Two-Stage Approach and Minimally Invasive Vitrectomy for Severe Ocular Perforation Injury: A Case Report

Introduction

Open-globe injury (OGI) refers to a full-thickness injury involving the layers of the eye. It may be caused by blunt or sharp trauma; subtypes include globe rupture, penetration, perforation, intraocular foreign bodies (IOFBs), and mixed forms. Ocular perforation injury is a severe type of OGI characterized by simultaneous entrance and exit wounds. IOFBs are present in most cases. Although the incidence of perforation injury is low, representing approximately 2% to 3.5% of OGI [1,2], multiple ocular tissues are often severely damaged. These injuries are usually accompanied by intraocular or orbital foreign bodies, retinal detachment, and secondary infection, which contribute to complex management challenges [3,4]. Posterior scleral laceration can directly damage critical structures, including the optic nerve, macula, and major retinal vessels, resulting in severe visual impairment or complete loss of light perception. Massive vitreous hemorrhage and proliferative vitreoretinopathy may lead to severe tractional retinal detachment, which is often difficult to manage and associated with a poor prognosis [4,5]. Additionally, the risk of endophthalmitis after OGI is substantial, with an incidence of 2% to 8%; when IOFBs are present, up to 30% of patients may develop endophthalmitis [6].

Through advances in vitrectomy, early IOFB removal and repairs of damaged or detached retinas have become feasible, preventing severe vitreoretinal proliferation and substantially improving patient prognosis. Vitrectomy has gradually become the primary surgical method for managing these injuries. We report a case in which a 2-stage approach and minimally invasive vitrectomy were used to treat a posterior scleral laceration and giant retrobulbar hematoma caused by perforation injury.

Case Report

A 22-year-old man experienced vision loss in the right eye for 2 h after a wire injury. He had removed the wire himself before presentation, so no IOFB was identified. Ophthalmic examination showed uncorrected visual acuity of 20/400 and intraocular pressure of 3.2 mmHg in the right eye. A full-thickness penetration wound approximately 2 mm in length was visible in the middle of the lower eyelid, with conjunctival and scleral laceration at the corresponding site. The cornea and lens appeared transparent. Traumatic vitreous hemorrhage was present, without obvious abnormalities in the superior retina; choroidal elevation was evident in the inferior and temporal peripheral areas. After emergency admission, the patient underwent initial debridement and suturing under local anesthesia. During the procedure, an 8-mm full-thickness scleral laceration was identified at the inferior corneoscleral limbus, extending approximately 7 mm posteriorly. Routine postoperative treatment was administered to prevent infection, reduce inflammation, and control bleeding, after which the intraocular pressure gradually normalized.

One week after emergency surgery, B-scan ultrasonography showed persistent vitreous hemorrhage in the right eye and a suspected posterior scleral rupture. Fundus examination revealed dense preretinal hemorrhage and chorioretinal laceration (Figure 1). The diagnosis was revised to perforation injury of the right globe.

Ten days later, the patient underwent a second procedure consisting of 25-gauge vitrectomy to remove the vitreous hemorrhage and repair retinal damage. After removal of the vitreous hemorrhage, a long chorioretinal wound extending from the inferior posterior pole to the equator was observed, reaching deeply toward the retrobulbar sclera. Hemorrhage and vitreous surrounding the wound were completely removed, whereas hemorrhage within the wound was preserved to provide self-tissue tamponade. Laser photocoagulation was applied around the wound to form a “separation wall,” and the eye was filled with air at the end of the procedure (Figure 2).

One week after vitrectomy, B-scan ultrasonography and fundus examination were repeated. The retinal wound had healed, and the retrobulbar hematoma persisted (Figure 3). The patient was reexamined 3 months after hospital discharge. The best-corrected visual acuity of the injured eye was 20/25, the intraocular pressure was normal, the retina was flat, and the posterior wound had closed. Unexpectedly, B-scan ultrasonography showed complete resolution of the retrobulbar hematoma, and optical coherence tomography revealed no abnormalities in the macular area (Figure 4).

Discussion

OGI typically requires prompt medical intervention to preserve visual function. Management of ocular perforation injury primarily depends on surgery; minimally invasive vitrectomy currently is the main treatment approach. During repair of perforating wounds, watertight closure is essential and represents a critical step in ocular reconstruction. Wounds anterior to the equator should be sutured whenever possible during the initial procedure. Posterior globe wounds are usually located near the posterior pole and are difficult to suture. Some surgeons believe that small posterior wounds do not require suturing because natural healing can tolerate the perfusion pressure of vitrectomy [7]. Others advocate filling the posterior wound with autologous tissue, typically harvesting Tenon’s tissue from the ocular surface and packing it into the posterior defect. The packing height is adjusted to approximate the surrounding retina, followed by laser photocoagulation and injection of silicone oil or long-acting gas [7,8]. Additionally, some surgeons support direct suturing of the posterior wound within the eye [9]. Both of these approaches involve substantial technical challenges.

