A system for classifying mechanical injuries of the eye (globe). The Ocular Trauma Classification Group

Clinical characteristics and outcomes of fall-related open globe injuries in Japan

PURPOSE

To investigate the clinical characteristics and visual outcomes in patients with fall-related open globe injuries and to evaluate differences between fall-related and non-fall-related open globe injuries in Japan.

METHODS

A retrospective review of patients with open globe injury who presented to Japan-Clinical Research of Study (J-CREST) hospitals between 2005 and 2015 was enrolled. Clinical information including age, sex, initial visual acuity, final visual acuity, type of injury, status of the crystalline lens, zone of injury, wound length, presence of retinal detachment, proliferative vitreoretinopathy, expulsive hemorrhage, and endophthalmitis was recorded.

RESULTS

A total of 374 eyes were enrolled, of which 120 (32.1%) suffered from fall-related injury with average age of 73.7 ± 15.9 years (range, 11-101 years). A majority of patients were female (55.8%). Of 120 patients with fall-related injury, 109 (90.8%) presented with rupture and 11 (9.2%) with laceration. A multiple regression analysis revealed that final visual acuity was significantly associated with initial visual acuity (r = 0.99, P < 0.001). Compared to non-fall-related open globe injuries, fall-related open globe injuries were associated with elderly age, female sex, poorer initial and final visual acuity, rupture, absence of the lens, larger wound size, retinal detachment, expulsive hemorrhage, and absence of endophthalmitis (P < 0.01).

CONCLUSIONS

Fall-related open globe injuries were more frequent in elderly female and accompanied by larger wound lengths and severer ocular complications. Visual outcomes in patients with fall-related open globe injuries were related to initial visual acuity.

Endophthalmitis: Then and Now

PURPOSE

To report historically evolving strategies (then and now) in prevention and management of endophthalmitis.

DESIGN

A perspective on relevant topics in the prophylaxis and management of endophthalmitis.

METHODS

This is an author-selected review of studies leading to changes in strategies for endophthalmitis management over the last 100 years.

RESULTS

The current perspective discusses the trends and strategies over the past century. Historically, 3 endophthalmitis time-periods have existed and include the pre-antimicrobial era, the predominantly systemic antimicrobial era, and the current intravitreal antimicrobial era. The management of endophthalmitis from different etiologies, including endogenous, postinjection, post-cataract surgery, and other anterior segment-related (eg, post-penetrating keratoplasty), bleb-associated, glaucoma drainage device-associated, and open globe injury-associated, are discussed. Specific etiologies may predict most common microbial causes and may guide differing management strategies. Pars plana vitrectomy offers theoretical advantages but is generally reserved for patients with more advanced disease.

CONCLUSIONS

Despite advances over the past 100 years, endophthalmitis is an important sight-threatening complication. Timely management with the appropriate use of antimicrobial agents may optimize visual outcomes.

Acute vitreoretinal trauma and inflammation after traumatic brain injury in mice

Objective

Limited attention has been given to ocular injuries associated with traumatic brain injury (TBI). The retina is an extension of the central nervous system and evaluation of ocular damage may offer a less‐invasive approach to gauge TBI severity and response to treatment. We aim to characterize acute changes in the mouse eye after exposure to two different models of TBI to assess the utility of eye damage as a surrogate to brain injury.

Methods

A model of blast TBI (bTBI) using a shock tube was compared to a lateral fluid percussion injury model (LFPI) using fluid pressure applied directly to the brain. Whole eyes were collected from mice 3 days post LFPI and 24 days post bTBI and were evaluated histologically using a hematoxylin and eosin stain.

Results

bTBI mice showed evidence of vitreous detachment in the posterior chamber in addition to vitreous hemorrhage with inflammatory cells. Subretinal hemorrhage, photoreceptor degeneration, and decreased cellularity in the retinal ganglion cell layer was also seen in bTBI mice. In contrast, eyes of LFPI mice showed evidence of anterior uveitis and subcapsular cataracts.

Interpretation

We demonstrated that variations in the type of TBI can result in drastically different phenotypic changes within the eye. As such, molecular and phenotypic changes in the eye following TBI may provide valuable information regarding the mechanism, severity, and ongoing pathophysiology of brain injury. Because vitreous samples are easily obtained, molecular changes within the eye could be utilized as biomarkers of TBI in human patients.

POSTTRAUMATIC ENDOPHTHALMITIS: An 18-Year Case Series

PURPOSE

To describe the demographics, characteristics, management, and visual outcomes of eyes diagnosed with endophthalmitis after open globe injury.

METHODS

Retrospective cohort analysis of all patients diagnosed with endophthalmitis after open globe injury from 1997 to 2015 at University Hospital, Newark, NJ.

