Visual Acuity After Vitrectomy Combined Phaco Fragmentation in Patients Having Trauma Ocular Contusion in Vietnam

DOI: https://doi.org/10.21203/rs.3.rs-1761869/v1

Abstract

Purpose

To evaluate visual acuity pre and post-vitrectomy combined phaco fragmentation and fixation scleral IOL in patients with contusion trauma to the eyeball.

Patients and Methods:

Prospective, interventional, non-control study, from July 2018 to October 2021 at the National Eye Hospital. One hundred three patients (69 men/34 women). We assessed visual acuity before and after surgery at each time point lasting up to one year after surgery. The related factors were evaluated by multivariable logistic regression.

Results

Comparing the visual acuity results between the time points before surgery, after surgery, 2 weeks and 1 month showed a statistically significant difference with p < 0.05. After 6 months of surgery, the rate of a visual outcome of 0.2 or more was 56%. At 12 months, the rate of visual acuity of 0.2 or more was 51.6%. Factors related to surgical results include: age under 40 years (OR = 1.8, p < 0.05), position of lens luxation (OR = 2.0, p < 0.05), corneal edema (OR = 4.8, p < 0.05), iridodialysis (OR = 3.0, p < 0.05), pupil dilation (OR = 3.4, p < 0.05) and vitreous hemorrhage (OR = 2.8, p < 0.05).

Conclusion

The results of vitrectomy combined with phaco fragmentation fixed IOL improved visual acuity after 12 months. Factors related to visual acuity outcomes include age, the position of lens deviation, corneal opacity, iris tear, pupil dilation, and vitreous hemorrhage.

Introduction

Lens subluxation or dislocation are pathological conditions of the eye in which the lens is displaced from its normal anatomical position[1]. For cases of lens subluxation or dislocation accompanied by cataracts, the treatment still uses two main techniques: vitrectomy or removing the cataract through the surgical limbal of the cornea or sclera[2]. The method of vitrectomy is only applicable to cases where the nucleus pulposus is still soft. The process of bringing out the cataract through the scleral-corneal limbal has the disadvantages of large surgical margins, complicated surgery, and many complications such as corneal edema, uveitis, and intraocular hemorrhage. The phaco fragmentation method in the vitreous chamber can overcome the limitations of the two techniques mentioned above[3]. There have been no reports in Vietnam documenting the results of fragmented phaco. Therefore, we studied "visual acuity after vitrectomy combined phaco fragmentation in patients having trauma ocular contusion in vietnam."

Patients And Methods

This research has been approved by the Scientific and Technical Board of the Vietnam National Eye Hospital and the Hanoi Medical University, Vietnam. All patients provided written informed consent, and this study was conducted following the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

We conducted the prospective, interventional, non-control study design.

Inclusion criteria: Patients over 18 with trauma and trauma drop the lens into the vitreous cavity.

Exclusion criteria: Patients are old and weak, have systemic diseases, and cannot afford surgical treatment. Patients with preoperative visual acuity are no light perception. Slight lens subluxation is indicated for treatment by other methods. Lens dislocated to the anterior chamber.

Variables: The outcome variable is Best Corrected Visual Acuity (BCVA) pre and post operation vitrectomy and phaco fragmentation and/ or other procedure. According to the classification of the International Ophthalmology Association (2002): Count finger (CF) 1m(0,02) > BCVA ≥ Light perception (LP) (+), CF 3m (0,05) > BCVA ≥ CF 1m(0,02), 0.2 > BCVA ≥ CF 3m (0,05), 0.5 > BCVA ≥ 0.2, BCVA ≥ 0.5[4]. At one year, visual acuity was assessed as good when BCVA was 0.2 or higher (Snellen visual acuity).

The influencing factors include WHO age classification (under 40 years old, 40–60 years old, and over 60 years old) [5], gender, time of hospital admission (under 24h, 24h-36h, 36h-72h, and > 72h), IOP (Goldmann tonometer) average value is 12–24 mmHg[6], the degree of cataract according to the classification of Buratto (1998)[7].

