Simultaneous Bilateral Open-Globe Repair and Vitreoretinal Surgery for Explosive-Related Ocular Injury

Abstract

Purpose: To report an approach to explosive injuries with simultaneous, co-surgeon bilateral ruptured globe repair and pars plana vitrectomy for bilateral intraocular foreign bodies (IOFBs). Methods: A case and its findings were analyzed. Results: A 31-year-old man had bilateral vision loss after an air compressor malfunction that caused a high-pressure explosion to his face. An examination showed bilateral open-globe injuries and IOFBs, necessitating urgent repair. Given the risk for endophthalmitis and the need for expeditious repair, open-globe repair surgery was performed in both eyes simultaneously by co-surgeons followed by pars plana lensectomy, vitrectomy with IOFB removal, and silicone oil placement. The final visual acuity after bilateral scleral-fixated intraocular lens implantation was 20/20 OD and 20/25 OS. Conclusions: This case of bilateral open-globe injuries and IOFBs required expeditious repair with bilateral, simultaneous surgery that ultimately resulted in excellent visual outcomes. Simultaneous surgery may be an option for bilateral ocular trauma.

Introduction

Ocular trauma is a significant cause of blindness in young adults. ¹ Traumatic endophthalmitis is a dreaded complication of ocular trauma, and the presence of an intraocular foreign body (IOFB), particularly if contaminated with organic matter, significantly increases the risk for post-traumatic endophthalmitis. ² Rapid repair of penetrating and perforating injuries as well as removal of the IOFB are critical for the best possible visual outcome, with several studies reporting an increased risk for endophthalmitis if treatment is delayed. ²

Potential reasons for a delay in ocular trauma repair include patient transport to a trauma center, surgeon and operating room availability, the need to address concurrent medical morbidities secondary to the trauma (eg, surgical repair of life-threatening injuries), and repair of the first eye in the case of bilateral eye trauma. With delay in treatment as a risk factor for endophthalmitis and a decreased visual outcome, expeditious repair is critical to maximize potential visual recovery.

We describe a simultaneous, bilateral, co-surgeon approach that includes open-globe repair and pars plana vitrectomy (PPV) to remove IOFBs. Although same-day bilateral cataract surgery ³ and pediatric vitreoretinal surgery ⁴ have been described, we report a new approach to simultaneous open-globe repair and IOFB removal in a patient with an explosion-related injury that required urgent repair.

Case Report

A 31-year-old man with no significant ocular history presented to the emergency department with bilateral vision loss and eye pain after an air compressor malfunction that resulted in a high-pressure explosion to his face. This threw him several yards. He lost consciousness and his left arm was fractured and casted at an outside hospital, resulting in delayed presentation for his eye trauma evaluation. The visual acuity (VA) was counting fingers at less than 1 ft OD and light perception OS. Intraocular pressures (IOPs) could not be obtained, and an external examination showed multiple shrapnel facial skin lacerations with dirt and sludge.

A slitlamp examination of the right eye showed a subconjunctival hemorrhage, a 2.0 mm hyphema, superior iridodialysis, and a traumatic cataract with no view to the posterior pole. The left eye showed a subconjunctival hemorrhage with a temporal scleral laceration, numerous corneal metallic debris, a total hyphema, and a traumatic cataract with no view to the posterior pole. A computed tomography scan showed multiple hyperdense lesions bilaterally in the eyelids, superficial ocular structures, and vitreous cavities along with intraocular air pockets and a suprachoroidal hemorrhage in the left eye, all consistent with bilateral open-globe injuries with metallic IOFBs (Figure 1). Intravenous (IV) moxifloxacin was started. Because of the surgical urgency of the case given that both eyes had severely contaminated wounds for an estimated 12 hours, leading to a high risk for endophthalmitis, the decision was made to repair both eyes in tandem.

Figure 1.

A preoperative computed tomography (CT) scan shows bilateral metallic foreign bodies. A brain CT scan without contrast obtained before surgery indicates the presence of numerous metallic foreign bodies in and around the orbits bilaterally (arrowheads). Axial (A and B), coronal (C and D), and sagittal (E and F) slices are shown at 2 depths (slice widths, 5.0 mm).

Abbreviations: L, left; OD, right eye; OS, left eye; P, posterior; R, right.

Surgical Technique

The operating room was organized as shown in Figure 2. The scrub technician opened setup Tray 1 between a vitrectomy machine (Alcon Constellation) and Surgeon 1. Next, the circulating nurse opened a completely different instrument Tray 2 next to Surgeon 2. General anesthesia was induced, both eyes were prepped in a sterile fashion using 5% povidone–iodine, and sterile drapes were placed to allow exposure of both eyes. Both surgeons sat and operated on the temporal sides of the patient, as we previously described. ⁵ Both surgeons wore surgical loupes and headlamp illumination to aid in visualization during globe repair.

