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Prognostic Indicators for No Light Perception AfterOpen-Globe Injury: Eye Injury Vitrectomy Study

KANG FENG, YUN TAO HU, AND ZHIZHONG MA

● PURPOSE: To describe ocular characteristics, surgicalnterventions, and anatomic and visual outcomes ofraumatized eyes with no light perception (NLP) follow-ng open-globe injury and to investigate prognostic pre-ictors for NLP cases after open-globe injury.

● DESIGN: Interventional case series study.● METHODS: Thirty-three traumatized eyes with NLP

ere selected from the Eye Injury Vitrectomy Studyatabase, a hospital-based multicenter prospective cohorttudy. Inclusion criteria were NLP cases following open-lobe injury with outcomes of anatomic restoration,hthisis bulbi, or enucleation. Exclusion criteria wereases with missing records, undergoing vitrectomy afternjury at nonparticipating hospitals, direct optic headnjury, endophthalmitis, and hypotonous or silicone oil–ustained eyes. All cases underwent vitreoretinal surgeryr enucleation after exploratory surgery and were fol-owed up for at least 6 months. Two outcomes weressessed: favorable outcome (anatomically restored eyelobes with light perception [LP] or better vision) andnfavorable outcome (NLP, phthisis bulbi, or enucle-tion).

● RESULTS: The following 7 risk factors were significantbetween the 2 groups: rupture (P � .021); open globe III(P � .046); scleral wound >10 mm (P � .001); ciliaryody damage (P < .001); severe intraocular hemorrhageP � .005); closed funnel retinal detachment or retinalrolapse (P � .005); and choroidal damage (P � .001).

● CONCLUSIONS: These 7 risk factors are possible pre-dictors of poor prognosis. Traumatized eyes with NLPcan be anatomically restored with LP or better vision ifvitreoretinal surgery is attempted, and a favorable ana-tomic and visual outcome is increased by having adecreased number of these risk factors. (Am J Oph-thalmol 2011;152:654–662. © 2011 by Elsevier Inc.All rights reserved.)

O PEN-GLOBE INJURY IS ONE OF THE MOST COMMON

worldwide causes of monocular visual impair-ment and blindness.1–4 Open-globe injury that

causes no light perception (NLP) typically carries a dismalprognosis.5,6 Considering the risk of sympathetic ophthal-

Accepted for publication Apr 14, 2011.From the Peking University Eye Center, Peking University Third

Hospital, Beijing, People’s Republic of China.Inquiries to Zhizhong Ma, Peking University Eye Center, Peking

University Third Hospital, Huayuan North Street 49, Haidian, Beijing
100191, People’s Republic of China; e-mail: [email protected]
© 2011 BY ELSEVIER INC. A54

mia, many ophthalmologists usually select primary enuc-leation for traumatized eyes with NLP.7,8 With the ad-vancement of vitreoretinal surgery, some traumatized eyeswith NLP, which would have previously been enucleated,are now saved and recover light-perception (LP) or bettervision. When performing exploratory surgery on trauma-tized NLP cases, clinicians can now make a choice be-tween vitreoretinal surgery and enucleation according tothe ocular findings. However, few published reports de-scribe in detail the intraocular characteristics, surgicalinterventions, and outcomes of traumatized eyes with NLPfollowing open-globe injury. Further, because of a lack ofprognostic indicators, there are no decision-making guide-lines that can be used during exploratory surgery in orderto make an accurate assessment of prognosis.

In this study, we described the ocular characteristics,surgical interventions, and the anatomic and visual out-comes of 33 traumatized NLP cases following open-globeinjury and tracked the prognostic indicators for trauma-tized eyes with NLP vision.

METHODS

CASES IN THIS STUDY WERE SELECTED FROM THE EYE IN-

jury Vitrectomy Study database, which began in January1997. The Eye Injury Vitrectomy Study is a hospital-based multicenter prospective cohort study whose pur-pose is to investigate the epidemiology, intervention ofvitreoretinal surgery, and prognosis of severe eye injury.Six tertiary referral hospitals in China have successivelyparticipated in it. All injured patients in the databaseconsented to enroll in the Eye Injury Vitrectomy Study.Its inclusion criteria were patients who suffered fromsevere eye injury and were treated with vitreoretinalsurgery, enucleation, or evisceration. Exclusion criteriawere patients with an eye injury who did not needvitreoretinal surgical intervention.

