Corresponding Author: Eun Kyoung Lee, MD, PhD. Department of Ophthalmology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea. Ocular trauma is a leading cause of monocular blindness in adults aged 22 to 44 years [1]. Ocular trauma incidences have been increasing due to factors such as industrial accidents, traffic collisions, and recreational activities [2]. According to the Birmingham Eye Trauma Terminology (BETT) system [3], ocular trauma is classified into closed globe injury or open globe injury based on the presence of full-thickness damage to the ocular wall. Trauma can damage various intraocular structures and result in diverse clinical manifestations.
Among trauma-related ocular conditions, posterior segment involvement often results in irreversible vision loss, significantly impairing patient quality of life. Notably, traumatic retinal detachment (TrRD) is a severe complication of the posterior segment. TrRD requires prompt surgical intervention to reattach the retina. However, given the concomitant damage to the ocular structures caused by trauma and the serious nature of retinal detachment, failure to reattach the retina may result in phthisis bulbi and permanent blindness. In young, active individuals, TrRD not only affects personal well-being but also imposes substantial economic burdens on society.
Despite its poor prognosis and socioclinical significance, sufficient research on TrRD is lacking. The limited number of studies is probably attributable to lower TrRD incidences compared to primary rhegmatogenous retinal detachment (RD) in the general population, and the patient population being primarily referred to tertiary care hospitals [4-7]. In addition, the advances in retinal microsurgical techniques since 2000, such as small-gauge vitrectomy, wide-angle fundus viewing systems, and the use of perfluorocarbon liquids, may have changed the postoperative prognosis for patients with severe ocular trauma and TrRD. Furthermore, no comprehensive analyses of large cohorts including patients with TrRD have been conducted in South Korea.
We hypothesized that open globe injuries would demonstrate worse clinical presentations and poorer functional outcomes compared to closed globe injuries due to the direct nature of tissue damage and higher likelihood of complications. This study established a large cohort of South Korean patients with TrRD over a 20-year period since 2000 and analyzed their clinical features and surgical outcomes based on the mechanism of ocular injury. The factors associated with anatomical and functional success of these patients were also evaluated.
Materials and Methods
Ethics statement
This study was approved by the Institutional Review Board of Seoul National University Hospital (No. 2303-141-1416). The need for written informed consent was waived due to the retrospective design of the study and the use of deidentified patient information. All study procedures were conducted in accordance with the Declaration of Helsinki.
Study participants
We retrospectively reviewed the medical records of consecutive patients diagnosed with TrRD who visited the Department of Ophthalmology at Seoul National University Hospital in Seoul, Korea, between January 2000 and December 2022. The study included patients who underwent surgical treatment for TrRD and followed up for a minimum of 6 months postoperatively. TrRD was diagnosed when patients had the following: (1) a clear documented history of ocular trauma; (2) temporal relationship between trauma and symptom onset (even if delayed); (3) absence of preexisting retinal pathology on previous examinations when available; and (4) retinal break patterns consistent with traumatic etiology (e.g., giant retinal tears, retinal dialysis, or breaks in typical traumatic locations). For delayed-onset cases, we relied on detailed patient history, witness accounts when available, and characteristic fundoscopic findings. Preexisting retinal diseases were excluded by reviewing previous records when available, excluding patients with documented history of retinal diseases, and excluding patients with macular holes, epiretinal membranes, or age-related macular degeneration that could affect visual function prior to trauma.
The eyes were categorized into two groups based on the mechanism of ocular injury: closed globe injury and open globe injury [3]. Open globe injury was defined as a full-thickness wound in the corneoscleral wall of the eye, subdivided into ruptures and lacerations. Lacerations were further subdivided into penetrating injuries, intraocular foreign bodies, and perforating injuries. Closed globe injury was subdivided into contusion and lamellar laceration depending on the presence of a partial-thickness wound. All open globe injuries underwent primary wound repair prior to or concurrent with RD surgery. Primary wound closure was always performed first, followed by RD repair during the same session or subsequently based on clinical judgment.
Clinical assessments
The demographic characteristics and mechanisms of ocular trauma were reviewed at the initial visit of all patients. Ocular examinations included best-corrected visual acuity (BCVA), intraocular pressure (IOP), and slit-lamp and fundus examinations. The manifestations of TrRD, including macular involvement, RD extent, presence of vitreous or subretinal hemorrhage, number of retinal tears, presence of giant retinal tears (GRTs) or retinal dialysis, retinal incarceration, grade of proliferative vitreoretinopathy (PVR), and choroidal detachment, were evaluated.
