Early versus Delayed Timing of Primary Repair after Open-Globe Injury: A Systematic Review and Meta-analysis.

TOPIC: The timing of primary repair of open-globe injury is variable in major trauma centers worldwide, and consensus on optimal timing is lacking. CLINICAL RELEVANCE: Surgery is the mainstay of open-globe injury management, and appropriate timing of surgical repair may minimize the risk of potentially blinding complications such as endophthalmitis, thereby optimizing visual outcomes. METHODS: A systematic literature review was performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines (International Prospective Register of Systematic Reviews identifier, CRD42023442972). The Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and ISRCTN registries and ClinicalTrials.gov were searched from inception through October 29, 2023. Prospective and retrospective nonrandomized studies of patients with open-globe injury with a minimum of 1 month of follow-up after primary repair were included. Primary outcomes included visual acuity at last follow-up and the proportion of patients with endophthalmitis. Certainty of the evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. RESULTS: Fifteen studies met inclusion criteria, reporting a total of 8497 eyes. The most common injury types were penetrating and intraocular foreign body (IOFB). Meta-analysis found that primary repair less than 24 hours after open-globe injury was associated with 0.30 odds of endophthalmitis compared with primary repair conducted more than 24 hours after trauma (odds ratio, 0.39; 95% confidence interval [CI], 0.19-0.79; I2 = 95%; P = 0.01). No significant difference was found in reported visual outcomes between patients whose open-globe injuries were repaired more than, compared with less than, 24 hours after trauma (odds ratio, 0.89; 95% CI, 0.61-1.29; I2 = 70%; P = 0.52). All included studies were retrospective and nonrandomized, demonstrating an overall low certainty of evidence on GRADE assessment. DISCUSSION: Only retrospective data exist around the effect of timing of open-globe repair, resulting in low certainty of the available evidence. However, this review of current evidence, predominantly including penetrating and IOFB injuries, suggests that primary repair performed less than 24 hours after open-globe injury is associated with a reduced endophthalmitis rate compared with longer delays, consistent with delay to primary repair increasing endophthalmitis risk. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

The Risk of Sympathetic Ophthalmia Associated with Open-Globe Injury Management Strategies: A Meta-analysis.

TOPIC: Sympathetic ophthalmia (SO) is a sight-threatening granulomatous panuveitis caused by a sensitizing event. Primary enucleation or primary evisceration, versus primary repair, as a risk management strategy after open-globe injury (OGI) remains controversial. CLINICAL RELEVANCE: This systematic review was conducted to report the incidence of SO after primary repair compared with that of after primary enucleation or primary evisceration. This enabled the reporting of an estimated number needed to treat. METHODS: Five journal databases were searched. This review was registered with International Prospective Register of Systematic Reviews (identifier, CRD42021262616). Searches were carried out on June 29, 2021, and were updated on December 10, 2022. Prospective or retrospective studies that reported outcomes (including SO or lack of SO) in a patient population who underwent either primary repair and primary enucleation or primary evisceration were included. A systematic review and meta-analysis were carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Random effects modelling was used to estimate pooled SO rates and absolute risk reduction (ARR). RESULTS: Eight studies reporting SO as an outcome were included in total. The included studies contained 7500 patients and 7635 OGIs. In total, 7620 OGIs met the criteria for inclusion in this analysis; SO developed in 21 patients with OGI. When all included studies were pooled, the estimated SO rate was 0.12% (95% confidence interval [CI], 0.00%-0.25%) after OGI. Of 779 patients who underwent primary enucleation or primary evisceration, no SO cases were reported, resulting in a pooled SO estimate of 0.05% (95% CI, 0.00%-0.21%). For primary repair, the pooled estimate of SO rate was 0.15% (95% CI, 0.00%-0.33%). The ARR using a random effects model was -0.0010 (in favour of eye removal; 95% CI, -0.0031 [in favor of eye removal] to 0.0011 [in favor of primary repair]). Grading of Recommendations, Assessment, Development, and Evaluations analysis highlighted a low certainty of evidence because the included studies were observational, and a risk of bias resulted from missing data. DISCUSSION: Based on the available data, no evidence exists that primary enucleation or primary evisceration reduce the risk of secondary SO. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Temporary keratoprosthesis and primary corneal graft for ocular trauma: a systematic review and meta-analysis.