After patient demographics were obtained at admission,all initial ophthalmic examinations of the injured patientswere conducted and reviewed by the chief of staff, andfindings were confirmed by the chief surgeon before sur-gery. Information including patient age, sex, involved eye,best-corrected visual acuity (BCVA) after injury, andopen-globe repair was recorded on a “Register of EyeInjury” form. Type and zone of injury conform to the
recommendations of the United States Eye Injury Registry
LL RIGHTS RESERVED. 0002-9394/$36.00doi:10.1016/j.ajo.2011.04.004

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and the International Society of Ocular Trauma (Birming-ham Eye Trauma Terminology [BETT9]) and “A Systemor Classifying Mechanical Injuries of the Eye.”10 Cornea,

sclera, iris, lens, ciliary body, retina, choroid, intraocularforeign body (IOFB), intraocular hemorrhage, direct injuryof optic nerve head, and endophthalmitis were examinedand assessed during open-globe repair or exploratory sur-gery and recorded as baseline information on the “Registerof Eye Injury” form by the chief surgeon. In addition,details of the vitreoretinal surgery and any subsequentsurgical procedures and nonsurgical interventions werealso recorded. Follow-up information, including the fol-low-up period, BCVA and intraocular pressure (IOP) atthe last visit, tamponade of vitreous cavity, and anatomicoutcome was recorded at outpatient follow-up after no lessthan 6 months.

The baseline and follow-up sheets were collected anddata were input in the Eye Injury Vitrectomy Studyelectronic database using Epidata (The EpiData Associa-tion, Odense, Denmark). A cross-check for errors wasconducted by 2 data entry clerks. If a variable could not beidentified or was missing in the record, the data wereexcluded from this cohort.

In this study, the inclusion criteria were NLP casesfollowing open-globe injury. As of December 31, 2009,there were 72 NLP eyes post open-globe injury in the EyeInjury Vitrectomy Study database. These injured eyes didnot include cases of missing records, ones that underwentvitreoretinal surgery after injury at nonparticipating hos-pitals, and those with direct optic head injury, endoph-thalmitis, and a follow-up period of less than 6 months.The exclusion criteria were hypotonous or silicone oil–sustained cases. In total, 33 traumatized eyes with NLP (33patients) met the study’s outcome criteria of anatomicallyrestored eyes, phthisis bulbi, or enucleation.

● STUDY TERM DEFINITIONS: NLP. NLP vision was de-ermined by an examination using an indirect ophthalmo-cope with the highest-intensity light while the fellow eyeas fully occluded. All injured patients who had docu-ented NLP in the emergency room or other nonpartici-

ating hospitals were referred to and examined by at leastsenior trauma staff ophthalmologists after admission. Asfinal step, NLP vision was confirmed by the chief surgeonrior to exploratory surgery.

Zone of injury. The zone of injury is defined by locationf the most posterior full-thickness aspect of the globepening according to The Ocular Trauma Classificationroup:10 open globe I, wound involvement is isolated to

the cornea or corneoscleral limbus; open globe II, full-thickness wound involves the sclera no more posteriorthan 5 mm from the corneoscleral limbus; open globe III,
full-thickness wound is posterior to open globe II. s
PROGNOSTIC INDICATORS FOR OPEN-VOL. 152, NO. 4

Lens or iris extrusion. Lens or iris is fully prolapsed out ofthe globe (missing or under the conjunctiva) at the time ofinjury, which was confirmed during open-globe repair orexploratory surgery.

Intraocular hemorrhage. In some patients, almost all ofthe vitreous was lost when the open-globe injury oc-curred, especially following an eyeball rupture. Theprolapsed vitreous dragged the whole retinal incarcera-tion into the wound tract, forming a closed funnel, andthe hemorrhage accumulated in the subretinal space.When the choroidal laceration occurred, the subretinaland suprachoroidal spaces connected with one another,so the hemorrhage was actually accumulated within the2 gaps. Under such circumstances, it was quite difficultto discern which types of hemorrhage were in an injuredeye globe with severe intraocular tissue disorder. Hence,we considered it more appropriate to refer to this as an“intraocular hemorrhage,” which was confirmed duringglobe exploration. In this study, an intraocular hemor-rhage included a vitreous hemorrhage, a subretinalhemorrhage, and a suprachoroidal hemorrhage. Severeintraocular hemorrhage was defined as a hemorrhage toodense to allow visualization of the optic disc andidentification of the intraocular tissues.

Large scleral wound. A large scleral wound was definedas a scleral wound length of 10 mm or more, which wasexamined during open-globe repair or exploratorysurgery.