The time from trauma to the first surgical intervention for TrRD, surgical techniques performed, intraocular tamponade type used, and use of perfluorocarbon liquids were reviewed. Postoperative complications, including epiretinal membrane, macular hole, increased IOP, choroidal neovascularization, and phthisis bulbi, were analyzed. The need for additional surgical procedures, such as glaucoma surgery or corneal transplantation, and the proportion of patients who could not undergo silicone oil removal were also assessed. The postoperative anatomical and functional outcomes were investigated.
Anatomical success was defined as complete retinal reattachment on fundus examination at final follow-up, regardless of tamponade agent presence. Functional success was defined as achieving a BCVA of ≥20 / 200 (≤1.0 logarithm of the minimum angle of resolution [logMAR]) at the final visit. We chose ≥20 / 200 based on prior studies that established this threshold as representing ambulatory vision and clinically meaningful functional success in TrRD populations [8,9]. The prognostic factors associated with anatomical and functional success were also identified.
Outcome measures
The primary outcome measures were the comparison of initial presentations, clinical courses, and outcomes of patients with TrRD categorized according to the mechanism of ocular injury: closed versus open. The secondary outcomes included a prognostic factor analysis associated with anatomical and functional successes for the entire TrRD cohort.
Statistical analysis
Normality of continuous variables was assessed using the Shapiro-Wilk test. Data are presented as mean ± standard deviation for normally distributed variables and median (interquartile range, IQR) for non-normally distributed variables. The demographic data at initial presentation, clinical characteristics of TrRD, and surgical techniques performed between the groups were analyzed using Student t-test or Mann-Whitney U-test for continuous variables and the chi-square test or Fisher exact test for categorical variables. Univariate and multivariate logistic regression analyses were performed to analyze the factors associated with anatomical and functional successes at the final visit. Multicollinearity was assessed using variance inflation factors, with <3 considered acceptable. Variables with a significance of p < 0.10 in the univariate analyses were included in the multivariate analysis. Statistical analyses were conducted using IBM SPSS ver. 27.0 (IBM Corp). A p-value of <0.05 was considered significant.
Results
Demographics
During the study period, 4,456 eyes of 4,456 patients who underwent surgical treatment for RD at Seoul National University Hospital and had a minimum follow-up period of 6 months were analyzed. Among them, 98 eyes of 98 patients were diagnosed with TrRD and these 98 eyes were included in the analyses. A detailed flowchart of patient selection is provided in Fig. 1. Table 1 summarizes the patient baseline demographic characteristics. The median age at diagnosis was 41.5 years (IQR, 20.8-55.3 years) and 83 (84.7%) were male. Of the 98 eyes, 37 (37.8%) were classified into closed injury group and 61 (62.2%) as open injury group.
According to the BETT system [3], 23 eyes (37.7%) in the open injury group had a rupture, 16 (26.2%) had a penetrating injury, 8 (13.1%) had a perforating injury, and 14 (23.0%) had an intraocular foreign body. Among 37 eyes in the closed injury group, 36 (97.3%) had a contusion, and 1 eye (2.7%) had a lamellar laceration. At initial presentation, BCVA was >20 / 50 in 7 eyes (7.1%), between 20 / 200 and 20 / 50 in 9 eyes (9.2%), and between 1 / 200 and 19 / 200 in 16 eyes (16.3%). The majority of patients (59 eyes, 60.2%) presented with an initial BCVA between light perception and hand movement, whereas 7 eyes (7.1%) did not have light perception.
A comparison of demographic characteristics between the closed and open groups revealed no significant differences in mean age or sex distribution. However, initial BCVA showed a significant difference between groups, with 10 of 37 patients (27.0%) in the closed group having initial BCVA ≥20 / 200 compared to only 6 of 61 (9.8%) in the open group (p = 0.026). The time from trauma to the first RD surgery showed a significantly longer delay in the closed group (median, 41.0 days; IQR, 11.5-153.5 days) compared to the open group (median, 10.0 days; IQR, 3.0-27.0 days), suggesting a higher rate of delayed-onset TrRD in closed group injuries (p < 0.001). The overall median follow-up period was 1,050 days (IQR, 525-3,777 days).
