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S.S. Dahr, T.J. McCulley, R.C. Kersten, S.S. Schneider, R.K. Hutchins; Decision Factors for Primary Enucleation in a Trauma Setting: A Clinicopathologic Study . Invest. Ophthalmol. Vis. Sci. 2003;44(13):822.
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Purpose. To evaluate the medical and social considerations that suggest proceeding with primary enucleation instead of primary repair in the setting of an open globe injury. Methods. The medical records of 10 consecutive patients (8M, 2F, mean age 32 years, range 16 to 51 years) with open globe injury who underwent primary enucleation at the University of Cincinnati medical center during the study period (January 1, 1999 to November 30, 2002) were reviewed for factors influencing the decision to proceed initially with enucleation as an alternative to attempted repair. Results. Presenting visual acuity was NLP in 5 patients and LP in 1 patient; 4 patients were unconscious and their acuity could not be assessed. The initial injury was a gunshot wound in 4 patients, fireworks injury in 2 patients, assault with a metal object in 2 patients, a motor vehicle accident in 1 patient, and a fishing hook accident in 1 patient. The fellow eye had a normal exam in 8 of 10 patients; one patient had a stellate corneal laceration that was repaired primarily; one patient had a mild thermal corneal burn. Preoperative counseling was performed and consent for possible enucleation was obtained from the patient in 6 of 10 cases and from family in 2 of 10 cases where the patient was unconscious and medically unstable. In 2 of 10 cases preoperative counseling and consent were impossible to perform secondary to patient medical status and lack of available family. In those 2 cases the patients’ unstable medical status played a role in the decision to proceed with primary enucleation without consent, as the trauma surgery service was concerned about the risks to the patient’s life associated with a second trip to the operating room for secondary enucleation after primary repair. Of the 4 patients who were unconscious and unaware prior to enucleation, all survived and none expressed regret or malice regarding his or her management. Pathologically, all 10 eyes featured greater than 20 mm of corneoscleral rupture or laceration with gross prolapse and/or loss of retinal and uveal tissue. Conclusions. In the setting of a severely ruptured or lacerated globe with gross prolapse and/or loss of retinal and uveal tissue, primary enucleation is a valid alternative to primary repair with anticipated secondary enucleation. Considerations include the status of the fellow eye, the opportunity for patient and/or family counseling and consent, and the patient’s medical status. In medically unstable patients primary enucleation may limit surgical risks to the patient’s life.
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