Ciliary body damage. In this study, ciliary body damageincluded ciliary epithelium detachment, ciliary body de-tachment, ciliary body defect, ciliary process atrophy, andformation of ciliary membrane, which was confirmedduring exploratory surgery.

Closed funnel retinal detachment. In open-globe injuredeyes, almost all the vitreous prolapsed because of a suddendrop of IOP. The prolapsed vitreous dragged the wholeretinal incarceration into the wound tract, forming aclosed funnel. Closed funnel retinal detachment was diag-nosed during exploratory surgery.

Choroidal damage. In this study, choroidal damage in-luded choroidal laceration, choroidal detachment, cho-oidal rupture, choroidal incarceration, and choroidalefect, which was confirmed during exploratory surgery.

Massive suprachoroidal hemorrhage. Defined as a hemor-hage in the suprachoroidal space of sufficient volume toause extrusion of the intraocular contents of the eye or toorce the inner retinal surfaces into apposition due to a
harp drop of IOP after onset of the open-globe injury.
GLOBE INJURED EYES WITH NLP 655

TABLE 1. Ocular Characteristics, Surgical Interventions, and Visual Outcomes of Traumatized Eyes With No Light Perception After Open-Globe Injury in Favorable OutcomeGroup

No

Age

(years) Type of Injury Zonea

Time to

PPV

(days)

Corneal/Scleral

Wound (mm)

Extrusion of

Lens/Iris

Ciliary

Body

Damage Retina PVR

Choroidal

Damage

Severe

IOH

Main Surgical

InterventionsbF/U

(months)

Final

BCVA

1 39 Perforating III 3 Yes / �10 � / � � RD � � � Lx, C3F8 6 CF 1’

2 19 Penetrating II 3 No / �10 � / � � F-RD � � � Lx, UF, C3F8 6 20/160

3 41 Rupture III 3 Yes / �10 � / � � RD � � � Lx, Rx, C3F8 29 LP

4 37 Rupture II 3 No / �10 � / � � RD � � � TSD, C3F8 9 CF 0.2’

5 26 Rupture II 4 No / �10 � / � � RD � � � Rx, C3F8 11 20/500

6 8 Perforating II 5 No / �10 � / � � RD � � � C3F8 7 HM

7 35 Perforating III 5 Yes / �10 � / � � RD � � � Lx, C3F8 6 20/50

8 27 Rupture III 10 No / �10 � / � � RD � � � Rx, SO 7 CF 0.5’

9 37 Penetrating III 10 No / �10 � / � � RD � � � MP, Rx, C3F8 14 CF 0.5’

10 28 Rupture III 11 No / �10 � / � � F-RD � � � Lx, UF, C3F8 10 20/40

11 36 Rupture III 12 No / �10 � / � � F-RD � � � UF, TSD, SO 47 LP

12 46 Rupture III 14 No / �10 � / � � RD � � � C3F8 7 20/160

13 49 Rupture III 27 No / �10 � / � � F-RD � � � Lx, MP, Rx, UF, SO 11 LP

14 37 Perforating II 30 Yes / �10 � / � � RD � � � MP, Rx, SO 6 20/320

15 21 IOFB I 30 Yes / No � / � � RD � � � MP, Rx, SO 7 CF 0.5’

16 41 Rupture III 42 Yes / �10 � / � � RD � � � TKP, MP, Rx, C3F8 7 CF 0.5’

17 41 Penetrating II 45 Yes / �10 � / � � RD � � � MP, Rx, SO 6 20/100

18 30 Rupture III 52 Yes / �10 � / � � F-RD � � � MP, Rx, UF, SO 6 LP

BCVA � best-corrected visual acuity; CF � counting fingers; F-RD � closed funnel retinal detachment; F/U � period of follow-up; HM � hand movement; IOFB � intraocular foreign body;

IOH � intraocular hemorrhage; LP � light perception; Lx � lensectomy; MP � membrane peeling; PPV � pars plana vitrectomy; PVR � proliferative vitreoretinopathy; RD � retinal detachment;

Rx � retinotomy or retinectomy; SO � silicone oil; TKP � temporary keratoprosthesis; TSD � trans-scleral drainage; UF � unfold closed funnel retinal detachment.aZone I: wound involvement is isolated to the cornea or corneoscleral limbus; Zone II: full-thickness wound involves the sclera no more posteriorly than 5 mm from the corneoscleral limbus;

Zone III: full-thickness wound is posterior to zone II.bAll cases underwent 20-gauge PPV; endolaser and perfluorocarbon were used in cases that required a retinal operation.