Comparison between closed and open injuries
The preoperative clinical manifestations of TrRD are summarized in Table 2. The overall mean number of retinal breaks per eye was 1.61 ± 1.42. GRTs extending for ≥90° were present in 15 eyes (15.3%), retinal dialysis was identified in 23 eyes (23.5%), and a PVR grade B or higher was documented for 38 eyes (38.8%). A comparative study showed no significant differences in lens status, macula involvement, RD extent, number of retinal breaks, GRT presence, retinal dialysis, or PVR grade between the two groups. However, patients in the open group were more likely to exhibit vitreous hemorrhage and subretinal hemorrhage than those in the closed group (vitreous hemorrhage: 75.4% vs. 45.9%, p = 0.003; subretinal hemorrhage: 26.2% vs. 2.7%, p = 0.003). Retinal incarceration was observed exclusively in the open group (16.4%).
The surgical techniques performed are summarized in Table 3. The primary surgical method was pars plana vitrectomy in 64 eyes (65.3%), followed by combined vitrectomy with scleral buckling or encircling in 24 eyes (24.5%) and scleral buckling or encircling in 11 eyes (11.2%). Silicone oil tamponade was used in 67 eyes (68.4%) and intraoperative retinectomy was performed in 23 eyes (23.5%). A comparative study showed no significant differences between the two groups regarding the types of surgery performed, use of perfluorocarbon liquids, intraoperative retinectomy, or application of retinopexy. Silicone oil tamponade was more frequently used in the open group than in the closed group with marginal significance (75.4% vs. 56.8%, p = 0.054).
The anatomical and functional outcomes and postoperative complications of the study participants are summarized in Table 4. At the final follow-up, anatomical success was achieved in 81 eyes (82.7%) and functional success was attained in 32 eyes (32.7%). Postoperative complications included epiretinal membrane in 12 eyes (12.2%), macular hole in 3 eyes (3.1%), elevated IOP in 17 eyes (17.3%), choroidal neovascularization in 1 eye (1.0%), and phthisis bulbi in 6 eyes (6.1%). A comparative study revealed no significant difference in anatomical outcomes between the two groups: the anatomical success rates were 89.2% and 78.7% for the closed and open groups, respectively (p = 0.236). Fig. 2 shows the fundoscopic findings of two representative cases with anatomical success (Fig. 2A) and failure (Fig. 2B). However, the percentage of patients who achieved functional success was significantly higher in the closed group than in the open group (45.9% vs. 24.6%, p = 0.043). The proportion of postoperative complications and the percentage of patients requiring additional surgery did not differ between the two groups. A significantly higher proportion of patients unable to remove the silicone oil were in the open group than were in the closed group (42.6% vs. 13.5%, p = 0.003).
Prognostic factors associated with anatomical and functional success
Univariate and multivariate regression analyses were performed to determine the prognostic factors associated with the anatomical success of TrRD for the entire patient cohort (Table 5). Among the various clinical characteristics and management factors, the multivariate logistic regression analysis showed that the absences of GRT (odds ratio [OR], 0.131; 95% confidence interval [CI], 0.031-0.554; p = 0.006), retinal incarceration (OR, 0.119; 95% CI, 0.024-0.592; p = 0.009), and PVR grade B or higher (OR, 0.219; 95% CI, 0.061-0.785; p = 0.020) were significantly associated with anatomical success.
Similar analyses were performed to identify prognostic factors associated with the functional success of TrRD in the entire patient cohort (Table 6). In the multivariate analysis, only three factors were significantly associated with favorable functional outcomes: better preoperative BCVA (OR, 0.294; 95% CI, 0.158-0.546; p < 0.001), intraoperative intraocular lens (IOL) insertion (OR, 3.864; 95% CI, 1.192-12.518; p = 0.024), and no intraoperative retinectomy (OR, 0.066; 95% CI, 0.006-0.674; p = 0.022). Notably, injury type (open vs. closed) showed significance in univariate analysis (OR, 0.410; 95% CI, 0.171-0.983; p = 0.046) but was not significant in multivariate analysis (OR, 0.958; 95% CI, 0.229-4.017; p = 0.953).
Discussion
This study analyzed the clinical features and surgical outcomes of one of the largest cohort of patients with TrRD who presented to a tertiary hospital in South Korea. We found that patients with TrRD with an open globe injury were more likely to exhibit vitreous hemorrhage, subretinal hemorrhage, and retinal incarceration than those with a closed globe injury. Although the anatomical success rate did not differ between the two groups, the percentage of patients who achieved functional success with a final BCVA of 20 / 200 or better was significantly higher in the closed group. In an analysis of factors associated with prognosis in the entire TrRD cohort, the absences of GRT, retinal incarceration, and PVR grade B or higher were identified as factors associated with anatomical success, whereas better preoperative BCVA, intraoperative IOL insertion, and no intraoperative retinectomy were associated with functional success. These results provide specific evidence regarding prognostic factors and expected outcomes to inform clinical decision-making in TrRD management.
