Ophthalmic Emergency Visits in the Wake of the COVID 19 Pandemic: Our Experience at a Tertiary Hospital in Israel

BACKGROUND

In response to the coronavirus disease-2019 (COVID-19) pandemic, routine clinical visits to the ophthalmic emergency department (OED) were deferred, while emergency cases continued to be seen.

OBJECTIVES

To assess the consequences of the COVID-19 pandemic for ophthalmic emergencies.

METHODS

A retrospective chart analysis of patients who presented to the OED during the peak of the COVID-19 pandemic was conducted. The proportions of traumatic, non-traumatic-urgent, and non-traumatic-non-urgent presentations in 2020 were compared to those of the same time period in 2019. Duration of chief complains and best-corrected visual acuity were also assessed.

RESULTS

There were 144 OED visits in 2020 compared to 327 OED visits during the same 3-week-period in 2019. Lower mean age of OED patients was present in 2020. Logarithmic expression (LogMAR) best corrected visual acuity (BVCA) was similar in both years. In 2020 there was a reduction in traumatic, non-traumatic-urgent, and non-traumatic-non-urgent cases compared to 2019 (15.4% reduction, P = 0.038; 57.6% reduction, P = 0.002; 74.6% reduction, P = 0.005, respectively). There was a higher proportion of same-day presentations at commencement of symptoms in 2020 compared with 2019 (52.8% vs. 38.8%, respectively P = 0.006).

CONCLUSIONS

During the COVID-19 pandemic, the number of OED visits at a tertiary hospital dropped by more than half. Although the drop in visits was mostly due to decrease in non-traumatic-non-urgent cases, there was also decrease in non-traumatic-urgent presentations with possible important visual consequences. Additional studies should elucidate what happened to these patients.

Open Globe Injury Patient Identification in Warfare Clinical Notes

The aim of this study is to utilize the Defense and Veterans Eye Injury and Vision Registry clinical data derived from DoD and VA medical systems which include documentation of care while in combat, and develop methods for comprehensive and reliable Open Globe Injury (OGI) patient identification. In particular, we focus on the use of free-form clinical notes, since structured data, such as diagnoses or procedure codes, as found in early post-trauma clinical records, may not be a comprehensive and reliable indicator of OGIs. The challenges of the task include low incidence rate (few positive examples), idiosyncratic military ophthalmology vocabulary, extreme brevity of notes, specialized abbreviations, typos and misspellings. We modeled the problem as a text classification task and utilized a combination of supervised learning (SVMs) and word embeddings learnt in a unsupervised manner, achieving a precision of 92.50% and a recall of89.83%o. The described techniques are applicable to patient cohort identification with limited training data and low incidence rate.

Triaging and Coding Ophthalmic Emergency - the Rome Eye Scoring System for Urgency and Emergency (RESCUE): A Pilot Study of 1000 Eye-Dedicated Emergency Room Patients

PURPOSE

Ophthalmic emergency (OE) triage is essential for prompt recognition of urgent cases. To date, no formal eye-dedicated triaging system has been widely accepted. The purpose of the present study is to propose a fast, accurate, and reproducible coding scale called the Rome Eye System for Scoring Urgency and Emergency (Rescue).

METHODS

Phase 1 of the study is a retrospective analysis of electronic medical records (EMR); phase 2 is a prospective consecutive series. Phase 1 included 160,936 patients. Phase 2 included 1000 consecutive patients referred to the emergency department (ED) of our institution. In phase 1, the authors retrospectively analyzed EMRs of patients presenting to the ED, listing signs and symptoms most frequently associated with hospitalization. Redness, pain, loss of vision, and the risk for an open eye were identified and assigned a score ranging from 0 to 12. Color coding was assigned based on increasing scoring: 0-3 white, 4-7 green, 8-12 yellow code. In phase 2, 1000 consecutive ED patients were enrolled and prospectively coded according to RESCUE. After diagnosis and proper treatment, EMRs were retrospectively reviewed by a masked physician and patients recoded (Retro coding) according to clinical course. Correlation between Rescue and Retro coding was calculated.

MAIN OUTCOME MEASURES

Prospective and retrospective ED color coding correlation.