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TABLE 2. Ocular Characteristics, Surgical Interventions, and Anatomic Outcomes of Traumatized Eyes With No Light Perception After Open-Globe Injury in UnfavorableOutcome Group

No

Age

(years) Type of Injury Zonea

Time to

PPV

(days)

Corneal /

Scleral

Wound (mm)

Extrusion of

Lens / Iris

Ciliary

Body

Damage Retina PVR

Choroidal

Damage

Severe

IOH

Main Surgical

InterventionsbF/U

(months) Outcome

1 27 Rupture III 7 No / �10 � / � � All-pro � � � Enucleation – EN

2 38 Rupture III 9 No / �10 � / � � F-RD � � � Lx, UF, SO 6 PB

3 51 Penetrating III 10 Yes / �10 � / � � F-RD � � � Enucleation – EN

4 25 Rupture III 12 No / �10 � / � � All-pro � � � TKP, SO 7 EN

5 32 Rupture III 12 Yes / �10 � / � � F-RD � � � Lx, UF, SO 7 PB

6 41 Rupture III 13 No / �10 � / � � F-RD � � � Enucleation – EN

7 33 Rupture III 13 No / �10 � / � � F-RD � � � Lx, UF, Rx,

SO

7 EN

8 25 Rupture III 13 Yes / �10 � / � � RD � � � SB, TSD,

C3F8

9 AR(NLP)

9 22 Rupture III 14 No / �10 � / � � All-pro � � � MP, SO 8 EN

10 47 Rupture III 16 No / �10 � / � � All-pro � � � C3F8 8 PB

11 13 Rupture III 16 No / �10 � / � � RD � � � Lx, MP,

C3F8

79 PB

12 23 Rupture III 18 Yes / �10 � / � � F-RD � � � SB, UF,

MP, Rx,

C3F8

6 EN

13 10 Rupture III 19 Yes / �10 � / � � F-RD � � � MP, UF,

Rx,

C3F8

5 EN

14 13 Rupture III 24 Yes / �10 � / � � RD � � � TKP, Rx,

C3F8

7 EN

15 21 Rupture II 49 Yes / �10 � / � � F-RD � � � MP, Rx,

UF,

C3F8

7 AR(NLP)

All-pro � all prolapsed; AR � anatomic restoration; EN � enucleation; F/U � period of follow-up; F-RD � closed funnel retinal detachment; IOH � intraocular hemorrhage; Lx � lensectomy;

MP � membrane peeling; NLP � no light perception; PB � phthisis bulbi; PPV � pars plana vitrectomy; PVR � proliferative vitreoretinopathy; RD � retinal detachment; Rx � retinotomy or

retinectomy; SB � scleral buckle; SO � silicone oil; TKP � temporary keratoprosthesis; TSD � trans-scleral drainage; UF � unfold closed funnel retinal detachment.aZone II: full-thickness wound involves the sclera no more posteriorly than 5 mm from the corneoscleral limbus; Zone III: full-thickness wound is posterior to zone II.bAll cases underwent 20-gauge PPV except for cases 1, 3, and 6; endolaser and perfluorocarbon were used in cases that required a retinal operation.

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Anatomically restored eyes. Determined after a period offollow-up no less than 6 months, IOP � 8 mm Hg, vitreouscavity filled with aqueous humor, retinal attachment, oronly local detachment that does not require surgery.

Hypotonous eyes. Determined after a period of follow-upo less than 6 months, IOP � 8 mm Hg, vitreous cavitylled with aqueous humor that exhibits the Tyndall effectwing to the presence of damage to the blood-oculararrier.

Silicone oil–sustained eyes. Silicone oil–sustained eyesefers to eyes injected with silicone oil because of anncomplete treatment, lower IOP (�8 mm Hg), unrecov-red retinal detachment, or inoperable retinal detachment.

Favorable outcome. Favorable outcome is defined asnatomically restored eyes whose final BCVA is LP or

TABLE 3. Seven Prognostic Factors for Outcomes ofOpen-Globe Injured Eyes With No Light Perception

Count (Column %)

Favorable

Outcome

Unfavorable

Outcome Pa

Type of injury

Othersb 8 (44.4) 1 (6.7) .021

Rupture 10 (55.6) 14 (93.3)

Zone of injuryc

Zone I / Zone II 7 (38.9) 1 (6.7) .046

Zone III 11 (61.1) 14 (93.3)

Scleral wound (mm)

None / �10 12 (66.7) 1 (6.7) .001

�10 6 (33.3) 14 (93.3)

Ciliary body

Normal 12 (66.7) 0 (.0) �.001

Damage 6 (33.3) 15 (100.0)