In cases of severe ocular perforation, vitrectomy timing requires careful consideration. When IOFBs are present, removal during the first stage along with wound closure and vitrectomy is advisable. The general consensus is that IOFBs, particularly metallic ones, should be removed as early as possible to reduce endophthalmitis risk and alleviate the toxic effects of metal on intraocular tissues. However, a small number of IOFBs that are inert or encapsulated by the posterior scleral wall may not require removal if extraction poses considerable difficulty [10,11]. Perforating ocular injuries are often associated with massive vitreous hemorrhage, posterior chorioretinal damage, proliferation, and detachment. Emergency vitrectomy may be unable to fully remove the vitreous body and can be complicated by intraocular hemorrhage that obscures visualization. Therefore, when the IOFB is located posteriorly or has already been removed (as in the present case), vitrectomy can be performed after intraocular bleeding stabilizes and the inflammatory response subsides, allowing safe repair of intraocular tissues or combined removal of residual foreign bodies. In some instances, IOFB removal and primary wound closure can be completed in the initial procedure, followed by vitrectomy in a second stage when the condition stabilizes. In a retrospective study of 110 patients with ocular trauma, Chauhan et al [12] found that early vitrectomy – particularly within the same day – significantly improved final visual acuity and reduced the risks of proliferative vitreoretinopathy and eye enucleation; however, they emphasized that such timing is feasible only under appropriate conditions. In most cases of severe ocular trauma, primary vitrectomy is not possible due to injury complexity and emergency resource limitations. Reviews of the literature indicate that recommended timing varies widely: within 3 days, within 4 days, 4 to 10 days, 8 to 14 days, and 15 to 30 days after injury. A recent cross-sectional survey of ocular trauma experts showed that 45.5% preferred conducting vitrectomy at least 7 days after the initial repair [13]. Based on our experience with more than 500 ocular trauma surgeries, we generally schedule the second procedure 7 to 10 days after the primary operation.

With regard to the choice of intraocular filler, most surgeons use silicone oil to ensure retinal reattachment and closure of the posterior scleral wound. Reports of successful management with simple air tamponade are limited. In cases involving silicone oil tamponade, silicone oil has been reported to migrate into the orbit through the posterior scleral wound [14]. This complication occurs because the exit wound of a perforation injury is often located posteriorly, can be difficult to suture, and allows heavy liquids and silicone oil to leak into the orbit during or after surgery. To address this issue, subretinal hemorrhage or blood clots within the wound tract may be preserved during surgery to help seal the tract. However, the vitreous must be thoroughly removed – particularly the anterior vitreous and the tissue surrounding the wound tract. When intraocular pressure is stable and laser photocoagulation effectively reinforces the wound margins, simple air tamponade is adequate, and silicone oil tamponade is not required as a universal precaution.

In the present case, the patient underwent secondary vitrectomy 10 days after the primary surgery. During the operation, the posterior scleral wound contained residual hematoma and vitreous. Under stable intraocular pressure, laser photocoagulation was applied to the wound margins, and the eye was filled with air. Despite the size and inferior location of the wound, silicone oil was not used. After a stable period of 3 months, the posterior scleral wound had healed, the retrobulbar hematoma had resolved, the globe position remained normal without proptosis or enophthalmos, and the best-corrected visual acuity improved to 20/25. For this patient, secondary vitrectomy 7 to 10 days after the initial repair was considered appropriate. Because intraocular pressure remained stable, suturing or packing of the posterior perforation wound was unnecessary. Complete removal of the vitreous surrounding the wound and of the anterior vitreous, followed by laser photocoagulation to create an isolation zone with healthy retina, was essential. Silicone oil was an unnecessary intraocular filler, and intraocular conditions permitted use of air tamponade.

Conclusions

In this case, a minimally invasive vitrectomy without long-acting tamponade was performed to treat the posterior exit wound of a penetrating injury, achieving satisfactory results. The patient’s best-corrected visual acuity improved to 20/25, with stable ocular structure and a well-healed wound; no complications were evident. In patients with complex ocular trauma, the timing of secondary vitrectomy should be optimized and the extent of surgery minimized to ensure favorable outcomes. This approach and the concept of minimally invasive intervention provide a reference for the management of similar cases, but they require validation through additional cases and long-term observation.