Figure 2.

Surgical setup and timeline. (A) The surgeons were seated temporally at each eye. A separate tray was placed for each eye. The scrub technician was available to assist Surgeon 1 with Tray 1, while Surgeon 2 obtained instruments directly from Tray 2. The microscope was away from the surgical field during the globe repairs while the surgeons wore surgical loupes with headlamps. (B) Timeline (in hours) for simultaneous surgical repair.

Abbreviation: PPV, pars plana vitrectomy.

Surgeon 1 initiated repair of the right eye with a 360-degree conjunctival peritomy, which revealed a 4.0 mm scleral laceration 5.0 mm from the limbus in the superotemporal quadrant, and closed the wound with several interrupted 8-0 nylon sutures. Multiple corneal metallic fragments and sludge-like debris were removed manually and with copious irrigation. Surgeon 2 simultaneously began globe repair on the more complicated traumatic injury of the left eye, first starting with a 360-degree conjunctival peritomy followed by closure of a long temporal scleral laceration using several interrupted 8-0 nylon sutures. The suprachoroidal hemorrhage was drained in the left eye using a 23-gauge cannula in the exposed suprachoroidal space while injecting a balanced salt solution via the pars plana using a 30-gauge needle. Multiple metallic foreign bodies and debris were removed from the corneal surface, and a small corneal flap was repaired with 10-0 nylon suture.

When Surgeon 1 completed the globe repair for the right eye, he brought the operative microscope over the surgical field, continued to sit temporally, and proceeded with a 23-gauge PPV. ⁵ First, anterior chamber (AC) washout and a pars plana lensectomy (PPL) were performed, followed by a complete vitrectomy with clearance of a vitreous hemorrhage. Several sub-millimeter metallic objects were noted in the vitreous cavity; the objects were washed and removed with multiple fluid–fluid exchanges. During this time, Surgeon 2 completed the globe repair for the left eye, rescrubbed, and proceeded to assist Surgeon 1 with the vitrectomy. A larger metallic foreign body associated with a large superior retinal tear was removed using an intraocular magnet. An endolaser was used to surround the retinal tear, a fluid–air exchange was performed, and silicone oil was instilled in the vitreous cavity. This was followed by intravitreal injections of vancomycin, ceftazidime, and voriconazole. The sclerotomies and conjunctiva were closed with 7-0 polyglactin suture.

The microscope was then shifted to the left eye, a new vitrectomy pack was used, and both surgeons rescrubbed. An AC washout, 23-gauge PPL, and PPV were performed. Similar to the right eye, there were multiple sub-millimeter metallic objects in the vitreous cavity, which were removed with fluid–fluid exchanges, and a few larger foreign bodies that resulted in multiple retinal tears, which were removed with a magnet. All retinal breaks were surrounded by endolaser, a fluid–air exchange was performed, silicone oil was instilled, and intravitreal injections of vancomycin, ceftazidime, and voriconazole were given. The sclerotomies and conjunctiva were closed with 7-0 polyglactin suture. Both globes were at physiologic IOP with watertight, sealed wounds.

Postoperatively, the retina remained attached with no signs of infection (Figure 3). The patient had silicone oil removal 4 months after the initial surgery in the right eye and 5 months after in the left eye. Scleral-sutured posterior chamber intraocular lenses were placed in both eyes a few months later. One year after the initial surgery, the best-corrected VA was 20/20 OD and 20/25 OS.

Figure 3.

Postoperative clinical fundus images. (A) Ultra-widefield image of the right eye 10 months after the initial surgery shows a healthy optic nerve and macula and an attached retina with laser scars superotemporally. (B) Ultra-widefield image of the left eye 10 months after the initial surgery shows a healthy optic nerve and macula and an attached retina with laser scars temporally.

Conclusions

Because of the nature of the trauma mechanism, numerous metallic foreign bodies, and dirty sludge material, our patient was at high risk for endophthalmitis, at which point a delay in repair can allow rapid bacterial growth, especially with a high initial bacterial burden.^{6 –8} We used a new surgical approach for bilateral, co-surgeon, simultaneous open-globe and IOFB repair, which resulted in a successful visual outcome. The risk for surgery-induced postoperative infection was mitigated by the use of separate sterile prep, drapes, and instrument packs, even though such risk seemed negligible in our case, in which there were likely multiple species of bacteria seeded by the metallic fragments and sludge. Simultaneous repair effectively reduced general anesthesia time significantly, allowed faster removal of the IOFBs in the second eye, reduced surgeon fatigue because of the shorter case time, and hastened the time to intravitreal antibiotic therapy for the second eye.

