APOTS-APVRS Session Shed Light on Management of Posterior Segment Trauma

Explore the latest insights and practical strategies in the management of posterior segment ocular trauma

On the final day of the 18th Congress of the Asia-Pacific Vitreo-Retina Society (APVRS 2025), leading vitreoretina (VR) surgeons convened as they dissected the challenges of posterior segment trauma. Each presentation delivers evidence-based updates, surgical tips and pearls of wisdom—from the nuances of blunt ocular trauma to controversies in open-globe management, the critical role of imaging and prevention of post-traumatic infections.

When blunt trauma reaches the macula

Closed-globe ocular trauma is often underestimated, yet its impact on the posterior segment—particularly the macula—can be devastating. As highlighted by Dr. Sanyam Bajimaya (India), these injuries are commonly seen in clinical practice and are most often sports-related, accidental, domestic, agricultural, or associated with physical assault and public demonstrations.

“Closed-globe injuries in the pediatric population can cause severe sight loss. Visual outcome depends on the integrity of the photoreceptor outer segments,” he explained.

Dr. Bajimaya emphasized that blunt trauma can disrupt photoreceptors, choroid and retinal vasculature, leading to a spectrum of macular complications—commotio retinae, choroidal rupture, traumatic macular holes and retinal detachment—which are key to vision-threatening outcomes.

“When you have blunt trauma, there’s always an indirect injury to the posterior segment,” he said. For example, choroidal rupture (which is often concentric to the optic disc) carries the long-term risk of choroidal neovascularization, which may develop months or even years later. “The primary concern is traumatic choroidal neovascularization, which may occur very late,” he explained.

Using established classifications of closed-globe injuries—based on mechanism, severity and ocular zones—Dr. Bajimaya focused his presentation on Zone III injuries involving the posterior segment. He reported epidemiological data from Nepal and India which consistently showed a strong male predominance, with children and adolescents particularly vulnerable.

Traumatic macular holes, though alarming, reported Dr. Bajimaya, often carry a favorable prognosis with timely management. Furthermore, with the help of optical coherence tomography (OCT) and OCT angiography (OCTA), imaging technologies now play a pivotal role in diagnosis and monitoring.

“The prognosis in traumatic macular holes is close to 90%,” said Dr. Bajimaya. However, delayed presentation remains a major challenge, particularly in children.

In his presentation, he illustrated this in one of the cases he presented: a striking pediatric case which showed how the lack of early examination after a festival-related injury led to macular hole and retinal detachment eventually requiring complex surgery. “Early surgical intervention—within seven to 14 days—leads to better outcomes,” he noted.

In conclusion, closed-globe trauma is common and potentially blinding, but is definitely preventable with early detection, vigilant imaging and timely surgical intervention. These measures are critical in preserving vision, especially in children where the stakes are highest.

Navigating uncertainty and innovation in traumatic eye injuries

Trauma to the eye presents one of the most challenging arenas in ophthalmology—from taser injuries delivering 50,000 volts to industrial accidents—surgeons face complex decisions to preserve vision, reported Dr. William F. Mieler (USA), during his talk titled Controversies in the Management of Posterior Segment Open-Globe Injuries.

“We tend to try to fix everything whenever possible, but certain outcomes can be quite variable,” said Dr. Mieler. Despite 25 years of advances, many controversies persist, particularly regarding timing of vitrectomy, prophylactic cryotherapy and use of buckles or antibiotics, emphasized Dr. Miller.

“Once you have a foreign body, if you don’t close that wound within about 24 hours, the risk of infection is higher and outcomes aren’t as good,” he explained. Foreign bodies significantly increase the risk of infection, with studies reporting rates up to 30% in retained intraocular objects. Early intervention, like most other conditions, is critical.

“Intervene promptly. We try to do a single approach rather than a staged approach, but that’s not absolutely essential,” said Dr. Miller. For example, in the case of prophylactic antibiotics, they are to be instilled cautiously. While vancomycin or ceftazidime may be indicated in high-risk contamination, indiscriminate use is not standard care due to rare but serious complications like hemorrhagic occlusive retinal vasculitis.

“Monitor for the possibility of infection; cautious use of antibiotics is warranted, particularly in organic matter contamination,” he explained.

Another evolving area, Dr. Mieler told the audience, is operating on eyes with NLP (no light perception) vision at presentation. According to available evidence, some eyes can regain vision after careful repair.