RESULTS

A total of 160,936 EMR were retrospectively analyzed; 2407 (1.4%) patients required hospitalization. Loss of vision (90%), redness (76%), and pain (47%) were the most frequent complaints. Rescue significantly correlated to Retro coding (p<0.01): 841/1000 patients coded exactly the same color, 45/1000 were overestimated by one color class, none by two, 107/1000 underestimated by one, and 6/1000 by two classes. The 32/1000 hospitalized patients in the prospective cohort had a Rescue score significantly higher than non-admitted patients (p<0.01) and color coding among admitted and dismissed patients was significantly different as well (p<0.01).

CONCLUSIONS

The Rescue system seems promising in terms of usefulness and ease of implementation. The high correlation between Rescue code assigned prospectively and the post-diagnosis coding, as well as the prompt discrimination of cases that eventually required hospitalization, may lead to a wider use of the Rescue system. Further testing on larger samples and different institutions is warranted.

Domestic Ocular Injuries: A Case Series

Purpose

To determine the nature and types of domestic eye injuries.

Methods

The authors prospectively analyzed data of 100 consecutive patients with domestic eye injury (104 eyes) referred to the emergency room of Farabi Hospital during October 2003. Standardized international classification of ocular trauma (Birmingham Eye Trauma Terminology) was used for eye injury classification.

Results

Domestic ocular trauma represented 4.85% of all ocular emergencies (2061 patients) referred to the emergency room during that period. Male to female ratio was 1.13 and mean age of patients was 26±18 years (range, 1–73). Cornea was involved in 50.0% and sclera, lens, and retina each was involved in 4.8%. There was severe visual loss (best-corrected distance visual acuity <20/200 due to trauma) in 4% of the patients. The most frequent domestic ocular injury was globe injury (93.7%) including mechanical (72.1% closed and 4.8% open), chemical (14.4%), and thermal (1.9%) injuries.

Conclusions

Closed mechanical injuries were the most common type of domestic ocular injury in our series. Considering the high rate of domestic eye trauma among ocular emergency cases, more preventive measures should be taken at home.

Ocular injuries from fireworks: the 11-year experience of a US level I trauma center

PurposeCharacterize ocular trauma and visual outcomes from firework injuries at a level I trauma center.MethodsRetrospective review of all firework injuries at Harborview Medical Center between 2003 and 2013.ResultsThree hundred and twenty-seven patients sustained firework injuries, of which 100 (31%) sustained ocular injuries. The average age of all patients who sustained fireworks injuries was 24.2 years, 89% were male and 54% of injuries occurred within 48 h of 4 July. Ocular injuries were most commonly caused by mortars (24%) and rockets (22%). Rockets were associated with four times the frequency of ocular injuries as compared with non-ocular injuries (P<0.001). Spectators were more likely to sustain ocular injuries than non-ocular injuries (P=0.001). The most common injuries sustained were corneal abrasions (67%), hyphemas (42%), eyelid injuries (39%), and ruptured globes (17%). Twenty-eight percent of patients with ocular injuries required surgical intervention. Ruptured globes occurred in 17% of patients, with the majority being complex corneoscleral lacerations. Fifty-eight percent of patients who sustained ruptured globes were left with no light perception in the affected eye. Average follow-up was 188 days. Average visual acuity significantly improved from logMAR 1.8±1.6 at presentation to logMAR 1.3±1.8 at last follow-up.ConclusionsFirework-related ocular trauma frequently results in vision-threatening pathology. Prompt referral to and treatment by ophthalmologists is critical. This study documents the dangers inherent in the personal use of fireworks and provides data that may help guide public policy to decrease the frequency of these devastating injuries.

Predictive Value Of Ocular Trauma Score In Open Globe Combat Eye Injuries

BACKGROUND

Prediction of final visual outcome in ocular injuries is of paramount importance and various prognostic models have been proposed to predict final visual outcome. The objective of this study was to validate the predictive value of ocular trauma score (OTS) in patients with combat related open globe injuries and to evaluate the factors affecting the final visual outcome.

METHODS

Data of 93 patients admitted in AFIO Rawalpindi between Jan 2010 to June 2014 with combat related open globe ocular injuries was analysed. Initial and final best corrected visual acuity (BCVA) was categorized as No Light Perception (NLP), Light Perception (LP) to Hand Movement (HM), 1/200-19/200, 20/200-20/50, and ≥20/40. OTS was calculated for each eye by assigning numerical raw points to six variables and then scores were stratified into five OTS categories.