Intraocular hemorrhage

Mild / Moderate 14 (77.8) 4 (26.7) .005

Severe 4 (22.2) 11 (73.3)

Closed funnel RD or

retinal prolapse

No 13 (72.2) 3 (20.0) .005

Yes 5 (27.8) 12 (80.0)

Choroid

Normal 10 (55.6) 0 (.0) .001

Damage 8 (44.4) 15 (100.0)

RD � retinal detachment.aP values calculated with Fisher exact test.bOthers include penetrating, intraocular foreign body, perfo-

rating.cZone I: wound involvement is isolated to the cornea or

corneoscleral limbus; Zone II: full-thickness wound involves the

sclera no more posteriorly than 5 mm from the corneoscleral

limbus; Zone III: full-thickness wound is posterior to zone II.

etter after 6 months of follow-up.

AMERICAN JOURNAL OF658

Unfavorable outcome. Unfavorable outcome is defined asases of phthisis bulbi or cases that underwent enucleation.natomically restored eyes whose final BCVA is NLP aftermonths of follow-up are also considered as an unfavor-

ble outcome.

● STATISTICAL ANALYSIS: Because the number of caseswas less than 40, the Fisher exact test was used to evaluatethe variables including interval of time between injury andvitrectomy, type and zone of injury, corneal and scleralwound, extrusion of iris or lens, ciliary body damage, severeintraocular hemorrhage, closed funnel retinal detachmentor retinal prolapse, proliferative vitreoretinopathy (PVR),and choroidal damage according to 2 main outcomes:favorable and unfavorable.

The statistical level of significance was preset at .05 andall the eligible data were analyzed using SPSS version 17.0statistical software (SPSS Inc, Chicago, Illinois, USA).

RESULTS

● DEMOGRAPHICS OF CASES: A total of 72 cases withNLP after open-globe injury were reviewed during this studyperiod, and 33 injured eyes (33 patients) met the criteria forthe evaluation of prognostic indicators. The number of eyesin the favorable outcome group and the unfavorable outcomegroup was 18 and 15 respectively.

The mean patient age was 33.2 years in the favorableoutcome group; the youngest patient and the oldest patientwere 8 and 49 years old respectively. The mean patient age

TABLE 4. Outcomes of Open-Globe Injured Eyes With NoLight Perception by Assorted Risk Factors

Favorable Outcomeb Unfavorable Outcomec

Risk Factorsa Count Row (%) Count Row (%)

0 3 100.0 0 .0

1 3 100.0 0 .0

2 2 100.0 0 .0

3 4 100.0 0 .0

4 2 66.7 1 33.3

5 2 66.7 1 33.3

6 1 16.7 5 83.3

7 1 11.1 8 88.9

aRisk factors include rupture, open globe III, scleral wound

�10 mm, ciliary body damage, severe intraocular hemorrhage,

closed funnel retinal detachment or retinal prolapse, and cho-

roidal damage.bAnatomically restored eyes with final vision of light percep-

tion or better.cAnatomically restored eyes with final vision of no light per-

ception, phthisis bulbi, or cases that underwent enucleation.

was 28.1 years in the unfavorable outcome group; the

OPHTHALMOLOGY OCTOBER 2011

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youngest and the oldest were 10 and 51 years oldrespectively.

The average follow-up period of the favorable outcomegroup was 11.2 months (ranging from 6 to 47.4 months).The average follow-up period of the unfavorable outcomegroup was 12.9 months, except for 3 cases that underwentprimary enucleation after globe exploration. The shortestfollow-up period was 5.4 months for 1 case that wasenucleated at a subsequent surgical procedure after a periodof follow-up. The longest follow-up time was 78.9 months(Tables 1 and 2).

● ANATOMIC AND VISUAL OUTCOMES OF EYES WITH

NLP: Of the 33 cases, 20 eyes were anatomically restoredwith follow-up visual acuity (VA) ranging from NLP to20/40; 4 eyes became phthisical after 6 to 79 months; 6eyes were enucleated at a subsequent surgical procedureafter follow-up period of 5 to 8 months; and 3 eyes wereenucleated after exploratory surgery. As to visual outcome,5 eyes recovered vision better than 20/200 (visual impair-ment); 1 eye retained vision of 20/320 (severe visualimpairment); 12 eyes had vision worse than 20/400 (pro-found visual impairment); and 15 eyes had NLP, enucle-ation, or phthisis.