Protocol

Record patient data on disease duration, mechanism of injury, accident cause, age, and occupation.

The patient's visual acuity was measured with the best-corrected visual acuity using the Snellen electronic visual acuity board at a distance of 5m. Or counting fingers, hand movement, or light perception.

A drop of Alkain 0.1% anesthetic in each eye (Alcon), stain with Fluorescein to measure intraocular pressure. Goldmann tonometer, BQ-900 model (Haag-Streit; Bern Switzerland) to obtain intraocular pressure readings from each eye at admission.

The patient underwent vitrectomy combined with phaco fragmentation using the ACCURUS® Surgical System 800CS vitrectomy machine (Alcon, USA). Combined surgeries include IOL fixation to the sclera (SF-IOL), cryotherapy + pneumatic retinopexy, laser coagulation + pneumatic retinopexy, iris dialysis repair, cryotherapy + scleral buckle, and trabeculectomy. All patients were performed by an experienced doctor at the trauma department, National Eye Hospital, Hanoi, Vietnam.

We monitored the status of visual acuity before and after surgery, intraocular pressure, the position of IOL, postoperative uveitis, and recurrent retinal detachment. Schedule a follow-up appointment after being discharged from the hospital for one week, one month, three months, six months, or 12 months.

Data processing: Data entry was completed using EpiData 3.1 software (EpiData, Odense, Denmark). Statistical analysis and data cleaning with STATA 16.0 (Stata Corp, College Station, TX, USA). Data are presented as mean, standard deviation, absolute value, and percentage. Compare the two proportions by the Chi-square test or the Fisher test. Using logistic regression statistics to evaluate the incidence of lesions with several independent variables in the body and eyes.

Result

We recorded the patient's lesion characteristics before surgery. The results are shown in Table 1.

 
Table 1

Patient characteristics preoperative

 

N

%

Gender

Male

Female

69

34

67

33

Age groups

Under 40

40–60

Upper 60

5

65

33

4.9

63.1

32

Time of admission

< 24h

24h-36h

36-72h

> 72h

10

46

35

12

9.7

44.7

34

11.6

IOP pre-OP

Nomal (12–24 mmHg)

Low (< 12 mmHg)

High (> 24 mmHg)

68

3

32

66

2.9

31.1

Grade of catarac

Grade 1

Grade 2

Grade 3

Grade 4

18

55

21

9

17.5

53.4

20.4

8.7

Position of lens

Vitreous chamber

Subluxation

Posterior retina

Peripheral retina

38

25

24

16

36.9

24.3

23.3

15.5

Anterior segment

Angle recession

Pupil dilation

Iridodialysis

Corneal edema

31

29

21

22

30.1

28.1

20.3

21.5

Posterior segment

Vitreous hemorrhage

Retinal detachment

Normal

27

11

65

26.2

10.7

66.1


Table 1 shows 100% of eyes with cataracts of varying degrees. In the anterior segment, the angle recession takes up the majority. There are 29 eyes with damaged iris. In the posterior segment, the rate of vitreous hemorrhage was highest, 26.2%. In addition, we also found retinal tears (11/103 eyes) during surgery.

INSERT FIGURE1 HERE

As shown in Fig. 1, almost all patients had visual acuity less than 0.02 (CF 1 meter).