PURPOSE: When severe retinal and corneal injury occur together, a temporary keratoprosthesis (TKP) is often a last resort to allow posterior segment visualization to enable vitreoretinal surgery, followed by a penetrating keratoplasty (PKP) which can restore corneal clarity in a single operation. We aimed to assess visual outcomes following combined PKP and vitreoretinal surgery with the use of a TKP for cases of ocular trauma. DESIGN: A systematic literature review was performed following PRISMA guidelines (PROSPERO registration number: CRD42023423518). METHODS: CENTRAL, MEDLINE, Embase, ISRCTN registry and ClinicalTrials.gov were searched from inception to 27 April 2023. Randomized and non-randomized studies assessing visual outcomes after combined vitreoretinal surgery and PKP with the use of a TKP after ocular trauma were eligible for inclusion. Outcomes included change in best corrected visual acuity, corneal graft survival and retinal reattachment at final follow up. Proportional meta-analysis was used to estimate the overall rate of the primary outcomes. Risk of bias for non-randomized studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist for case series. RESULTS: A total of 19 studies met inclusion criteria reporting a total of 352 eyes. All studies were retrospective and non-randomized with follow up times ranging from 6 to 91 months, with at least 79% of outcomes reported after 6 months. After combined surgery the rate of corneal graft survival was 52% (95% CI 0.41-0.62; I2 60%) successful retinal attachment was 79% (95% CI 0.73-0.84; I2 0%). and improved visual acuity, when compared to no change or decrease in visual acuity, was 45% (95% CI 0.32-0.59; I2 66%). CONCLUSION: Patients with severe injury affecting the anterior and posterior segments have very limited treatment options. This systematic review found that when combined vitreoretinal surgery and PKP with a TKP are performed, approximately half of corneal grafts survive, anatomically successful retinal reattachment is likely, and a similar proportion of patients benefit in terms of improved visual acuity, compared to their preoperative function. This systematic review of the available literature may help inform surgeons of the benefits of using a TKP for cases of ocular trauma.

The Use of Preoperative Prophylactic Systemic Antibiotics for the Prevention of Endopthalmitis in Open Globe Injuries: A Meta-Analysis.

TOPIC: This study reports the effect of systemic prophylactic antibiotics (and their route) on the risk of endophthalmitis after open globe injury (OGI). CLINICAL RELEVANCE: Endophthalmitis is a major complication of OGI; it can lead to rapid sight loss in the affected eye. The administration of systemic antibiotic prophylaxis is common practice in some health care systems, although there is no consensus on their use. METHODS: PubMed, CENTRAL, Web of Science, CINAHL, and Embase were searched. This was completed July 6, 2021 and updated December 10, 2022. We included randomized and nonrandomized prospective studies which reported the rate of post-OGI endophthalmitis when systemic preoperative antibiotic prophylaxis (via the oral or IV route) was given. The Cochrane Risk of Bias tool and ROBINS-I tool were used for assessing the risk of bias. Where meta-analysis was performed, results were reported as an odds ratio. PROSPERO registration: CRD42021271271. RESULTS: Three studies were included. One prospective observational study compared outcomes of patients who had received systemic or no systemic preoperative antibiotics. The endophthalmitis rates reported were 3.75% and 4.91% in the systemic and no systemic preoperative antibiotics groups, a nonsignificant difference (P = 0.68). Two randomized controlled trials were included (1555 patients). The rates of endophthalmitis were 17 events in 751 patients (2.26%) and 17 events in 804 patients (2.11%) in the oral antibiotics and IV (± oral) antibiotics groups, respectively. Meta-analysis demonstrated no significant differences between groups (odds ratio, 1.07; 95% confidence interval, 0.54-2.12). CONCLUSIONS: The incidences of endophthalmitis after OGI were low with and without systemic antibiotic prophylaxis, although high-risk cases were excluded in the included studies. When antibiotic prophylaxis is considered, there is moderate evidence that oral antibiotic administration is noninferior to IV. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Mitomycin C in the treatment of a Schneiderian (inverted) papilloma of the lacrimal sac.

Schneiderian papillomas are benign tumours, with an aggressive nature. A case with a recurrent Schneiderian papilloma of the nasolacrimal sac, who underwent an external dacryocystorhinostomy (DCR) with irrigation of the nasolacrimal system with 0.02% mitomycin C (MMC), is presented at 18 months follow-up. External DCR using MMC, as an adjuvant therapy, is a novel approach to the treatment of Schneiderian papilloma of the nasolacrimal tract. It allows preservation of function, compared with the conventional treatment of dacryocystectomy.