RESULTS

Mean age of study population was 28.77±8.37 years. Presenting visual acuity was <20/200 (6/60) in 103 (96.23%) eyes. However, final BCVA of ≥20/40 (6/12) was achieved in 18 (16.82%) eyes, while 72 (67.28%) eyes had final BCVA of <20/200 (6/60). Final visual outcome in our study were similar to those in OTS study, except for NLP in category 1 (81% vs. 74%) and ≥20/40 in category 3 (30% vs. 41%). The OTS model predicted visual survival (LP or better) with a sensitivity of 94.80% and predicted no vision (NLP) with a specificity of 100%.

CONCLUSIONS

OTS is a reliable tool for assessment of ocular injuries and predicting final visual outcome at the outset.

[Ocular disorders associated with occupations]

The ocular disorders associated with occupations include asthenopia caused by VDT work and eye disorders from eye injuries or exposure to organic solvents or ionizing radiation. The factors associated with the eye disorders can be divided into two groups: mechanical factors and non-mechanical factors. Furthermore, the latter factors can be divided into two subgroups: chemical factors and physical factors. It is said that we can prevent most accidents that cause occupation-related eye disorders if all workers wear suitable protective gear. However, the compliance with wearing protective gear is relatively low because of inattention or discomfort. The industrial specialists have to educate the workers about the proper use of the protective gear. Then, the safety and health promoters have to remind the workers to frequently check their field site for potential hazards.

Sport-related eye trauma

Sport-related eye injuries are a common cause of acute ocular injury. This article provides a basic clinical overview of the diagnosis and immediate medical management of sport-related eye injuries, and is relevant to all Armed Forces primary care and emergency medicine practitioners.

Sport-related eye injury in northern Israel

BACKGROUND

Eye injuries are common in sports. Sports-related eye injuries have the potential for major morbidity

OBJECTIVES

To investigate the occurrence and to classify sport-related eye trauma in northern Israel.

METHODS

We analyzed the records of the ophthalmology emergency department for the years 2007-2011 and classified the admissions according to type, severity of injury and demographic data.

RESULTS

In 2% of the patients the injuries occurred during a sport activity. Most of the injuries occurred during soccer, basketball or school sport activity (74%). The majority of patients were young males.

CONCLUSIONS

Most sports-related eye injuries can be prevented with adequate eye protection.

Optical coherence tomography morphologic grading of macular commotio retinae and its association with anatomic and visual outcomes

PURPOSE

To investigate the morphologic characteristics of macular commotio retinae using spectral-domain optical coherence tomography (SDOCT) and develop a grading system for traumatic photoreceptor damage.

DESIGN

Retrospective, observational case series.

METHODS

setting: Seoul National University Bundang Hospital. patients: Forty-nine patients with macular commotio retinae, examined by SDOCT within 7 days of the initial traumatic event. observations: A 4-step grading system was based on the morphology revealed by SDOCT. Best-corrected visual acuity (BCVA) and structural integrity of the 3 photoreceptor layers (cone outer segment tips [COST], inner/outer segment [IS-OS] junction, external limiting membrane [ELM]) were evaluated at baseline, at 1 month, and at the final visit. Visual and anatomic outcomes at 1 month and at the final visit were compared among subgroups. main outcome measures: The severity of photoreceptor damage as revealed by SDOCT and BCVA.

RESULTS

The following 4 distinct photoreceptor morphologic features were observed: increase in IS-OS junction reflectivity with the disappearance of the thin hyporeflective optical space (n = 8, grade 1), COST defect only (n = 5, grade 2), COST and IS-OS junction defects (n = 16, grade 3), and COST, IS-OS junction, and ELM defects (n = 20, grade 4). Eyes with higher grades at baseline had significantly worse visual (final BCVA, P = .002) and anatomic outcomes (complete photoreceptor recovery, P < .001).

CONCLUSIONS

The number of disrupted photoreceptor layers, as determined using SDOCT images, can be used to grade macular commotio retinae. This system may be useful in documenting the baseline severity of photoreceptor damage and in predicting visual and anatomic outcomes.