“Even when patients are NLP at presentation, I would repair the globe—if at all possible—and see if they recover some vision,” Dr. Mieler shared, adding that advances in surgical techniques, lens implantation and vitrectomy have improved outcomes, but ocular proliferation and cellular shutdown remain major challenges. The incidence of sympathetic ophthalmia is low (~0.1%), but timing of enucleation can still be a consideration in select cases, he said.

“In the past 25 years, we have advanced our understanding, yet eyes are still lost due to proliferation and cellular shutdown. The goal remains to save the eye whenever possible,” concluded Dr. Miller.

Ultimately, Dr. Miller reminded the audience, trauma ophthalmology requires a careful balance of urgency, innovation and individualized care, with the guiding principle: preserve vision and the globe whenever feasible.

Seeing beyond the swelling

Talking about Importance of Imaging in Posterior Segment Ophthalmic Trauma, Dr. Ari Djatikusumo (Indonesia) reiterated that ophthalmic trauma remains a major, yet often overlooked, global health challenge. Affecting both vision and quality of life, indeed the burden is immense and persistent.

“Ocular trauma is a significant cause of physical impairment and mental health impact worldwide,” said Dr. Djatikusumo.

According to World Health Organization estimates, around 1.6 million people are blind due to ocular trauma, with millions more sustaining injuries each year that lead to partial or permanent vision loss. Young adults, particularly men, are at greatest risk.

“Males experience a higher risk of ocular trauma due to greater involvement in high-risk activities,” explained Dr. Djatikusumo. Furthermore he presented data from his eye center which reinforced this trend. Among 1,184 trauma cases over two years, blunt trauma emerged as the most common mechanism, reflecting global patterns.

“Blunt trauma is the major mechanism of injury and often carries a poorer visual prognosis,” shared Dr. Djatikusumo. Clinical examination alone, he emphasized, is frequently insufficient in trauma settings. “Pain, swelling, hyphema and media opacity can obscure critical findings. And there are limitations to clinical examination in trauma cases—this is why imaging is essential,” he explained.

Seconding Dr. Bajimaya’s stand on the role of imaging in clinical trauma, Dr. Djatikusumo also reported that imaging enables accurate diagnosis, guides surgical decisions and identifies associated orbital or intracranial injuries. “Imaging serves as a non-invasive tool to evaluate injuries that are not visible clinically,” he added.

Computed tomography (CT), according to Dr. Djatikusumo, remains the first-line imaging modality in emergency settings, especially when open-globe injury, orbital fractures or intraocular foreign bodies are suspected. “CT scan is the gold standard for orbital and ocular trauma assessment,” he said. However, when CT is unavailable, ultrasound offers a valuable alternative particularly for detecting vitreous hemorrhage or retinal detachment—provided an open globe has been excluded.

Dr. Djatikusumo then presented various real-world cases that highlighted how timely imaging altered outcomes, from diagnosing traumatic optic neuropathy to localizing metallic intraocular foreign bodies. “Immediate imaging can reduce treatment delay and improve visual outcomes,” he said.

In conclusion, Dr. Djatikusumo noted that imaging is not an adjunct but a cornerstone of ocular trauma care, bridging diagnostic gaps, expediting intervention and ultimately preserving sight when every minute counts.

When standard repair isn’t enough

Repairing complex retinal detachment demands more than routine techniques, noted Dr. Amer Awan (Pakistan) when it was his turn on the podium. In eyes where the retina is shortened, stiff or distorted—often due to trauma or advanced proliferative vitreoretinopathy (PVR)—retinotomy and retinectomy become essential tools rather than last resorts, he noted.

“These are the cases where standard retinal detachment surgery is not going to work,” said Dr. Awan, emphasizing that retinal shortening may present during primary surgery or as a secondary procedure, particularly in trauma, grade C PVR, giant retinal tears, retinal incarceration or extensive subretinal bands. In such cases, according to Dr. Awan, the goals remain clear and uncompromising: “You want to attach the retina, achieve anatomical stability and improve vision.”

That definitely sounds easier than done, literally, as retinotomies can be focal or extensive. On the other hand, localized PVR folds may respond to a small relaxing retinotomy, while diffuse inferior PVR often requires a broader inferior retinectomy. What’s a vitreoretinal surgeon to do? “Don’t hesitate to enlarge your retinectomy—be generous when you do it,” advised Dr. Awan.

Meticulous surgical steps underpin success, hence complete vitreous removal, aggressive management of epiretinal and subretinal membranes, and careful marking of retinotomy edges make all the difference, warned Dr. Awan. “Adequate removal of anterior PVR is crucial. If you leave it behind, the retina will detach again,” he explained.

