Vitreoretinal surgery in the management of war-related open-globe injuries

Abstract

Ranking among the most severe combat damages, war-related open-globe injuries (WROGIs) are not uniform, so the treatment approaches are sometimes unclear. The essential issue is to define exact indications for time- and resource-intensive vitreoretinal surgery (VRS), known to be an effective procedure for severe posterior segment injuries. We studied WROGI structure, and summarized the experience of specialized ophthalmologic care (SOC) management during local armed conflicts (LACs). This was a retrospective multicenter study that included case series of 203 wounded subjects (314 eyes) with WROGIs sustained during LACs treated in the hospitals of first, second and third echelons of SOC. Ocular trauma was classified according to the International Society of Ocular Trauma (ISOT) classification, and only open-globe injuries (OGI) made up two groups of study: injured eyes that underwent VRS, n = 135, and those eyes on which VRS was not performed, n = 119. Two subgroups according to stages of VRS were also included. We reviewed the demographic characteristics, the time between injury and surgery, the number of stages in which surgery was performed, and initial visual acuity (IVA) at arrival and final visual acuity (FVA), 12 months after surgery. WROGI constituted 65.1 % of all eyes injured. The visual outcomes after VRS were favorable in ruptures of the eye, penetrating WROGIs, intraocular foreign body (IOFB) WROGIs, perforating WROGIs (types A, B, C, D) of grades 1-4. Those WROGIs of grade 5 had poor visual outcomes irrespective of the surgeries. In 19.1% of all cases wherein either the eye wall or eye content were extensively damaged (included types A, C, D, E of grade 5), all attempts to save the eye through reconstructive surgery were unsuccessful and led to enucleation (evisceration). Medical service management in LACs demands to define groups of priority for VRS between the wounded with WROGI during triage at the first echelon of SOC. Multistage VRS determines unfavorable outcomes of the WROGI. Treatment should be determined by diagnosis, and there is a need to introduce a new category into the OGI classification--eye destruction, because only this damage determines the choice of enucleation/evisceration of the eye.