In the 39 excluded cases, there were 38 silicone oil–sustained eyes and 1 hypotonous eye. One eye recoveredvision better than 20/200; 1 retained vision of 20/250; 28had vision worse than 20/400; and 9 had NLP (including1 hypotonous eye).

The proportion of eyes with favorable outcome anduseful vision (better than 20/200) in the entire series of 72cases was 25% (18/72) and 6.9% (5/72) respectively.

● PROGNOSTIC INDICATORS: In this study, the Fisherexact test showed that a rupture (P � .021), open globe III(P � .046), large scleral wound (P � .001), ciliary bodyamage (P � .001), severe intraocular hemorrhage (P �

005), closed funnel retinal detachment or retinal prolapseP � .005), and choroidal damage (P � .001) predicted annfavorable anatomic and visual outcome for traumatizedyes with NLP (Table 3).

There was a significant correlation between the proba-ility of a favorable outcome and the number of risk factorshen the Spearman rank correlation test was employed

correlation coefficient � �0.932, P � .001) (Table 4).

DISCUSSION

TREATING TRAUMATIZED EYES WITH NLP VISION AFTER

open-globe injury, which implied no further therapeuticintervention previously, is still a challenge for ophthalmol-ogists. During exploratory surgery, clinicians should makea rational choice of surgical interventions according to theocular characteristics of traumatized NLP cases. Based on
current published reports, there are no accepted prognostic

indicators for the NLP eyes after open-globe injury. In thisstudy, we have identified 33 cases with verified NLPfollowing open-globe injury that achieved their final out-comes, and investigated the factors that significantly pre-dicted prognosis.

The exclusion of patients is based on both their preop-erative characteristics and their postoperative stable out-comes. The main points of this study are evaluation ofwhether LP or better vision can be restored and whetheranatomic restoration can be achieved in injured eyes withNLP. Silicone oil–sustained eyes or hypotonous eyes wereexcluded for the following reasons: Under normal circum-stances, silicone oil was evacuated 3 months after vitreo-retinal surgery. In some cases, however, the retina did notattach after 3 months or onset of PVR. Therefore, a refillof silicone oil into the eye globe is necessary for reattach-ing the retina after membrane peeling and photocoagula-tion. In addition, silicone oil cannot be evacuated in somesilicone oil–sustained eyes because the detached retinadoes not reattach due to extensive fibrosis or scarring of theretina. Based on the clinical observation and authors’experience, the hypotonous eye’s status is unstable; that is,it might become phthisical or restore intraocular pressureof 8 mm Hg or more after a long period of follow-up.

Considering the poor prognosis and probability of sym-pathetic ophthalmia, many clinicians advocate primaryenucleation for traumatized eyes with NLP. According toMoshfeghi’s standards,8 open-globe injury with NLP visionis the indication for enucleation. Some scholars11 believe,

owever, that injured eyes with NLP can be repaired andave a functional outcome. Vitreoretinal surgery cannable injured patients to retain their own eye globes evenf LP or better vision cannot be restored. Furthermore, itas been shown that the occurrence of sympathetic oph-halmia is very small, so eyes with NLP can sustainong-term follow-up and be observed without the imple-entation of enucleation or evisceration.2,12–15 In our

study, contralateral sympathetic ophthalmia did not occurin any of the patients during the follow-up period.

The shortest and longest time interval between injuryand exploratory surgery in these cases is 3 and 52 daysrespectively, which mainly depended on the referral timeof patients to the participating hospitals. The delays werealmost all attributable to the limitation of economicconditions and medical resources. In China, there is anuneven distribution of medical resources and a poor levelof basic hospital treatment in rural areas, and somepatients are reluctant to seek medical treatment until thestatus of their injured eyes is unbearable. Six tertiaryreferral hospitals participated in this study. These hospitalstreat a large number of referred ocular injury patients fromnorth and south China each year, especially patients fromremote and rural areas.

This study shows there are 7 ocular characteristics thatcorrelate with the final anatomic and visual outcomes.
Rupture, open globe III, and large scleral laceration (�10