Therefore it is very important to stabilize and flatten the cornea. Enter perfluorocarbon liquids (PFCLs) followed by precise laser photocoagulation along retinotomy edges. Silicone oil—standard or heavy—provides long-term tamponade in most cases. “PFCL stability is key, and laser to the edges is non-negotiable,” Dr. Awan said.

Then he presented a series of challenging cases which illustrated the power of these techniques: traumatic detachments with subfoveal bands, giant retinal tears, post-endophthalmitis eyes and even single-eye patients. Visual outcomes improved remarkably—from counting fingers to 6/24, 6/60 and better—despite severe pathology.

“These detachments are difficult, but if you tackle them properly, you can still achieve good outcomes,” shared Dr. Awan. He closed his talk with a strong message: complex retinal detachment surgery is demanding but rewarding.

And when thoughtful planning, decisive membrane removal, and a willingness to be bold when necessary, come into play, then retinotomy and retinectomy can restore retinal anatomy—and meaningful vision—when all else fails.

Seeing beyond the cornea

In ocular trauma, visualization is often the first—and greatest—challenge. Corneal edema, opacification, sutures or anterior segment destruction can make conventional posterior segment surgery nearly impossible. This is where endoscopic vitrectomy has emerged as a powerful adjunct to routine vitreoretinal techniques.

“Endoscopy helps you bypass the anterior segment and directly address posterior segment pathology,” said Dr. Vivek Dave (India). He then proceeded to present cases where endoscopy changes both strategy and outcome. According to Dr. Dave, in severe chemical injuries, particularly common in rural settings, the cornea and limbus may be completely obscured. In such cases, although traditional B-scan ultrasonography can confirm retinal attachment, it offers no insight into optic nerve health or macular viability. “Preoperative imaging is often just a guesstimate,” he shared.

Diagnostic endoscopy allows surgeons to assess the retina, vasculature and optic disc directly—critical information when deciding whether a patient is a suitable candidate for keratoprosthesis.

Another frequent scenario involves traumatic retinal detachment with corneal decompensation and silicone oil. When B-scan becomes unreliable, endoscopy can confirm retinal attachment and even assess laser uptake.

“A few laser spots can tell you if the retina is truly attached,” he said. Perhaps the most impactful use of endoscopy, according to Dr. Dave, is in post-traumatic endophthalmitis with poor corneal clarity. “Instead of removing the cornea or inserting a temporary keratoprosthesis, surgeons can switch mid-procedure to an endoscopic approach. You halt your routine procedure, bring in the endoscope and the game changes,” he added.

Such an approach preserves the patient’s natural cornea, allowing it a chance to clear spontaneously—an advantage especially important in young patients. “Giving the natural cornea a chance may be better than a graft in the long run,” Dr. Dave shared.

Endoscopy also proved invaluable in managing recurrent traumatic iris cysts and occult intraocular foreign bodies hidden behind the iris or vitreous base—pathology invisible through conventional visualization.

In conclusion, endoscopic vitrectomy is not meant to replace standard surgery, but to complement it. “Even if the entire surgery isn’t endoscopic, there are moments where it can dramatically enhance visualization,” Dr. Dave explained.

After all, in trauma—where surprises are the rule rather than the exception—endoscopy offers surgeons the ability to truly see (and safely act!) when it matters most.

Practical tips on retained intraocular foreign bodies

When Dr. Hassan Khaqan (Pakistan) played his first surgical video on screen, it was the start of many gasping moments. Straight from the operating room where such cases seem to be the norm for Dr. Khaqan, he emphasized that managing retained intraocular foreign bodies (IOFBs) remains one of the most technically demanding challenges in vitreoretinal surgery.

“Success depends less on rigid rules and more on understanding where the foreign body lies, how it is embedded, and how best to remove it without creating secondary damage. There are different scenarios, and each scenario needs a different strategy,” he said.

In addition, Dr. Khaqan emphasized that one of the most important principles that VR surgeons need to have in handling these cases is restraint. “In metallic IOFBs lodged in the vitreous, a complete vitrectomy is not always the right answer. Do not do a complete vitrectomy, keep the posterior hyaloid as a scaffold,” he said.

