14.12 When Not to Operate

14.9Sympathetic Ophthalmia

This is a panuveitis of both the affected and fellow eye stimulated by the exposure of intraocular antigens to the immune system. Look for deep white spots in the retina, DalenÐFuchs nodules. The risk after trauma appears to be rare (0.1Ð0.3 %) (Allen 1969; Kraus-Mackiw 1990; Liddy and Stuart 1972). It may indeed be commoner after posterior segment surgery, that is, PPV, than after trauma (Kilmartin et al. 2000). Improved control of the condition with immunosuppression and better visual outcome has caused a shift away from primary enucleation (removal of the eye at presentation) as a method to prevent the uveitis. In severe ocular trauma, the eye can be repaired with, on occasion, surprising visual recovery or maintenance of a cosmetically acceptable eye; therefore, enucleation is not favoured. I have yet to see a proven case of sympathetic ophthalmia in my practice of 6,000 operations including patients with severe ocular trauma, and I have not performed enucleation or evisceration on any of my patients.

14.10 Proliferative Vitreoretinopathy

The incidence of PVR with the different presentation patterns is shown in the table (Cardillo et al. 1997), with vitreous haemorrhage the strongest predictor of its development. The complication is associated with a poorer visual outcome and is the reason for urgency of operation after presentation, frequent use of silicone oil insertion and careful follow-up.

or the anterior segment is unsightly. This is preferable to evisceration or enucleation (and its attendant orbital fat atrophy) if the eye is not painful. Band keratopathy may eventually occur if the eye remains formed. This may cause intermittent epithelial breakdown causing pain, usually a severe suddenonset pain lasting a few hours at a time. It can be treated with excimer laser ablation.

Note: Hypotony is a key surrogate marker for the health of the eye; if the IOP is in the normal range, then you can perform further surgery to maximise the vision. If the IOP is low with silicon oil in the eye and there is no other reason such as persistent RD, then the eye is unlikely to tolerate repeat operations. In this case, it may be best to leave the silicon oil in situ to maintain the cosmetic appearance of the eye. Cosmesis is important in these patients who are often relatively young.

14.12 When Not to Operate

14.12.1At Presentation

There are circumstances in severe trauma in which the chance of success from surgery is so low that to put the patient through surgery may not be the best approach. Surgery on a severely damaged eye may turn a blind comfortable eye into a blind painful eye. For example, a severe trauma with a closed CA12 CP12 funnel RRD is unlikely to obtain any useful vision even if a small island of retina is attached. The surgery is fraught with difÞculty such as bleeding, and there may be choroidal haemorrhage in addition. Evacuation of solid choroidal haemorrhage by surgical aspiration is rarely effective. By operating, the discomfort of the eye is increased and may take months to subside. Patients with severe trauma and choroidal haemorrhage often have an ache which improves slowly over many weeks after the injury; surgery increases the pain again and slows the recovery. Visual acuity of no perception of light is not a reason to avoid surgery as 26 % of patients who had NPL at presentation or on day one postoperatively have been shown to recover some vision (Salehi-Had et al. 2009).

14.11 Phthisis Bulbi

If a hypotonous eye is going phthisical, urgent insertion of silicone oil to allow preservation of the size of the globe is advised. If cyclitic membranes are present, these can be dissected and segmented in an attempt to regain some function of the ciliary body (Essex et al. 2007; Banaee et al. 2007). This may allow adequate cosmesis with a slight reduction in size of the eye, seen as a mild ptosis by the patient, or allow cornea scleral shell application if the shrinkage is noticeable

14.12.2Postoperatively

Be careful of repeated operations in an eye with a low IOP as each operation may exacerbate the risk of phthisis bulbi. Make sure you have a good reason to operate and a plan for improving the situation; otherwise, Ôcut your lossesÕ. Be aware that patients do not want their cosmetic appearance affected for no visual gain or to continue their period of pain and discomfort.