[Facial trauma and multiple trauma]

The human face contains the sense organs and is responsible for essential functions: swallowing, chewing, speech, breathing and communication. It is also and most importantly the seat of a person's identity. Multiple trauma adds a life-threatening dimension to the physical and psychological impact of a facial trauma.

The management of open globe eye injuries: a discussion of the classification, diagnosis and management of open globe eye injuries

Eye injuries occurred in 10% of UK military major trauma cases in Iraq and Afghanistan between 2004 and 2008, with 33% of these eye injuries open globe in nature(1). This article will consider the diagnosis, classification and management of open globe injuries in the role 1/ pre-hospital environment.

[Clinical characteristics of mechanical ocular injury and application of ocular trauma score]

OBJECTIVE

To summarize clinical characteristics of mechanical ocular injury and to analyze the role of ocular trauma score (OTS) in the estimation of final visual acuity.

METHODS

All cases of ocular trauma admitted to the Department of Ophthalmology from January 2009 to December 2010 were retrospectively reviewed. Data extracted included laterality of the injured eye, gender, age, presenting time, cause, ocular trauma classification, initial and final visual acuity. These injuries were classified by ocular trauma classification system (OTCS). We also used the OTS in evaluating the final visual outcome. Comparisons between groups for discontinuous variables were analyzed using rank-sum test. Rank correlation was used in analysis between initial visual acuity and final visual acuity or between final visual acuity and OTS. Chi-square test was used to analyze variables, such as age, cause, type and visual acuity. Comparison of ages between male and female was analyzed by using t-test.

RESULTS

Of the 168 eyes, there were 106 open globe injury (OGI) and 62 closed globe injury (CGI). There were 140 males (85.71%) and 22 females (14.29%). Presenting time median of OGI and CGI was 5 h and 10 h respectively, and there was significant difference between these two different injuries (Z = -2.547, P = 0.011). The high-risk age group was the young age group (100 eyes, 59.52%), vs. the middle age group (46 eyes, 27.38%) and the elder age group (22 eyes, 13.10%). Occupation-related injury (70 eyes) was the most common cause and mainly resulted in OGI (54/70). Initial and final visual acuities in CGI were better than those of OGI (χ(2) = 37.847, P = 0.000; χ(2) = 44.428, P = 0.000). Initial visual acuity was correlated with final visual acuity (r = 0.858, P = 0.000). Final visual acuity was significantly correlated with total score (r = 0.870, P = 0.000) and OTS (r = 0.869, P = 0.000).

CONCLUSIONS

In this group of mechanical ocular trauma patients, male is more common than the female. Main type of injury is OGI and presenting time of OGI is earlier than that of CGI. The high-risk age group is the young. Main cause of injury is occupation-related injury. Initial and final visual acuities in CGI are better than those in OGI. OTS calculated at initial examination may be a useful parameter for the estimation of prognosis.

The injured eye

Eye injuries come at a high cost to society and are avoidable. Ocular blast injuries can be primary, from the blast wave itself; secondary, from fragments carried by the blast wind; tertiary; due to structural collapse or being thrown against a fixed object; or quaternary, from burns and indirect injuries. Ballistic eye protection significantly reduces the incidence of eye injuries and should be encouraged from an early stage in Military training. Management of an injured eye requires meticulous history taking, evaluation of vision that measures the acuity and if there is a relative pupillary defect as well as careful inspection of the eyes, under anaesthetic if necessary. A lateral canthotomy with cantholysis should be performed immediately if there is a sight-threatening retrobulbar haemorrhage. Systemic antibiotics should be prescribed if there is a suspected penetrating or perforating injury. A ruptured globe should be protected by an eye shield. Primary repair of ruptured globes should be performed in a timely fashion. Secondary procedures will often be required at a later date to achieve sight preservation. A poor initial visual acuity is not a guarantee of a poor final result. The final result can be predicted after approximately 3-4 weeks. Future research in eye injuries attempts to reduce scarring and neuronal damage as well as to promote photoreceptor rescue, using post-transcriptional inhibition of cell death pathways and vaccination to promote neural recovery. Where the sight has been lost sensory substitution of a picture from a spectacle mounted video camera to the touch receptors of the tongue can be used to achieve appreciation of the outside world.