The majority of TrRD are rhegmatogenous and their underlying mechanisms vary depending on the type of ocular injury [10-12]. Both closed and open globe injuries can result in TrRD due to direct or indirect damage [3,4,8,12,13]. In closed globe injuries, the propagation of shock waves generated by trauma can cause retinal breaks because the retina’s low elasticity makes it vulnerable to such forces [14,15]. Negative pressure created during decompression of the eyeball following traumatic compression can lead to RD if the force surpasses the adhesion strength between the retina and underlying structures. Liquefied vitreous can amplify the effects of negative pressure during traumatic decompression owing to its reduced ability to absorb energy, thus increasing the chance for TrRD [15,16]. Open globe injuries can cause retinal breaks not only through the mechanisms observed in closed globe injuries, but also via direct retinal rupture or laceration. Additionally, these injuries may be accompanied by fibroblastic proliferation, which can lead to vitreous traction on the retina and exacerbate RD [15,17,18]. Illustrations depicting the mechanisms of TrRD in different types of ocular injuries are presented in Fig. 3A and 3B. It should be noted that in real-world situations, trauma mechanisms can overlap, and severe blunt trauma may sometimes result in open globe injuries. Our classification was based strictly on the BETT system according to the final anatomical injury pattern rather than the initial trauma mechanism.
Regarding the clinical presentation of TrRD, there were no significant differences in the RD characteristics between the closed and open groups, except for vitreous/subretinal hemorrhage and retinal incarceration. The similarities in the manifestations of TrRD after closed and open globe injuries suggest that both trauma types cause secondary indirect impacts that may be related, in most cases, to globe deformation rather than the direct insult by penetrating objects in open injuries. Previous studies have reported similar clinical manifestations in both groups, such as RD extent, frequency of macular involvement, number of retinal tears, PVR grade, and GRT presence or retinal dialysis, which are consistent with the results of this study [8,9]. Vitreous hemorrhage is a common sign of severe trauma and is frequently observed in open globe injuries [6,17-19]. Direct mechanical rupture in open globe injuries may be attributed to vascular injury and bleeding within the eyeball, including in the vitreous cavity and subretinal space. The significantly higher prevalence of vitreous and subretinal hemorrhage in open globe injuries likely contributes to the inferior functional outcomes observed in this group. These hemorrhagic complications can cause prolonged visual rehabilitation and permanent photoreceptor damage, which may explain why anatomical success rates were similar between groups while functional outcomes remained significantly different [20]. Retinal incarceration is typically caused by the trapping of the retina within a wound due to penetrating trauma and is inevitably preceded by an open globe injury.
A study conducted in 1986 reported anatomical recovery in 77.8% of the patients after surgical intervention for TrRD [21]. In a prospective study conducted from 2004 to 2007, anatomical success was achieved in 92% of the patients with TrRD secondary to open or closed globe injuries [8]. More recently, Nowomiejska et al. [22] documented an anatomical success rate of 78% after vitrectomy in patients with RD followed by severe eye trauma, including both closed and open globe injuries. The anatomical success rates for TrRD are 70% to 90%, which are in line with the 82.7% success rate in the present study. Depending on the mechanism of ocular injury, the anatomical success rates for TrRD with closed injury is 89% to 96% [8,10,16], whereas those with open injury are limited to 63% to 91% [6,8,9,23], suggesting relatively lower success rates in the open group. Open globe injuries may frequently induce risk factors for retinal re-detachment, such as postoperative PVR [6,9,24]. However, previous studies that compared TrRD based on the mechanism of ocular injury reported no significant differences in the anatomical success rates between the two groups, which are consistent with the results of the present study [8,9,11]. The improvement in anatomical success rates for TrRD with open injury is probably attributed to treatment strategies that preferentially use pars plana vitrectomy as first-line management and the remarkable advances in vitreoretinal surgical techniques, including endolasers, vitreous substitutes (silicone oil and perfluorocarbon liquid), and newer instruments.
The functional success for TrRD has been defined differently in studies, resulting in greater variability in reporting success rates. In a retrospective study that evaluated the outcome of TrRD with PVR, 30.6% of the patients had visual acuity of 20/200 or better [25]. In a comparative study of open and closed globe injuries, a final visual acuity better than 20 / 200 was achieved in 80% of the total population [8]. Wenzel et al. [9] reported 40% of the patients achieved a final visual acuity of 20 / 200 or better, a functional success rate of 60% for the closed group and 9.1% for the open group, which are consistent with our results showing a better functional success rate for the closed group. In contrast, similar functional outcomes of open and closed globe injuries have been observed in other comparative studies [8,11,26]. The lack of a standardized definition for functional success across studies may contribute to discrepancies when comparing their results. However, the poorer functional success rate for the open group suggests that injury type had a greater impact on functional outcomes than current surgical advancements.