Preserving vitreous support helps prevent the foreign body from dropping onto the retina or macula, where it can cause irreversible injury. If the IOFB is momentarily lost, a simple but effective maneuver can help, shared Dr. Khaqan as he showed more surgical videos—where succeeding wasn’t always the case for him. “Indent the vitreous base…you will often find the foreign body hiding there,” he shared.

When foreign bodies are partially embedded in the retina, the approach shifts. Intensive laser barricade around the IOFB stabilizes the tissue before extraction. “Laser first, then remove the foreign body,” added Dr. Khaqan.

Here are a few more practical tips that Dr. Khaqan shared:

There shouldn’t be a debate about wound size, only whether it is adequate.
Never manipulate the macula if you can avoid it.
Mistakes are how we learn. Mistakes are meant to be shared.

Overall, based on what he shared during his talk, it seems like Dr. Khaqan has been operating on cases others are the least likely to do. But Dr. Khaqan conveyed that modern IOFB management is guided by adaptability, meticulous planning and humility. With thoughtful technique—and respect for the retina—surgeons can safely navigate even the most complex foreign body scenarios while preserving vision, concluded Dr. Khaqan.

What to do with post-traumatic endophthalmitis

Opening his presentation titled Prevention and Treatment of Post-Traumatic Endophthalmitis, Dr. Paul Siopongco (Philippines) presented a case of a 44-year-old man who arrived at the emergency department after a metal grinding accident, suffering a corneal laceration. Initial B-scan showed no vitritis or foreign body, but days after a lensectomy, the patient developed pain, redness and worsening vision.

The diagnosis, according to Dr. Siopongco, was clear: post-traumatic endophthalmitis, a severe intraocular infection involving the vitreous and aqueous. “Endophthalmitis is a severe intraocular inflammation involving the vitreous and the aqueous. It essentially happens when bacterial infection occurs in these compartments,” he reminded the audience.

Trauma-related endophthalmitis, although accounting for a small percentage of eye injuries (1% to 3%), contributes disproportionately to severe vision loss, noted Dr. Siopongco. “Open globe injuries should be closed within 24 hours to reduce the risk of endophthalmitis. Prevention is the first line: meticulous wound cleaning, broad-spectrum antibiotics and early repair are crucial,” said Dr. Siopongco.

Historically, vitrectomy was reserved for patients with poor vision due to high surgical risks and limited technology, he told the audience. Today, high-speed, small-gauge vitrectomy systems allow early and complete intervention, changing outcomes dramatically. “Complete and early vitrectomy (CEVE) rapidly reduces microbial load, clears inflammatory debris, improves antibiotic penetration and allows better visualization,” shared Dr. Siopongco.

In various cases he presented, the common thread offering patients the best chance to preserve vision is the evolving standard of care: prevention, prompt recognition and aggressive surgical intervention remain the pillars of successful management in post-traumatic endophthalmitis.

Balancing repair and surgery

Open globe injuries present a complex challenge in ophthalmology, requiring careful consideration of repair versus enucleation or evisceration. These injuries are often due to sharp objects, fireworks or trauma. And the outcomes are heavily influenced by the extent of damage, presenting vision and timing of intervention.

“Repair is something that we really want to do as far as possible, irrespective of presenting vision,” said Dr. Mae Lynn Catherine Bastion (Malaysia).

Sad to say, but anatomical surgery options include evisceration, where the globe contents are removed but the scleral shell preserved. On the other hand, enucleation removes the entire eye. The choice depends on the severity of injury, risk of infection and potential for sympathetic ophthalmia.

“Evisceration may be faster with better motility, but enucleation reduces the risk of sympathetic ophthalmia. We try our very best to preserve the integrity of the eyeball, especially in younger patients, but very severe injuries may require enucleation or evisceration,” explained Dr. Bastion.

Sympathetic ophthalmia, though rare, can occur when initial trauma is missed. Ultimately, according to Dr. Bastion, the decision balances functional, physiological and psychological considerations, including pain control and cosmesis.

While repair is preferred whenever possible, anatomical surgery becomes necessary when the eye is irreparably damaged or infection is uncontrollable—once more emphasizing what other speakers have already said: that timely intervention, careful assessment of injury severity, and individualized decision-making are central to optimizing outcomes in open globe injuries.

Editor’s Note: This content is intended exclusively for healthcare professionals. It is not intended for the general public. Products or therapies discussed may not be registered or approved in all jurisdictions, including Singapore. Reporting for this story took place during the 18th Congress of the Asia-Pacific Vitreo-Retina Society (APVRS 2025) from 12-14 December in Manila, Philippines.