Farm-related ocular trauma in Makurdi, Nigeria

BACKGROUND

Benue State, Nigeria, is largely an agrarian community. Farm related ocular injuries abound in this environment. Approximately two-third of all patients presenting to the eye casualty department do so because of ocular trauma sustained on the farm. This study aims to study the pattern and burden of farm related ocular injuries and its consequences and institute appropriate measures that will minimize visual loss from such injuries.

METHODS

A retrospective analysis of 1560 patients' record treated for ocular injuries between June 2000 and May 2005. The biodata extracted for each patient included age, sex, occupation, cause of injury, ongoing activities at time of injuries, severity of injury, time interval before presentation and entry and exit visual acuity.

RESULTS AND CONCLUSION

Result showed that of the 1560 patients' record audited, 1113 (71%) were male and 447 (29%) female. Their age ranged between 2 and 75 years with peak age incidence in the 2nd and 3rd decades. More than two-third of all ocular injuries were sustained in the farm environment with spear-grass corneal abrasion being the most common lesion. Only 25% presented for attention on the day of injury. On presentation, 55% presented with visual impairment, 15% presented blind in the affected eye. Closed eye injuries were more common than open eye injuries with the former having better prognosis.

Sources of error in the use of a system for classifying mechanical injuries of the eye

BACKGROUND

ocular trauma produces psychological, social and occupational effects that can cause significant impairment. Evaluation of ocular trauma has been standardized by a system for classifying mechanical injuries of the eye (SCMIE). Parameters that are most commonly a source of error for the evaluator and that may lead to classification errors have not been identified.

METHODS

an observational, retrospective, descriptive, cross-sectional and open study was conducted. Files of patients of either gender, aged 6 years or older, with ocular trauma graded with the SCMIE between 1997 and 2009 were re-evaluated by an independent investigator. The rate and 95% confidence intervals (95% CI) of evaluations that resulted in errors during the re-evaluation of ocular trauma were identified in the sample and in general for each parameter. The disparity between the initial evaluation and the re-evaluation (MacNemar) and the concordance between the evaluations (kappa) were analyzed.

RESULTS

of 817 evaluations, 294 had at least one grading error (36%, 95% CI 32.7-39.3). The most frequent error source was the parameter type. The disparity was significant in parameters type A, D, grade 2 and zone II. Overall concordance was good.

CONCLUSIONS

it is necessary to reinforce the learning curve for some parameters of the SCMIE, especially type, in order to improve its evaluation, so that it can become a valid communication tool that favors early referral to the specialist.

[Expected effect of treatment on the rate of visual deficiency after ocular trauma]

BACKGROUND

Ocular trauma (OT) is a common cause of monocular blindness and visual impairment worldwide. The Ocular Trauma Score (OTS) is a scale that estimates visual function that an injured eye can achieve 6 months after OT. In a sample population, the OTS may be useful to compare the expected functional result with the result of therapeutic interventions in OT. We undertook this study to identify the expected effect of treatment on the rate of visual deficiency 6 months after OT.

METHODS

The rate of eyes with trauma-related visual deficiency (best corrected visual acuity <20/40) at the time of diagnosis was compared with that estimated 6 months later using the OTS (95% confidence intervals, CI).

RESULTS

We evaluated 742 patients; 46% had visual deficiency initially (95% CI 43-50.2) and 32.1% would demonstrate it 6 months later (95% CI 28.7-35.4, p <0.001, OR 0.54). The rate changed from 29.1 to 18% in closed-globe (CG) trauma and from 84.3 to 63% in open-globe (OG) trauma.

CONCLUSIONS

Treating OT would reduce the proportion of visual deficiency by 14.5 percentage points (11 in CG, 21.3 in OG trauma). Up to 66% of the injured eyes could reach normal vision. OT prevention requires enhancement because a high rate of eyes would remain disabled despite receiving the best available treatment.

Factors affecting the visual outcome in hyphema management in Guinness Eye Center Onitsha

BACKGROUND

This study aims of determining the complications, outcome of hyphema treatment and recommend ways of enhancing good visual outcome.

METHOD

The records of all cases of hyphema seen from 1st January 2001 to 31st December 2005 were reviewed retrospectively. The variables analyzed were the biodata of all the patients, the agents causing hyphema, associated injuries and complications. Visual acuity at presentation, discharge and last visit was analyzed.