 
Table 2

Applied surgical methods

No

Treatments

N

%

1

Vitrectomy + Phacofragmentation

103

100

2

Fixed scleral IOL immediately

83

80,6

3

Fixed scleral IOL later

20

19,4

4

Cryo therapy + pneumatic retinopexy

10

9,7

5

Laser coagulation + pneumatic retinopexy

7

6,8

6

Iris dialysis repair

3

2,9

7

Cryotherapy + scleral buckle

5

4,8

8

Trabeculectomy

3

2,9


As can be seen from Table 2, 100% of patients underwent vitrectomy with fragmentation. There were 83 eyes with IOL placed by the primary scleral fixation method. After three months, the remaining 20 eyes received SFIOL after treatment for stable chorioretinal lesions. We found eleven eyes with peripheral retinal tear during surgery and six cases of retinal damage caused by touching surgical instruments. We performed cryotherapy or laser coagulation. During follow-up, five patients with retinal detachment complications in the 3rd month underwent cryotherapy + scleral buckle, with good retinal results and increased visual acuity. We performed a trabeculectomy with three patients. Because after vitrectomy, these patients did not respond well to anti-glaucoma drugs.

Figure 2 presents the BCVA of the group under 1m CF (67/103 eyes) is the majority at the time of surgery. One and three months later, BCVA over 20/100 predominates (40/103 eyes and 42/103 eyes, respectively). A two-week and one-month comparison between pre-OP and post-OP showed a statistically significant difference in BCVA outcomes with p < 0.05 (Wilcoxon-Mann-Whitney test). At six- and twelve months post-OP, the percentage of BCVA results of 0.2 or higher was 56% and 51.6%, respectively.

We evaluate the multivariable relationship between the degree of visual acuity improvement and several related factors. The results are shown in Table 3.

 
Table 3

The multivariable association between BCVA and some related factors: logistic regression

 

Model 1

Model 2

Variables

OR

95% CI

p

Variables

OR

95% CI

p

Gender

Male

Female

1

1.79

0.7–4.4

> 0.05

Angle recession

No

Yes

1

1.1

0.4–2.7

> 0.05

Age groups

Under 40

40–60

Upper 60

1

1.1

1.8

0.5–6.9

1.5–2.3

> 0.05

< 0.05

Pupil dilation

No

Yes

1

3.4

1.3–9.3

< 0.05

Time of admission

< 24h

24h-36h

36-72h

> 72h

1

1.12

0.95

1.06

0.13 − 9.31

0.12–7.72

0.3–1.09

> 0.05

> 0.05

> 0.05

Iridodialysis

No

Yes

1

3.0

1.5- 9.2

< 0.05

IOP pre-OP

Nomal

Low

High

1

1.8

1.1

0.5–6.9

0.5–2.3

> 0.05

> 0.05

Corneal edema

No

Yes

1

4.8

1.7–13.7

< 0.05

The drop position of lens

Subluxation

Posterior retina

Peripheral retina Vitreous chamber

1

1.13

1.79

2.0

0.48–1.9

0.45–2.5

1.3–3.5

> 0.05

> 0.05

< 0.05

Vitreous hemorrhage

No

Yes

1

2.8

1.04–7.7

< 0.05

Grade of cataract

Grade 1

Grade 2

Grade 3

Grade 4

1

0.7

0.5

0.8

0.1 − 4.3

0.2–6.4

0.5–3.2

> 0.05

Retinal detachment

No

Yes

1

2.9

0.7–14.1

> 0.05

Discuss

This is the first study in Vietnam on treating traumatic lens dislocation by vitrectomy combined with phaco fragmentation with/without some surgical methods.

The current study found that 50.49% of eyes had a visual acuity of 0.2 or more after one year of follow-up. The most prominent finding from the analysis is that this study selects a group of patients with severe lens damage, leading to luxation into the vitreous; the combined lesions were also diverse.

Several reports have shown that the age factor is related to the degree of visual acuity improvement [1, 2]. This study confirms that the age group under 40 has a higher chance of vision improvement than patients aged 40 years and older.

Shah's study mentioned the effect of treatment duration and visual outcome in trauma patients[3]. This study differs from the findings presented here; there was no effect between the treatment time and the progression of vision.

