He Y, Zhang L, Wang F, et al. Timing influence of outcomes of vitrectomy for open-globe injury: A prospective randomized comparative study. Retina April 2020; 40:725-734.
Ocular trauma is still one of the leading causes of blindness and visual impairment worldwide. Many incidences of open-globe injury involve damage to the posterior pole, which necessitates vitrectomy surgery either subsequent to or in conjunction with primary repair. The optimal timing of vitrectomy after open globe injury is still controversial. This prospective randomized comparative study of 53 patients with open globe injury recruited between April 2011 and June 2017 was performed to determine whether early or delayed repair led to superior outcomes.
All patients underwent primary debridement and wound repair within 24 hours of trauma. The early vitrectomy group had surgery within 4 days while the delayed vitrectomy group received surgery between 10 and 14 days after injury. All participants underwent a 23-gauge pars plana vitrectomy, with lensectomy, membrane peeling, or laser performed as necessary. Silicone oil, balanced salt solution (BSS) or perfluoropropane (C3F8) were used for tamponade. No adjunctive scleral buckles were performed. There were no statistically significant differences in demographic, clinical characteristics, or extent of injury between the two groups at baseline. Of note, vitreous hemorrhage (94%), retinal detachment (87%), and lens rupture (54%) were the most common concomitant ocular injuries.
The rate of PVR was significantly higher (P=0.000) in the delayed surgery group (76%) compared to the early surgery group (5%). At 6-month followup, 83% of eyes in the early surgery group achieved reattachment with a single surgery versus 32% of eyes in the delayed surgery group (P=0.001). However, an additional 11% of the early group and 36% of the delayed group achieved reattachment by the second surgery, leading to a difference in reattachment rates that was no longer statistically significant (P=0.142). Additionally, 38% of the early surgery group gained ≥3 lines of vision and 52% gained between 1 and 3 lines of vision, versus 12% and 48% of the delayed surgery group, respectively.
The major conclusion of this study is that early vitrectomy, within 4 days after injury, leads to better anatomic and functional outcomes. The authors observed that the significantly higher incidence of PVR in eyes in the delayed surgery group increased the difficulty of surgical intervention and caused them to have a higher susceptibility to relapse of PVR; they therefore posited that early vitrectomy may slow or halt the progression of fibroblastic tissue formation within the vitreous.
While this article is limited by its small sample size and short followup period, the study provides a compelling argument for early vitrectomy due to its randomized, prospective design with equitable allocation of eyes to each group. A larger randomized clinical trial with a longer follow-up in the future would be needed to confirm these findings.
Judy Chen, MD
West Coast Retina
California Pacific Medical Center
San Francisco, CA