RESULTS

Twenty-six eyes were identified (all male patients; mean age: 37 ± 15 years). Cultures were positive in 16 eyes (62%), with Staphylococcus species (7 eyes, 44%) being the most common organism. Twelve eyes (46%) presented with open globe injury and concurrent endophthalmitis; 14 eyes (54%) developed endophthalmitis a mean of 14 days after open globe repair (OGR; 1 outlier of 98 days excluded). All eyes were managed with systemic and intravitreal antibiotics. The presence of intraocular foreign body (P < 0.05) and delayed primary OGR (P < 0.03) were significantly more common with concurrent versus post-OGR endophthalmitis. Four (29%) eyes in the post-OGR endophthalmitis group had corneal wound leak after OGR. Four (15%) eyes with no light perception vision were enucleated. Ten (40%) of 25 eyes with documented best-corrected visual acuity had final best-corrected visual acuity ≥20/200; final best-corrected visual acuity ranged from no light perception to 20/20.

CONCLUSION

The presence of intraocular foreign body and delayed presentation were significantly more common with concurrent endophthalmitis. Twenty-nine percent of eyes that presented with endophthalmitis after OGR had a wound leak. Final best-corrected visual acuity ≥20/200 was achieved in 40% of cases.

Epidemiology of Adult Open Globe Injury

OBJECTIVE

The aim of this study was to evaluate the epidemiology and outcomes of adult open globe injuries (OGI) in the eastern part of Turkey.

METHODS

The retrospective study included all the patients who were diagnosed with OGI (436 eyes in 425 patients) at our clinic between 1997 and 2015. The OGI patients aged over 16 years were included into the study. Open globe injuries were classified according to the Ocular Trauma Classification. Age, gender, medical history, time between trauma and hospital admission, and mechanism of injury were recorded for each patient.

RESULTS

The incidence of OGI in adults was found to be 3.40/100,000, with 5.00/100,000 in males and 1.67/100,000 in females. Open globe injuries were mostly seen in the age group of 17 to 29 years and in October and November. The patients included 79.5% males and 20.5% females. Intraocular foreign body was detected in 99 (22.7%) eyes. A strong, linear, negative correlation was found between the Ocular Trauma Classification values and final visual LogMAR (rp = -0.602, P = 0.0001). The most common mechanism of injury was occupational accident (38.4%).

CONCLUSION

Open globe injuries remain a serious public health problem, resulting in significant vision loss. Open globe injuries are mostly seen in the young, middle-aged, and male working population. Additional preventive measures should be taken for the individuals in these groups.

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.

A five-year retrospective study of the epidemiological characteristics and visual outcomes of pediatric ocular trauma

BACKGROUND

Pediatric trauma can lead to serious visual impairment as a result of the trauma itself or secondary to amblyopia. Precise data on epidemiological characteristics and visual outcomes of pediatric ocular injuries are valuable for the prevention of monocular blindness.

METHODS

A total of 268 cases of pediatric ocular trauma admitted to the Department of Ophthalmology of the Lithuanian University of Health Sciences Hospital from January 2008 to December 2013 were retrospectively reviewed. Data analysed included age, sex, cause, type and treatment of injury, initial and final visual acuity (VA) and tissues involvement. Eye injuries were classified by Birmingham Eye Trauma Terminology (BETT) and Ocular Trauma Classification System (OTCS).

RESULTS

The age of children ranged from 6 months to 17.5 years. Boys were more likely to suffer ocular injury than girls. Home was the leading place of eye injury (60.4%), followed by outdoors (31.7%), school (5.2%) and sporting area (2.2%). The highest percentage of eye injuries in children were caused by blunt (40.3%) and sharp objects (29.9%), followed by burns (9.3%), falls (6.7%), explosions (4.5%), fireworks (4.1%), gunshots (1.9%) and traffic accidents (0.7%). Closed globe injury (CGI) was the most common type of eye injury (53.4%). CGI were noted to be higher in children aged 13-18 years, while open globe injury (OGI) were higher in the pre-school age group. Injury of grade 4 and grade 5 were more common in OGI, while grade 1 and grade 2 predominated in cases of CGI. Hypotony, traumatic cataract, iris laceration, vitreous prolapse and uveitis were the most common presentations of OGI, while hyphema, secondary glaucoma and retinal edema were significantly related with CGI. Final diagnoses contributing to poor final visual outcome such as corneal scar corneal opacity, hypotony, aphakia, and retinal detachment were statistically significant related only with OGI. Overall, 65.63% of children regained good visual acuity (VA ≥ 0.5), but for 18.4% of them, the trauma resulted in severe visual impairment (VA ≤ 0.1).

