Acupuncture resulting in eye penetration and proliferative v
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Open globe injuries are a dangerous form of ocular trauma and can cause irreparable vision loss. These injuries can damage any structure of the eye and give rise to several complications including hypotony, increased intraocular pressure (IOP), cataract, and detachment, and proliferative vitreoretinopathy (PVR) etc..

A 49-year-old woman presented with a 3-h history of pain and vision loss in her left eye. She was undergoing acupuncture treatment for left-sided headache with needles being inserted around the orbital rim. She described acute pain, red eye, and loss of vision in the left eye. Her past ocular history was positive for a metallic foreign body in her cornea which had been removed years prior with no sequelae.
On initial examination, her best corrected visual acuity (BCVA) was 20/20 in the right eye and light perception in the left. IOP by Goldmann applanation was 15 mmHg in the right and 8 mmHg in the left. Anterior segment examination of the left eye revealed a 180-degree subconjunctival hemorrhage from 6:00 to 12:00 on the nasal side which was Seidel negative. The anterior chamber had 4+ cells (SUN Uveitis Criteria) and significant fibrin material. The cornea and lens appeared clear, with no visible entry sites. Posterior segment examination showed a dense vitreous hemorrhage with a large area of white material nasal to the disc presumed to be bare sclera. An urgent diagnostic and therapeutic 25-gauge pars plana vitrectomy was performed to seal the entry site and repair the presumed retinal injury.

The subconjunctival space was explored for occult perforation. No entry site was found anterior to the equator. Under widefield visualization, a posterior vitreous detachment was induced, and the significant vitreous hemorrhage removed. Nasal to the disc, a large area of bare sclera was visible with overlying loss of the retina and choroid, extending almost from the ora serrata to the nasal side of the disc. A significant subretinal hemorrhage was present. Decalin (C10H18) was instilled to protect the fovea and an air-fluid exchange was performed to flatten the periphery allowing for endolaser to be applied around the large retinal tears. The decalin was removed via an air-fluid exchange and the eye filled with silicone oil.

One-month post-op the patient was consented for a second vitrectomy, epiretinal membrane peel, and silicone oil exchange with administration of intravitreal triamcinolone acetonide. Five weeks post-op, the retina was flat with a BCVA of 20/400, but PVR had recurred with significant fibrosis prompting the initiation of intravitreal methotrexate treatment (Fig. 3). Intravitreal 200 μg/0.1mL methotrexate injections were initiated every 2–3 weeks for a total of 9 treatments. Six months after presentation, the BCVA was 20/40 and the macula was flat and fibrosis stable without progression following the initiation of methotrexate . Ten months following the presentation, the patient underwent phacoemulsification and intraocular lens implant for cataract and removal of significant membranous proliferation. Further installation of silicone oil was deemed necessary due to the extent of the ongoing PVR and traction seen superior-temporally .

At last follow-up, 15 months after presentation, the patient's BCVA was 20/40 and the periphery was flat with fibrosis stable. The IOP was elevated at 30 mmHg OS and a combination brimonidine tartrate 0.2% and timolol 0.5% drop were added to control IOP.

In summary, open globe injuries are a subtype of ocular trauma which can cause irreparable vision loss. This case highlights the extensive potential complications which can occur following traumatic injury to the retina and choroid, as well as the role of both surgical and medical management of retinal detachment and PVR. In addition, this is the first report of the use of off-label adjunctive intravitreal methotrexate to control post-traumatic PVR.

Source: https://www.sciencedirect.com/science/article/pii/S2451993620300098
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