensive management of the injured eye often entails a poleto- pole approach and requires ophthalmologists that are fully trained to work on the anterior as well as the posterior segment of the eye or to have a comprehensive team available. There is currently an ongoing multicenter clinical trial investigating the comprehensive approach; such research will help to answer these controversies.

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