CONCLUSION

Ocular trauma in children still remains an important preventable cause of ocular morbidity. This study provides data indicating that ophthalmological injuries are a significant cause of visual impairment in children.

SMOKING IS A RISK FACTOR FOR PROLIFERATIVE VITREORETINOPATHY AFTER TRAUMATIC RETINAL DETACHMENT

PURPOSE

To determine the incidence of retinal redetachment due to proliferative vitreoretinopathy after open-globe trauma in smokers and nonsmokers.

METHODS

A total of 892 patients comprising 893 open-globe injuries, in whom 255 eyes were diagnosed with a retinal detachment, and 138 underwent surgical repair were analyzed in a retrospective case-control study. Time to redetachment was examined using the Kaplan-Meier method and analysis of risk factors was analyzed using Cox proportional hazards modeling.

RESULTS

Within one year after retinal detachment surgery, 47% (95% CI, 39-56%) of all 138 repaired retinas redetached because of proliferative vitreoretinopathy. Being a smoker was associated with a higher rate of detachment (adjusted hazard ratio 1.96, P = 0.01). As shown in previous studies, the presence of proliferative vitreoretinopathy at the time of surgery was also an independent risk factor for failure (adjusted hazard ratio 2.13, P = 0.005). Treatment with vitrectomy-buckle compared favorably to vitrectomy alone (adjusted hazard ratio 0.58, P = 0.04). Only 8% of eyes that redetached achieved a best-corrected visual acuity of 20/200 or better, in comparison to 44% of eyes that did not redetach (P < 0.001).

CONCLUSION

Proliferative vitreoretinopathy is a common complication after the repair of retinal detachment associated with open-globe trauma, and being a smoker is a risk factor for redetachment. Further study is needed to understand the pathophysiologic mechanisms underlying this correlation.

Systematic analysis of ocular trauma by a new proposed ocular trauma classification

Purpose:

The current classification of ocular trauma does not incorporate adnexal trauma, injuries that are attributable to a nonmechanical cause and destructive globe injuries. This study proposes a new classification system of ocular trauma which is broader-based to allow for the classification of a wider range of ocular injuries not covered by the current classification.

Methods:

A clinic-based cross-sectional study to validate the proposed classification. We analyzed 535 cases of ocular injury from January 1, 2012 to February 28, 2012 over a 4-year period in an eye hospital in central India using our proposed classification system and compared it with conventional classification.

Results:

The new classification system allowed for classification of all 535 cases of ocular injury. The conventional classification was only able to classify 364 of the 535 trauma cases. Injuries involving the adnexa, nonmechanical injuries and destructive globe injuries could not be classified by the conventional classification, thus missing about 33% of cases.

Conclusions:

Our classification system shows an improvement over existing ocular trauma classification as it allows for the classification of all type of ocular injuries and will allow for better and specific prognostication. This system has the potential to aid communication between physicians and result in better patient care. It can also provide a more authentic, wide spectrum of ocular injuries in correlation with etiology. By including adnexal injuries and nonmechanical injuries, we have been able to classify all 535 cases of trauma. Otherwise, about 30% of cases would have been excluded from the study.

Tilt, Decentration, and Internal Higher-Order Aberrations of Sutured Posterior-Chamber Intraocular Lenses in Patients with Open Globe Injuries

Purpose

To evaluate the tilt, decentration, and internal higher-order aberrations (HOAs) of sutured posterior-chamber intraocular lenses (IOLs) in patients with open globe injuries.

Methods

46 consecutive patients (47 eyes) who underwent transsclerally sutured IOL implantation were enrolled in this prospective cohort study. Nineteen eyes had a history of open globe injury. The tilt and decentration of the IOLs and the visual quality were measured 1 month after surgery.

Results

The horizontal tilt and decentration of the IOLs in the open-globe-injury group were significantly higher than those in the control group (both P < 0.05). In the open-globe-injury group, the horizontal decentration was significantly greater in the limbus-sclera-involved group (n = 11) than in the only-cornea-involved group (n = 8, P = 0.040). The internal coma, 3rd-order, and total HOA values at pupil sizes of 4 mm (P = 0.006) and 6 mm (P = 0.013) were significantly higher in the open-globe-injury group than in the controls. Consequently, the optical quality data for the modulation transfer function and the Strehl ratio (all P < 0.05) were significantly poorer in the open-globe-injury group.

Conclusions

Open globe injuries damage the structural integrity of the eyeball, resulting in more-misaligned sutured IOLs and poorer visual quality.

