Ozdek S, Hasanreisoglu M, Yuksel E. Chorioretinectomy for perforating eye injuries. Eye 2013; 27: 722-27.
In a nutshell
This article gives a fascinating account of the state of the art of chorioretinectomy. The subjects were 13 patients, nine with perforating eye injuries (entry and exit wounds) and four with penetrating injuries (single wounds, with retained foreign bodies in the choroid/sclera). Most were gunshot injuries and the rest due to iron fragments. In four cases there was associated retinal detachment. Most cases had initial visual acuities of hand-movements, and most had final acuities of counting-fingers.
With traditional surgery of meticulous wound repair, pars plana vitrectomy (PPV), and endolaser to the retina surrounding the wound, results tend to be very poor because of proliferative vitreoretinopathy (PVR). This complication arises from proliferation of retinal pigment epithelial (RPE) cells and wound/blood fibrous proliferation, and occurs in
60-90% of cases.
Chorioretinectomy removes all fibroproliferative tissue, and incarcerated vitreous and retina from the wound, as well as a rim of retina and choroid around the wound. Retinal detachment is prevented (or treated) by silicone oil tamponade and endolaser.
In this series anatomical success was excellent – 100% globe survival and 85% retinal attachment.
Taboos in ophthalmic surgery have sometimes hindered progress. Sir Harold Ridley was strongly criticised by his peers for daring to suggest that the deliberate introduction of a foreign object (intraocular lens) into the eye could be a safe, beneficial procedure.
Every effort was made not to disturb the vitreous body until vitrectomy was originated by Robert Machemer in late 1969. Pars plana vitrectomy is now an essential and common procedure.
Until the technique of chorioretinectomy was first described by Kuhn et al. in Birmingham, Alabama, in 2004, the retina was considered sacred and manipulated to a minimal degree, just enough to restore normal anatomy.
The series described by Kuhn et al. was only five cases, and an important difference to this series was the timing of the surgery. Kuhn et al. proposed that the ideal time for surgery was within 100 hours of the injury, to minimise the development of PVR. Ozdek et al. have shown that it is preferable to wait about two weeks post-injury (having closed open ocular wounds), and then to operate with a less inflamed eye, and with the posterior hyaloid detachment which follows injury, making surgery easier.
- The technique of chorioretinectomy is relatively new. This study confirms the benefits, and describes important modifications
- The most important advance has been the limitation of post-injury and post-operative retinal detachment due to proliferative vitreoretinopathy
- The anatomical results are excellent, but the functional results remain poor because of corneal and macular damage.