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Posterior involvement in fencing wire open globe injuries

Ocular trauma in Australia is the fourth most common cause of severe unilateral visual impairment, representing 10% of cases. Prompt repair of an injury is essential, with a four-fold increased risk of post-traumatic endophthalmitis if primary repair is delayed ≥12 h. For this reason, it is important to have an epidemiological understanding of characteristic structural involvement for fencing wire associated open globe injuries. Australia is a country with an expansive rural setting where a significant portion of the population resides. Fencing wires are commonly utilised in agricultural industries and residential properties. Characterising fencing wire penetrating eye injuries in particular is important, as it is the most common cause of penetrating eye injury in Australia. By extension, these findings are relevant in countries with similar population distribution. Our study team reviewed cases of open globe injuries recorded in our prospective ocular trauma audit between April 2016 and September 2021. Our institution, the Royal Victorian Eye and Ear Hospital (RVEEH) is located in Melbourne, Australia and serves as the tertiary referral centre for Victoria. Ethics was approved by the RVEEH Human Research Ethics Committee (HREC:21/1516HL) and adhered to the tenets of the Declaration of Helsinki. Informed written consent for repair of open globe injury was obtained by a registrar or consultant ophthalmologist. Patient demographics are summarised in Table 1. A total of 11 cases of open globe injury were attributed to fencing wire. A majority were male (72.7%) with a mean age of 47.9 years, SD 17.8. Presenting visual acuity (VA) was poor in all patients with moderate or worse vision impairment based on World Health Organisation classification. Moderate visual impairment is classified as VA as worse than 6/18 up to 6/60, with severe visual impairment or blindness worse than 6/60. All patients had their eyes shielded after initial assessment, offered prophylaxis tetanus vaccination, commenced on oral ciprofloxacin 750 mg for 1 week and sent for orbital computed tomography to assess for intraocular foreign bodies and identifying posterior injuries. We found a large proportion of our open globe injuries to have posterior involvement (63.6%), shown in Table 2. Of these, 5 (45.5%) were non-perforating retinal injuries such as retinal tear or impact (focal haemorrhages) and 2 (18.2%) were perforating injuries with an exit wound posterior to the entrance site. The two cases of perforating injuries were not diagnosed on initial presentation. One case involved a scleral penetrating injury initially repaired; however had postoperative findings of choroidal haemorrhage and retinal detachment. An exploratory vitrectomy revealed a perforating wound more posterior to the initial scleral wound. The other case involved a zone I corneal penetrating injury that was initially repaired; however experienced persistent postoperative hypotony and deteriorating vision despite a clinically sealed wound. Exploration with 360 peritomy demonstrated a scleral perforating wound. We observed there was high proportion of patients with occult posterior injury that was not identified on primary ocular trauma examination (85.7%). These diagnoses were missed at presentation due to poor view secondary to vitreous haemorrhage or corneal haze. We believe this is an important study finding; our recommendations regarding future workup for fencing wire injuries in this setting are summarised in the concluding paragraphs of this letter. The vitreoretinal unit played an important role in the management of fencing wire injuries with seven cases (63.6%) requiring vitrectomy and one case (9.1%) requiring retinal laser for a tear. Two patients experienced complications involving choroidal haemorrhage with retinal detachment and the other having endophthalmitis (9.1%). A majority of cases had good final vision, with 81.8% having 6/18 or better VA. The one case of worse than 6/60 vision is due to aphakia with intended secondary intraocular lens implantation. The mean duration of followup was 4.3 months. This study highlights the importance for ophthalmologists to have high clinical suspicion of posterior involvement in all cases of fencing wire related open globe injuries, especially if there is a poor or no fundal view. We hypothesise that the high rate of posterior involvement with fencing wire may be due to sharp edges of cut wire, combined with rapid recoil due to high tensile force when suddenly released (e.g., cut or freed). It may be difficult to identify posterior injury early in presentation of penetrating eye injury with a lack of view Received: 3 November 2021 Revised: 18 December 2021 Accepted: 20 December 2021