Nuclear magnetic resonance analysis of emulsified silicone oil RMN-3 (Oxane HD).

BACKGROUND: Oxane HD is a mixture of 5700 cs silicone oil and RMN-3 (a partly fluorinated olefin), which has a specific gravity greater than water, thereby enabling endotamponade of inferior retinal breaks. Droplets of emulsified oil were found in the anterior chamber of two patients with complex retinal detachments who had been treated with Oxane HD. Samples removed from these two eyes were analysed in order to investigate the nature of the emulsified substance. METHODS: Samples were dissolved in CDCl3 and, if necessary, dried using magnesium sulphate. Nuclear magnetic resonance (NMR) was used to compare these samples with the unused commercial product. RESULTS: NMR analysis of the samples removed from the anterior segment of both eyes were mainly silicone oil with only trace amounts of RMN-3. Samples taken from different areas of an unused syringe of Oxane HD demonstrated varying concentrations of the RMN-3 compound within the silicone oil. CONCLUSION: First, the mixture of RMN-3 and silicone oil is not homogenous either in vitro or in vivo. Second, emulsified oil found in the anterior chamber is composed almost entirely of silicone oil, containing only trace amounts of RMN-3.

Mass and shape as factors in intraocular foreign body injuries.

OBJECTIVES: To relate the nature, mass, and shape of intraocular foreign bodies (IOFBs) in a consecutive series of 69 patients to the mechanism, location, and visual outcome of the injuries and to compare these outcomes with data collected in our department over the last 70 years. DESIGN: Interventional case series of consecutive patients with IOFBs. PARTICIPANTS: Sixty-nine patients with unilateral IOFBs. INTERVENTION: All patients underwent surgical removal of the IOFB. MAIN OUTCOME MEASURES: Patient data included best-corrected visual acuity (BCVA), imaging and complication rates. For the IOFBs, material, mass, shape, and entry site were determined. RESULTS: The IOFB was metallic in 91% of cases. All but 2 patients were male (mean age, 37). Increasing IOFB mass was associated with posterior segment injury, retinal impact, presenting and final BCVAs< or =20/200, the need for a primary globe repair before secondary IOFB removal, increasing complications, and the development of retinal detachment. Blade-shaped IOFBs penetrated to the posterior segment (97%) more frequently (P<0.05) than disc (74%), cylinder (7.5%), or sphere (7.5%) shapes despite having the second lowest mass. Two patients were shown to have a second previously unrecognized IOFB on computed tomography (CT). Overall, 49% of patients experienced some sort of complication as a result of their injury. The development of endophthalmitis was associated with the failure to use prophylactic systemic antibiotics. There was no association between increased time to IOFB removal and the development of endophthalmitis. The frequency of posterior vitreous detachment was not increased in eyes with more severe injury or those in which surgery was deferred. Final BCVA> or =20/40 was achieved in 56% of the patients. CONCLUSIONS: Intraocular foreign bodies of greater mass were associated with worse outcomes. We have observed an 82% reduction in number of IOFB injuries presenting over the last 70 years and outcomes have improved with advances in surgical technique. We advise that all patients with a visible or suspected IOFB be investigated with x-ray or CT and that they should all receive systemic antibiotics. We detected no advantage or disadvantage in delaying surgery until optimal surgical expertise and/or environment is available.

Triamcinolone during pars plana vitrectomy for open globe trauma: a pilot randomised controlled clinical trial.