This case warranted immediate and simultaneous surgical repair because the wounds were deeply contaminated, presentation had already been delayed and, in general, open-globe injury and the presence of IOFBs are urgent surgical indications. The exact timing for IOFB removal and the antibiotic regimen to reduce the risk for endophthalmitis, however, are less clear and early removal may not be clinically feasible. Multiple factors, including the patient’s overall health status and concurrent injuries, the composition of the IOFB (metal vs glass), the nature of the injury such as high-explosive and heat-sterilized projectiles vs contaminated IOFBs, and both operating room and surgeon availability may ultimately drive surgical timing.

In military settings, Colyer et al ⁹ reported no cases of post-trauma infectious endophthalmitis in delayed IOFB removal for injuries sustained by high-velocity munition injuries; however, patients had immediate open-globe repair with topical and IV antibiotic therapy. A few small case series corroborated this finding and found no difference in endophthalmitis rates with delayed IOFB removal; however, these series had low rates of endophthalmitis overall or were underpowered.^{10 –12} Other case series did note a difference in endophthalmitis rates if IOFB removal was delayed for more than 24 hours; however, in many cases, primary globe repair was also delayed.^13,14

The literature supports that the risk for post-traumatic endophthalmitis is multifactorial, and prompt open-globe repair with antibiotics (either systemic or topical) may be beneficial in reducing the risk for infection. Most case series suggest that the presence of an IOFB increases the risk for post-traumatic endophthalmitis over that with open-globe injuries without an IOFB, and higher infection rates have been reported when retained IOFBs are contaminated with organic matter from a rural setting. ¹⁵ Many factors associated with the injury affect the final visual outcome, including the presenting VA, retinal detachment, the presence of an afferent pupillary defect, and endophthalmitis. Thus, it is often difficult to isolate each risk factor. Post-traumatic endophthalmitis outcomes may range significantly depending on the virulence of the microbe, the timing of treatment, and the presence of an IOFB. Overall, studies suggest that the final visual outcomes are worse in the setting of post-traumatic endophthalmitis, which supports efforts to mitigate this risk.^12,16

Sequential, same-day procedures have been studied for cataract surgery, vitreoretinal surgery, and intravitreal injections with good safety profiles.^3,4,17,18 Certain clinical scenarios in which the patient would benefit from sequential repair include pediatric intraocular surgery to limit multiple episodes of anesthesia, bilateral rhegmatogenous detachments, and bilateral ocular trauma. Simultaneous, bilateral open-globe repair and IOFB removal may not be feasible in all situations and relies on the availability of 2 highly trained licensed surgeons as well as all the necessary equipment and surgical staff to perform 2 surgeries simultaneously. In the present case, the wounds could be appropriately visualized with surgical loupes and headlamp lighting during vitrectomy in the fellow eye; however, greater magnification and lighting with a surgical microscope may be required for certain injuries. Also, having an experienced team, including the scrub technician and circulating nurse, is extremely important to avoid cross-contamination of instruments between the 2 eyes. Therefore, in our case Surgeon 2 was acquiring instruments himself from Tray 2 during globe repair. Tandem surgery would only seem feasible if all team members are already experienced in ocular trauma cases.

When conditions are met, however, a tandem co-surgeon approach offers significant advantages, such as less time to repair and mitigating surgeon fatigue with increased efficiency and a shortened operating time. Other surgical specialties have reported benefits using this approach. In the orthopedic literature, a randomized controlled trial found that a simultaneous co-surgeon bilateral total knee arthroplasty vs a sequential approach shortened the median operating time and complications at 90 days. ¹⁹ Another study in orthopedics assessed co-surgeon utility in single-event multilevel surgery for cerebral palsy and also found decreased operating time and decreased operating room utilization costs. ²⁰ Co-surgeons in bilateral breast reconstruction have a decreased operating time and average postoperative hospital length of stay. ²¹ Co-surgeons in unilateral ophthalmic surgery would be less feasible because of the limited operating field and globe movement with manipulation; however, bilateral simultaneous ocular surgery may be appropriate in certain situations, as in our case.

To our knowledge, this is the first reported case of simultaneous open-globe repair and tandem vitrectomy for IOFB removal that ultimately resulted in an excellent visual outcome. Consistent with previous reports of bilateral surgery, we recommend using separate sterile instrumentation, medications, and vitrectomy packs for each eye to minimize cross-contamination.