Timing and staging of intervention critical in open-globe trauma

When treating a patient who has sustained an open-globe trauma, the clinician can conduct a staged or a comprehensive evaluation, the choice of which may be critical for the visual recovery of the patient, according to Ferenc Kuhn, MD, PhD, University of Alabama at Birmingham, United States.

Dr. Kuhn focused his discussion on the impact of the timing of treatment on the visual outcome.

In open-globe trauma, defined by a full-thickness ocular wound and posterior segment involvement, the outcome is determined by the initial mechanical damage, intervention, and body response to the treatment, Dr. Kuhn commented.

With the exception of cases of endophthalmitis, which require immediate intervention and comprehensive reconstruction, the clinician can use the most commonly performed staged approach for a patient with an open-globe trauma, consisting of either wound closure and a secondary comprehensive reconstruction (vitrectomy) at approximately day 10 after injury or wound closure, vitrectomy, and other necessary steps as part of the primary comprehensive reconstruction.

"An advantage of the staged approach is that there is no need for a detailed ocular evaluation; the evaluation is stopped once the wound is identified followed by wound closure," he said. "Exhaustive evaluation exposes the eye to further risk and identification of the wound followed by closure eliminates the potential for an expulsive hemorrhage."

Another advantage is that by restricting the evaluation to the basics, the surgery can be performed efficiently and appropriately. After the initial evaluation there is then time to further evaluate the eye and obtain the expertise of other specialists, form a strategy for further treatment, counsel the patient, allow the corticosteroids to reduce inflammation and improve visualization, and schedule and prepare the operating room.

The second option, the primary comprehensive approach, has the advantage of fewer surgical procedures, lower cost, prevention of endophthalmitis, and immediate access to posterior segment pathologies.

Deciding which approach to use is not found in evidence-based medicine, Dr. Kuhn pointed out, and the decision is based on clinician experience.

"In theory, a comprehensive primary approach has more advantages but also more risks, such as expulsive hemorrhage and potential primary enucleation," he said. "With the staged approach, the physician controls infection, inflammation, and IOP."

He advised surgeons not to simply follow their instincts but to devise a plan with which to approach surgery to cover all unexpected contingencies.