PURPOSE: To investigate the feasibility of conducting a randomised controlled trial in patients undergoing pars plana vitrectomy surgery following open globe trauma (OGT). Additionally, to investigate the treatment effect and toxicity of intensive anti-inflammatory agents. METHODS: A 2-year, pilot, single-centre prospective, participant and surgeon-masked randomised controlled trial (RCT). Forty patients requiring vitrectomy surgery following OGT were randomised to either standard (control) or study treatment (adjuncts) in a 1:1 allocation ratio. Perioperatively, the adjunct group received intravitreal and subtenons triamcinolone acetonide, oral flurbiprofen and guttae prednisolone acetate 1%. The control group received standard care. Primary outcome was anatomical success at 6 months. Secondary outcomes included final visual acuity, occurrence of proliferative vitreoretinopathy, intraocular pressure rise, number of operations and recruitment rate. RESULTS: 40 patients were recruited within 21 months. Primary outcome assessment showed similar results in anatomical success with 50% (10/20) in the adjunct group compared with 47% (9/19) in the standard group (OR 1.11, 95% CI 0.316 to 3.904). Visual outcomes were better in the adjunct group with a final median visual acuity of 31 Early Treatment Diabetic Retinopathy Study (ETDRS) letters compared with 25 ETDRS letters in the standard group. A higher proportion of patients gained 10, 20 and 30 ETDRS letters in the adjunct group (80%, 65% and 50%, respectively) compared with the standard group (52.6%, 52.6% and 42.1%). Fewer adjunct patients (15%, n=3) had poor visual outcomes (Zero ETDRS letters) compared with 42.1%, (n=8). CONCLUSIONS: An RCT in this population is deliverable and estimated recruitment rates are realistic. Results and patient discussions determined that the definitive study should have vision as a primary outcome. This pilot study is supportive of there being a positive treatment effect of intensive anti-inflammatory agents in OGT. TRIAL REGISTRATION NUMBER: European Clinical Trials Database 2007-005138-35; Results.

Small optical zones with aspheric profiles in laser refractive surgery for myopia: a surgical outcome and patient satisfaction study.

PURPOSE: To assess the outcomes of small optical zone (OZ) ablations used in conjunction with large transition zones (TZ) and a highly aspheric treatment profile. METHODS: Interventional case series of 39 consecutive patients with myopia or myopic astigmatism. Patient data included pre and postoperative refraction and visual acuities, laser treatment settings and pre and postoperative corneal topography as well as questionnaire responses about the use of glasses and the quality of vision postoperatively. RESULTS: The mean preoperative spherical equivalent was -4.50±2.11 dioptres (D) and the mean OZ and TZ diameters were 4.5±0.5mm and 8.1±0.4mm, respectively. The mean patient age was 40.7±10.4 years. Manifest spherical refraction was within ±0.5D in 87% of patients (±1.0D in 99%) and cylindrical refraction within 0.5D in 79% (≤1.0D in 95%). The need to wear distance glasses postoperatively was associated with dissatisfaction with the quality of daytime vision (p=0.05) and unhappiness with night vision was associated with symptoms of halos (p=0.03) and starbursts (p=0.02). The proportion of patients reporting symptoms of dysphotopsias included: ghosting 0%; glare 2%; halos 10%; and starbursts 15%. There was a significant difference in the measured mean effective OZ diameter (4.8±0.3mm) compared to the mean programmed OZ (4.5±0.5mm, p=0.00). CONCLUSIONS: Small ablation zones, when used in conjunction with a large diameter TZ, do not lead to a greater incidence of unwanted visual phenomena over that reported by many studies with larger OZs.

A pilot study of intraocular use of intensive anti-inflammatory; triamcinolone acetonide to prevent proliferative vitreoretinopathy in eyes undergoing vitreoretinal surgery for open globe trauma; the Adjuncts in Ocular Trauma (AOT) Trial: study protocol for a randomised controlled trial.

BACKGROUND: Eyes sustaining open globe trauma (OGT) is a group at high risk of severe visual impairment. Proliferative vitreoretinopathy (PVR) is the commonest cause of retinal redetachment in these eyes and is reported to occur in up to 45% of cases. Intensive anti-inflammatory agents have been shown to be effective at modifying experimental PVR and to be well tolerated clinically.The Adjuncts in Ocular Trauma (AOT) Trial was designed to investigate the benefits of using intensive anti-inflammatory agents (intravitreal and sub-Tenon's triamcinolone, oral flurbiprofen and guttae prednisolone 1.0%) perioperatively in patients undergoing vitrectomy surgery following open globe trauma. METHODS/DESIGN: Patients requiring posterior vitrectomy surgery following open globe trauma will be randomised to receive either standard treatment or study treatment. Both groups will receive the standard surgical treatment appropriate for their eye condition and routine perioperative treatment and care, differing only in the addition of supplementary adjunctive agents in the treatment group. The investigated primary outcome measure is anatomical success at 6 months in the absence of internal tamponade. DISCUSSION: This is the first randomised controlled clinical trial to investigate the use of adjunctive intensive antiinflammatory agents in patients undergoing vitrectomy following open globe trauma. It will provide evidence for the role of these adjuncts in this group of patients, as well as provide data to power a definitive study. EUDRACT NO: 2007/005138/35.