|Year : 1979 | Volume
| Issue : 4 | Page : 99-100
Closed vitrectomy after trauma
KV Mody, RK Blach, PK Leaver, D McLeod
M.G.M. Hospital, Parel, Mumbai, India
K V Mody
M.G.M. Hospital, Parel, Mumbai-12
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mody K V, Blach R K, Leaver P K, McLeod D. Closed vitrectomy after trauma. Indian J Ophthalmol 1979;27:99-100
|How to cite this URL:|
Mody K V, Blach R K, Leaver P K, McLeod D. Closed vitrectomy after trauma. Indian J Ophthalmol [serial online] 1979 [cited 2020 Jun 1];27:99-100. Available from: http://www.ijo.in/text.asp?1979/27/4/99/32588
New techniques and instrumentations developed for vitreous surgery and ultra-sonic diagnosis over past several years have opened up exciting possibilities in the management of ocular trauma.
Our study was undertaken to correlate the results of the surgery with nature and severity of injuries and type and extent of the procedure, to identify the indications for vitrectomy after, trauma and to assess the relevence of the time, interval between the injury and the surgery.
| Materials and Methods|| |
Forty-one eyes in 40 consecutive patients referred to the vitreous clinic following trauma were included in this study. There were 39 males and 2 females.
Four types of trauma were identified: (1) Contusion, (2) Laceration, (3) Penetrating injury with retained IOFB, and (4; Penetrating injury in which the FB was no longer intra-ocular.
Time interval between the initial injury - and vitrectomy being undertaken varied widely. In all eyes vitrectomy was carried out within I month of injury while in 30 it was not undertaken until more than 1 month afterwards.
Full clinical examination including assessment of the best corrected visual acuity, testing for relative afferent pupillary defect (RAPD), biomicroscopy, in direct ophthalmoscopy and B-Scan ultra-sonography was carried out before surgery and at the follow-up examinations.
Vitrectomy was undertaken under general anaesthesia using the Machemer Vise Mk VII, Douvas rotoextractor or Peyman vitreophage. The Ziess Mk 6 operating microscope was used in all cases. Method of illumination varied according to the type of the cases the co-axial light beam being used for anterior segment surgery, and either motorised slit illuminator or fibreoptic illumination being used for the posterior segment work. A fundus contact lens was used for vitrectomy in the posterior segment.
In most cases a pats plana approach was used, but a limbal approach was used occasionally, where it was considered necessary, an encircling buckle was created with a 2 mm silicone rubber band. The extent of the surgical procedure depended upon the type of the pathology present.
Five types of problems for which vitrectomv was considered suitable were: (1) Clearing of opacity in ocular media. (2) Relief of vitreo-retinal traction in the absence of retinal detachment. (3) Relief of vitreoretinal traction and re-apposition of the retina in traction retinal detachment. (4) Removal of intra ocular foreign body. (5) Restoration of aqueous flow.
| Observations and Comments|| |
In 33 eyes, vitrectomy was undertaken to remove the opacities of the lens/iris diaphragm, vitreous or both. The visual axis was successfully cleared which remained clear in all cases. In 25 eyes in which removal of such opacification was the primary indication for vitrectomy, the vision improved in 17, remained unchanged in 5 and was worse in 3 following surgery. In 8 eyes though the visual axis was clear there was no improvement in visual function post-operatively. There were 3 reasons for this anomalus result-MPR (5), severe amblyopia (1) and macular pucker (2).
In 10 eyes, there was vitreo-retinal traction without retinal detachment. Three types of vitreo-retinal tractions were identified. (1) Transgel traction bands, (2) posterior epiretinal membranes and (3) epiretinal membrane at the vitreous base. In 5 eyes, the traction was successfully relieved; 4 by division of transgel traction bands, and one by the creation of 360° buckle to relieve surface vitreous base traction. In 3 of 5 eyes in which traction was not relieved, it was posterior epiretinal traction and in the remaining two epiretinal membrane at vitreous base, (one of these progressed to reti-• nal detachment, subsequently treated with an encircling procedure). In only 2 of the 10 eyes with vitreo-retinal traction there was a primary indication for surgery. Both were of tran.sgel type and vitrectomy was successful with improvement in visual acuity.
In sixteen eyes vitreo-retinal traction was associated with retinal detachment. In 6 of these, retina flattened after surgery, and in all 10 which failed to flatten, there was pre-existing posterior surface proliferation which could not be relieved by membranectomy or buckling. In 8 eyes traction retinal detachment was the primary indication for vitrectomy, but in only 2 eyes the retina reattached while in one of these the visual function remained poor due to macular pucker.
In 4 eyes vitrectomy was undertaken to facilitate removal of intra ocular foreign body. In 3, this was successful, but in one case, the foreign body was deeply embedded in optic nerve head and could not be located.
In the remaining 2 eyes, vitrectomy was carried out as an adjuant to glaucoma therapy following trauma. In both cases, the displaced vitreous was successfully excised and aqueous flow restored.
| Conclusion|| |
Indications for surgery depend on the main pathological problem and they are classified on the basis of clinical and ultrasonic observations, opacity in the media, vitreo retinal traction without retinal detachment or with retinal detachment, intra ocular foreign body etc. The time interval in our study showed little significance. This study has established that vitrectomy has an important place in the management of ocular trauma. It deals with different types of problems. It is possible to reduce the failure rate by careful pre and post-operative assessment, planning and choice of surgical procedure, timing, proper instrumentation, clinical judgement and surgical skill.
The higher failure rate in cases of vitreoretinal traction with or without retinal detachment could be attributed to progressive epiretinal proliferation and other forms of fibrosis.
It may appear that 60% visual improvement and high anatomical success are quite encouraging but if we look at the failure rate in the visual results (failure to improve the vision) it is 40% and it is quite disappointing a figure compared to a very small failure rate in other surgical procedures in ophthalmology. At present vitreous surgery has certain limitations. However, further study in the nature and control of pathological processes and improvement in the technique and instrumentation, it is hoped, will eliminate these limitations and will increase the rate of success.
Ultra-sonic assessment is essential and extremely useful as it aids the surgeon in selection of the patient, timing and choice of surgical procedures.