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mm) are significant factors in both the favorable andunfavorable groups. Multivariate analysis in Rofail andassociates’ report3 shows injured eyes with a large lacera-ion (�10 mm) and rupture are prone to obtain annfavorable final visual acuity. Rahman and associates16

reported that a blunt mechanism of open-globe injury(rupture) on presentation was a significant risk factor thatwas associated with eventual enucleation. Research byMatthews and associates7 also indicates that significantpredictive factors for final visual outcome include thelocation of the wound and the mechanism of injury.Wounds located posterior to the equator and blunt injuryin open globes predict a poor final visual outcome. Themechanism of a rupture is also an important predictor ofoutcome in Schmidt and associates’ classification andregression tree model.17 Furthermore, traumatized eyelobes with open globe III usually present serious ocularnjury characteristics. Thus, the more posterior the woundxtends, the greater the probability of a no-vision out-ome. Moreover, a rupture is often accompanied by a largecleral laceration and a prolapse of the intraocular contentsollowing sudden drop of intraocular pressure, which pres-nt difficulties on wound closure and severely damage theetina and choroid. To summarize, a rupture, open globeII, and a large scleral wound are strong predictors of anventual unfavorable outcome. In addition, the type andone of injury and scleral laceration can be examineduring open-globe repair, so these ocular characteristics areseful in patient counseling and in clinical decision mak-ng regarding further therapeutic interventions.

Ciliary body dysfunction attributable to trauma is usu-lly responsible for prolonged or progressive hypotony thatould result in irreversible structural and functionalhanges in the globe, which can lead to phthisis bulbi, aondition where the globe is permanently shrunken andysfunctional and vision is lost.18 A functional ciliary body

is essential for retaining the eye globe, and an injured eyeglobe could not be anatomically restored if the ciliary bodywas seriously damaged. In this study, ciliary body damageoccurred in all the unfavorable outcome group cases, whileit occurred in 6 cases (33.3%) of the favorable outcomegroup (P � .001). So it appears that ciliary body damageafter injury is destructive to both visual outcome andanatomic outcome.

Based on clinical observation, severe intraocular hem-orrhage usually occurs following severe damage of theintraocular contents such as the choroid, retina, and ciliarybody. Articles documenting poor prognosis attributable tovitreous hemorrhage are numerous.19 In our study, severeintraocular hemorrhage is also a risk factor of unfavorableoutcome, and it did not occur in cases with 3 or fewer riskfactors. The authors consider that severe intraocular hem-orrhage is not only a predictor of an unfavorable outcome,but also a reflection of the seriousness of the oculardamage, which includes severe intraocular tissue injury,
such as to the choroid and retina. d

In this study, closed funnel retinal detachment or aprolapsed retina is statistically significant (P � .005)between the favorable and unfavorable outcome groups.There are not many published articles on this factor.According to the authors’ clinical observation and expe-rience, the occurrence of closed funnel retinal detachmentis often accompanied by choroidal damage and extensiveciliary body damage in eyes with NLP following open-globe injury, and the prognosis for injured eyes is muchworse when they occur simultaneously. There were 2 cases(11.1%; 2/18) in the favorable outcome group and 8 cases(53.3%; 8/15) in the unfavorable outcome group thatsimultaneously had closed funnel retinal detachment, cho-roidal damage, and ciliary body damage (P � .020). There

ere 4 cases of retinal prolapse in the unfavorable outcomeroup: 1 phthisis bulbi occurred after 8 months; 1 injuredye was enucleated after exploratory surgery; and 2 eyesere enucleated after 7 and 8 months respectively. Theyes in these 4 cases were more severely injured than thethers, and all 4 cases were complicated by choroidal andiliary body damage.

Articles have been published about suprachoroidal hemor-hage during cataract surgery,20 pars plana vitrectomy,21–23

glaucoma surgery,24,25 penetrating keratoplasty,26 and mas-sive spontaneous choroidal hemorrhage.27 There are alsopublications about choroidal ruptures,28–30 which are mainlyattributable to blunt closed-globe injury. Few published arti-cles, however, document the outcome of direct damage to thechoroid following open-globe injury. In our study, all caseshad direct choroidal damage after open-globe injury except 1case that had a choroidal rupture following blunt injury(rupture, open globe II). It has been reported that choroidalhemorrhages are primarily caused by the vortex vein tears.31

The authors consider that the choroidal hemorrhage is themain source of dense intraocular hemorrhage in severelyinjured eyes, for it is usually followed by a massive supracho-roidal hemorrhage. The difference between a massive supra-choroidal hemorrhage caused by trauma and one that occursduring corneal transplant surgery or neovascular glaucoma isthat there is a choroidal laceration in open-globe severe eyeinjuries. In open-globe injured eyes with choroidal lacera-tions, surgical reattachment of the choroid is very difficultbecause the choroidal tissue and blood vessels contain abun-dant collagen and elastic fibers, which constrict and make thechoroidal wound shorter. Schepens32 considered that persis-ent choroidal detachment may also be an important factor ofypotony after vitrectomy. In this study, choroidal damageccurred in all cases of the unfavorable group and 8 cases44.4%; 8/18) of the favorable group (P � .001). These datandicate that choroidal damage is the main risk factor for annfavorable outcome as well as the main source for a densentraocular hemorrhage of injured eyes.