RESULTS

Seventy four patients that had hyphema were reviewed. The male:female ratio was 3.5:1. Trauma was predominantly main cause of hyphema. The common agents of injury include whip (23.2%) and fist (18.8%). The common complications were secondary glaucoma (52.5%), corneal siderosis (30.0%) and rebleeding (10%). Visual outcome is related to time ofpresentation, complications and treatment. Significant improvement was achieved following treatment.

CONCLUSION

Hyphema is a common complication of eye injuries. It is commonly associated with other eye injuries like vitreous haemorrhage and cataract. Common complications include secondary glaucoma, corneal siderosis and rebleeding. Visual outcome is dependent on time of presentation, severity and nature of complications. Visual outcome can be improved by early presentation and detection of complications and appropriate treatment.

Pattern and visual outcome of eye injuries in children at Abakaliki, Nigeria

BACKGROUND

Most studies on ocular injuries have been conducted in urban areas to the neglect of other areas.

OBJECTIVE

To ascertain the pattern and visual outcome following eye injuries in children at Abakaliki, a largely agricultural communityy in Southern Eastern Nigeria

METHODS

A retrospective study of all the children aged 0-15 years, who had eye injuries and presented to the Federal Medical Center, Abakaliki, Nigeria, between May 2004 and June 2006. Their medical case records were retrieved and extracted data for analysis included age, sex, type and cause of eye injury and duration prior to presentation.

RESULTS

Of the 119 medical records of patients (adults and children) with eye injuries within the study period, 34 (28.6%) patients were those of children aged 0-15 years. There were 24 (70.6%) males and 10 (29.4%) females, giving a male to female ratio of 2.4:1.0. Blunt ocular injury constituted 27 (79.4%) cases whereas penetrating injury were 5 (14.7%) cases. Sharp or pointed objects accounted for 14 (41.2%) cases of agents of injuries, sticks being the commonest. While the most common place of trauma was at home 17 (50%) cases, followed by trauma at schools 9 (26.5%) cases, the commonest activity at occurrence of injuries was playing 13 (38.2%) cases. Only three (8.8%) cases presented to the hospital within 24 hours. Majority, 31 (91.2%) cases presented late. Visual prognosis was poorer in penetrating injuries than in mild blunt injuries. Final visual acuity (VA) could not be determined in 11 (32.4%) patients because they were either under age or defaulted from follow up. Of the remaining 23 (67.6%) patients, 12 (35.3%) had a final VA better than 6/18, 1 (2.9%) had VA in the range of 6/18-6/60, 6 (17.6%) had VA of < 6/60 while 4 (11.8%) had NPL. 8 (23.5%) patients needed hospital admission.

CONCLUSION

Blunt eye injury is the commonest type of injury in rural or agricultural Abakaliki, South-Eastern Nigeria. An increase in parental and care giver awareness and education is emphasized.

Potential Impact of Seatbelt Use on the Spectrum of Ocular Injuries and Visual Acuity Outcomes after Motor Vehicle Accidents with Airbag Deployment

PURPOSE

To investigate the association between seatbelt use and (1) the spectrum of ocular injuries and (2) visual acuity outcomes after motor vehicle accidents (MVAs) with airbag deployment.

DESIGN

Single-center retrospective observational case series.

PARTICIPANTS

Forty-seven patients involved in MVAs with airbag deployment.

METHODS

Medical record review of all patients evaluated after an MVA with airbag deployment between January, 1997, and August, 2005, at a single level 1 trauma center.

MAIN OUTCOME MEASURES

Type of ocular injury and visual acuity at 3 months after an MVA.

RESULTS

Seventy-one percent of patients who did not wear seatbelts experienced type III ocular injuries compared with 31% who wore seatbelts (P<0.0002). Posterior segment injuries occurred only in patients who did not wear seatbelts. At the 3-month follow-up, 76% of patients who did not wear seatbelts achieved a visual acuity of 20/40 or better compared with 96% of patients who wore seatbelts (P>0.10); a visual acuity worse than 20/200 was measured in 14% and 0% of patients in the 2 groups, respectively (P<0.03).

CONCLUSIONS

In the current study, the use of seatbelts was associated with less severe ocular injuries and better visual outcomes.