Lens drop positions include the posterior retina, on the peripheral retina at 6 o'clock, or in the vitreous cavity. The position of the lens falling into the vitreous chamber is the most. Positions in the vitreous cavity or the peripheral retina at 6 o'clock are still Zinn ligaments, the vitreous spills out anteriorly, compressing the pupil border and pushing the lens backward. An ultrasound should be performed in the lying position to distinguish whether the Zinn ligament is intact or completely ruptured. It is necessary to sever the Zinn ligament for two purposes: first, to avoid jamming the vitreous into the surgical instruments; second, to control the lens rotation around the phaco tip actively. There was a higher rate of vision recovery when assessing visual acuity outcomes in patients with lens prolapse into the vitreous cavity. The result of this study indicates that visual acuity outcomes in patients with lens prolapse into the vitreous cavity, there was a higher rate of vision recovery. This result can be explained by the fact that the drop position of the lens does not affect the retina. Previous studies also concluded that the less associated damage, the higher the postoperative visual acuity[46].

Prior studies have noted the importance of angle recession as a cause of visual loss after trauma[7, 8]. This finding contradicts previous studies that have suggested that angle recession is the cause of glaucoma secondary to trauma.

This finding is consistent with Greven's research (2002), which showed that reduced visual acuity is related to iris damage[9].

The previous literature has reported a strong relationship between vitreous hemorrhage and vision loss [6]. This study supports evidence of earlier observations.

This result contrasts with Greven et al. (2002), who found retinal damage with visual outcome [11]. One possible explanation for these results could be that tears in the peripheral retina do not affect visible ability.

The limitation of this study is that it is an uncontrolled clinical trial. This method's evaluation of visual acuity outcomes limits the generalizability of other surgical procedures.

Conclusion

The first study of dislocated/luxated cataracts due to trauma using vitrectomy combined phaco fragmentation in Vietnam. The article described the clinical characteristics of dislocated/luxated cataracts and combined clinical symptoms in the traumatic eye.

The study provided the surgical outcomes of vitrectomy combined phaco fragmentation. We focused on the anatomical effect (treatment of dislocated/luxated cataract, treatment of combined lesions) and postoperative visual acuity functional outcome. It also provided the intra-operative and postoperative complications of the surgeries. Visual acuity recovered after one year with phaco fragmentation vitrectomy combined SF- IOL in patients due to contusion trauma to the eyeball.

The study revealed the success rate of surgical results and factors affecting surgical outcomes with statistical significance. Factors related to the effect of vision restoration include age, the drop position of the lens, iris damage, corneal edema, and vitreous hemorrhage.

Our study proved that vitrectomy combined phaco fragmentation is effective and indicated in treating dislocated/luxated cataracts. The study offers the time of intervention, location in the vitreous cavity, and parameter setting.

Abbreviations

BCVA

best-corrected vision acuity

IOP

intraocular pressure

Pre-OP

preoperative

Post-OP

postoperative

SF- IOL

sclera fixation intraocular lens

CF

count finger

HM

hand movement

LP

light perception

Declarations

Acknowledgments

We thank the Department of Trauma staff and the Director board of National Eye Hospital Vietnam for supporting this study.

Data Availability Statement

The data supporting this study's findings are available from the corresponding author upon reasonable request. If you are concerned about sharing the data, please contact [email protected].

Ethical statements

All participants were dispensed with written informed consents, and the protocol was approved by the Ethical Review Committee of the Hanoi Medical University and National Eye Hospital, Vietnam. All patients provided written informed consent, and this study was conducted following the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Consent for Publication

I understand that the Eye journal may be available in print and on the internet and will be available to a broader audience through marketing channels and other third parties. Therefore, anyone can read material published in the journal. Readers may include medical professionals, scholarly researchers and journalists, and general public members. If you have any queries, please get in touch with [email protected].

Disclosure

The author(s) declared no potential conflicts of interest to this article's research, authorship, and publication.

Funding

The author(s) received no financial support for this article's research, authorship, and publication.

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