The current study indicated that the absences of GRT, retinal incarceration, and PVR grade B or higher were significantly associated with anatomical success in patients with TrRD. According to a report from the European Vitreo-Retinal Society [27], the absence of GRT is associated with the final failure of RD repair. Murtagh et al. [28] reported that eyes with a giant retinal break were less likely to reattach after surgery than those with a smaller retinal break. Better anatomical and functional outcomes have been reported for patients in the vitrectomy combined with scleral buckling group than those in the retinectomy group for treatment of TrRD with retinal incarceration [24]. Comorbidities such as PVR formation and the necessity to perform relaxing retinectomy to relieve incarceration might be barriers to successful anatomical outcomes when retinal incarceration is present [24,29]. A reasonable assumption, based on the literature, is that an increasing PVR level corresponds to an increasing surgical failure rate, and our results support this expectation. Hsiao et al. [16] suggested that absence of PVR was significantly associated with primary anatomical success, in patients with TrRD following a closed globe injury. In a multicenter study, funnel-shaped RD and PVR grade C were significant variables associated with final retinal re-detachment after TrRD surgery in patients with self-injurious behavior [30].
Regarding functional predictive factors, in this study, better preoperative BCVA, intraoperative IOL insertion, and no intraoperative retinectomy were associated with functional success for patients with TrRD. The finding that a better baseline BCVA, namely, injury severity, was associated with a favorable functional outcome is consistent with the findings of previous studies [8,16,25,31]. We found a strong independent correlation (p < 0.001) between baseline BCVA and functional success in the multivariate regression analysis. The beneficial effects of IOL implantation on the visual function improvement are indisputable. However, we acknowledge potential selection bias regarding IOL implantation, as surgeons may have been less likely to implant IOLs in eyes with perceived poor visual potential. This could influence the observed association between IOL implantation and functional success, and our findings should be interpreted with this limitation in mind. In the current study, 68.8% of the eyes that underwent retinectomy during surgery presented with a PVR grade C or worse. Additionally, among the eyes with less severe PVR, one eye had preoperative retinal incarceration. The risk factors associated with poorer anatomical outcomes (PVR and retinal incarceration) in eyes that underwent retinectomy may lead to anatomical failure, ultimately contributing to functional failure. Previous studies have identified macular involvement as a significant factor for visual prognosis [8,31,32]. Although macular involvement was not determined to be a significant factor in the multivariate analysis in this study, a higher proportion of eyes without macular involvement achieved functional success (22 eyes, 57.9%) than those with macular involvement (10 eyes, 16.7%; p < 0.001), which suggests the prominence of macular status as a predictive factor for TrRD.
This study has several limitations. First, the study design was retrospective, and the follow-up period was inconsistent for each patient; therefore, it was not possible to determine the entire disease course of each patient. Second, our patient population was from a single tertiary care referral center. Therefore, our results may not be generalizable to all patients with TrRD. Although we were able to minimize selection bias by including all consecutive patients during the observation period, we cannot exclude the possibility that referral and socioeconomic biases were present. Third, given the exploratory nature of this study and multiple variables analyzed, we did not apply correction for multiple comparisons, which should be considered when interpreting our results. Fourth, important trauma-related findings such as choroidal rupture could not be adequately assessed in many cases due to obscured fundus visualization from vitreous and subretinal hemorrhage, which may have led to underestimation of certain prognostic factors. Finally, the highly heterogeneous nature of patients with trauma, including ocular trauma mechanisms and surgical techniques, may have influenced the outcomes. Differences in RD characteristics may exist within surgical categories, as well as biases in individual surgeon treatment preferences, which may have confounded the results. Due to the rarity of these patients and individualized approaches, a prospective randomized study would be challenging to conduct.
In conclusion, this study investigated the clinical characteristics, outcomes, and prognostic factors of TrRD in a large South Korean cohort over the past 20 years. No differences in anatomical success rates between the closed and open injury groups were observed, whereas the functional success rates were higher in the closed group. These findings suggest that although advances in vitreoretinal surgical techniques have improved anatomical outcomes, the injury type still has a significant impact on functional outcomes in patients with TrRD. By identifying specific prognostic factors associated with anatomical and functional success, this study provides evidence-based guidance for management and prognostication of patients with TrRD.
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