Controversies in the management of open-globe injuries involving the posterior segment

There are numerous unresolved issues and controversies regarding the manage ment of open-globe injuries involving the posterior segment. These areas in clude, but are not limited to, the following issues. Although vitrectomy ha s been shown to improve visual outcomes and allow retention of the eye in m any cases, the extent of visual improvement is often limited because of the nature of the injury. Timing of vitrectomy surgery has been and will conti nue to be debated by proponents of early versus delayed intervention. The m ultiple features of acute ocular injury make it very difficult to interpret retrospective data regarding the most appropriate timing for surgical inte rvention. The use of prophylactic cryotherapy, in the setting of a scleral laceration with possible retinal damage, is not as controversial at present , as there is now sufficient data indicating that cryotherapy may actually exacerbate intraocular proliferation and worsen the situation. The role and benefit of a prophylactic scleral buckle is very widely contested, and it is not known if it truly decreases the risk of subsequent retinal detachmen t. Another area of debate centers on the use of antibiotics. When there is a known clinical infection, intravitreal antibiotics are the mainstays of t herapy. However, in the absence of clinical infection, die use of prophylac tic antibiotics and their routes of administration are quite controversial. Although there are significant data regarding the use of antibiotics in th e postoperative setting, this information cannot be extrapolated into the s etting of open-globe injuries, as organisms and virulence factors differ. S imilarly, the use of vitrectomy versus vitreous tap in the setting of traum atic endophthalmitis is not fully resolved, although vitrectomy is used in most cases to repair concurrent damage from the injury itself. Finally, the placement of intraocular lenses in the acute trauma setting is controversi al, as the risk of complications is quite high. Prospective, controlled cli nical studies have not been done. This article reviews pertinent data regar ding these management issues and controversies, and provides recommendation s for treatment based on the available published data and the authors' pers onal experience. (C) 1999 by Elsevier Science Inc. All rights reserved.