This study shows that a rupture, open globe III, scleralound �10 mm, severe intraocular hemorrhage, closed

unnel retinal detachment or retinal prolapse, ciliary body
amage, and choroidal damage are all possible predictors of

an unfavorable outcome, and that they might be thereason for a higher enucleation rate in traumatized eyeswith NLP than injured eyes with LP or better vision.6

Traumatized eyes with NLP, however, are not beyondrepair, as demonstrated by the acceptable outcomes of NLPcases in this study. In this study, all cases that had no morethan 3 of the above risk factors were saved and obtained LPor better vision. In 4 cases (66.7%; 4/6) of injured eyes thathad 4 or 5 of the aforementioned risk factors, these eyesobtained a favorable outcome through vitreoretinal sur-gery. Even 2 injured eyes complicated by 6 to 7 of the riskfactors were saved and recovered LP vision by vitreoretinalsurgery (Table 1, Cases 11 and 13). The probability of afavorable outcome was increased following a decreasednumber of risk factors (correlation coefficient � -0.932,P � .001) (Table 4).

One of the primary limitations to this study is that ourdata are not adaptable to multivariate analysis. The samplepool of 33 cases is too small with respect to the 7independent variables. Moreover, the number of some
independent variables is zero under a certain condition of
Surv Ophthalmol 2000;44(4):277–301.

1

1

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the dependent variable. A multivariate model may bedeveloped with larger patient numbers. Applying suchanalysis may indicate a lack of independently statisticalsignificance of variables in prognosis, for there is possibleinteraction between the risk factors. For example, thewound of ruptured eyes often extends to open III zone. Inaddition, to ensure the accurate results of prognosticindicators, we excluded the 39 eyes (54.2%) that maybecome phthisical or anatomically restored after a longperiod. However, the exclusion may overestimate theproportion of eyes with favorable outcome and usefulvision. Hence, we report our results based on the entireseries of 72 cases, which is relevant and much morerealistic, though it may be underestimated.

Based on the results of this study, the authors recom-mend that every effort be made to salvage traumatized eyeswith NLP. Vitreoretinal surgery or enucleation should becarefully determined after a comprehensive assessment ofthe injured ocular tissues during exploratory surgery andreview of the 7 risk factors for poor prognosis developed
from this study.
PUBLICATION OF THIS ARTICLE WAS FUNDED BY A GRANT FROM THE PEKING UNIVERSITY HEALTH SCIENCE CENTER, 211Evidence-Based Medicine Discipline Groups, Beijing, China (No.03-9-02). The funding organization had no role in the design or conduct of thisresearch. The authors indicate no financial conflict of interest. Involved in design of the study (Z.Z.M.); conduct of the study (K.F., Z.Z.M., Y.T.H.);collection of the data (Z.Z.M., Y.T.H., K.F.); analysis and interpretation of the data (K.F.); and review and approval of the manuscript (Z.Z.M.). Thisstudy was approved by the review board/ethics committee of the Peking University Third Hospital. Informed consent was obtained from every patient.

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Biosketch

Kang Feng, MD, is currently the Attending Physician of Peking University Third Hospital’s Department of Ophthal-mology, Beijing, China. Feng’s research and clinical interests involve ocular trauma, clinical trials, epidemiology,evidence-based medicine, diabetic eye disease, and neuro-ophthalmology. Dr Feng completed his ophthalmology residencyat General Hospital of People’s Liberation Army in Beijing. Following residency, he has been engaged in the clinical studyof ocular trauma and surgical technique at Peking University Third Hospital’s Department of Ophthalmology.

PROGNOSTIC INDICATORS FOR OPEN-GLOBE INJURED EYES WITH NLPVOL. 152, NO. 4 662.e1

Biosketch

Zhizhong Ma, MD, is currently the Professor of Ophthalmology and Chairman of Peking University Third Hospital’sDepartment of Ophthalmology, Beijing, China. Ma’s research and clinical interests involve ocular trauma, clinical trials,and diabetic retinopathy. Currently Dr Ma is Chair of the Chinese Committee of Ocular Trauma, and the ChinaRepresentative of International Society of Ocular Trauma. He serves on the editorial boards of the Ocular Surgery NewsAsia-Pacific Edition and American Journal of Ophthalmology-Chinese Edition.

AMERICAN JOURNAL OF OPHTHALMOLOGY662.e2 OCTOBER 2011

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