Comparison of Regional vs. General Anesthesia for Surgical Repair of Open-Globe Injuries at a University Referral Center

PURPOSE

This study compares the clinical features and physician selection of either Regional Anesthesia (peribulbar or retrobulbar block) with Monitored Anesthesia Care (RA-MAC) or General Anesthesia (GA) for open globe injury repair.

DESIGN

A non-randomized, comparative, retrospective case series at a University Referral Center.

PARTICIPANTS

All adult repairable open globe injuries receiving primary repair between January 1st, 2004 and December 31st, 2014 (11 years). Exclusion criteria were patients less than 18 years of age and those treated with primary enucleation.

METHODS

Data was gathered via retrospective chart review.

MAIN OUTCOME MEASURES

Data collected from each patient was age, gender, injury type, location, length of wound, presenting visual acuity, classification of anesthesia used, duration of the procedure performed, months of clinical follow-up, and final visual acuity.

RESULTS

During the 11 years study period, 448 patients were identified who had open globe injuries with documented information on zone of injury. Globe injury repair was performed using RA-MAC in 351/448 (78%) patients and general anesthesia in 97/448 (22%) patients. Zone 1, 2 and 3 injuries were recorded in 241, 135, and 72 patients respectively. The rates in specific zones, of RA-MAC versus GA were as follows: Zone 1 - 213/241 (88%) vs 28/241 (12%), Zone 2 - 104/135 (77%) vs 31/135 (23%) and Zone 3 - 34/72 (47%) vs 38/72 (53%). Open globe injuries repaired under RA-MAC had significantly shorter wound length (p<0.001), more anterior wound location (p<0.001) and shorter operative times (p<0.001). RA-MAC cases also had a better presenting and final visual acuity (p<0.001). Neither class of anesthesia conferred a greater visual acuity improvement (p=0.06). The use of GA did not cause any delay in the time elapsed from injury until surgical repair (p=0.74).

CONCLUSIONS

RA-MAC is a reasonable alternative to GA for the repair of open globe injuries in selected adult patients. RA-MAC was selected more often for Zone 1 and Zone 2 injuries. For eyes with Zone 3 injuries, there are equal selection ratio for RA-MAC and GA.

Epidemiologic characteristics and outcomes of open globe injury in Shanghai

AIM

To investigate the epidemiologic characteristics and outcomes of open globe injury in Shanghai.

METHODS

A retrospective study was conducted for 148 unilateral open globe injury cases presenting to a tertiary referral hospital of Shanghai. Electronic medical records were reviewed and phone surveys were conducted to collect and analyze 1) background of patient; 2) setting of injury and clinical signs at presentation; 3) treatment procedure and outcome; 4) quality of life after injury.

RESULTS

There were more male patients (77.03%) than females (22.97%), more temporary habitants (79.05%) than residents (20.95%). The subjects in this study presented a significantly lower constitutional status of education than that of the whole Shanghai population (P<0.001). Occupational injury was the first cause of injuries (39.86%), followed by home accident (20.27%), road accident (16.89%), violent behavior (16.89%) and outdoor injury (6.08%). The 143 subjects (96.62%) were not wearing spectacles at the time of injury. Of all patients, 77 subjects (52.03%) had the outcome of no vision (including enucleation). The classification and regression tree (CART) prognosis presents 59.58% sensitivity to predict visual survival correctly and 80.19% specificity to predict no vision correctly. The patients whose injured eye had no vision reported more reduction of life quality.

CONCLUSION

We found that male subject, temporary habitants, low educational status and no eyewear are risk factors of open globe injury in Shanghai. Occupational injury is the leading cause. CART analysis presents a certain agreement to the actual visual outcome. The injury imposes negative impact on quality of life especially in no vision cases. The education of eye protection may help to avoid the injury.

Intraoperative B-scan ultrasonography and pars plana vitrectomy for severe open globe injury with hemorrhagic retinal and choroidal detachment

PURPOSE

Our purpose was to report the initial clinical experience of intraoperative B-scan ultrasonography in combination with 25-gauge pars plana vitrectomy for severe open globe injury with hemorrhagic retinal and choroidal detachment.

METHODS

Six eyes of six consecutive patients with severe open globe injury underwent intraoperative B-scan ultrasonography and 25-gauge pars plana vitrectomy at Osaka University Hospital in Japan. The feasibility of intraoperative B-scan ultrasonography, best-corrected visual acuity (BCVA), retinal reattachment, and intraoperative and postoperative complications were evaluated.

RESULTS

Five patients presented with a ruptured globe and one patient with double penetration. Preoperative best-corrected visual acuity was no light perception in four eyes and light perception in two eyes. All patients underwent intraoperative B-scan ultrasonography and 25-gauge pars plana vitrectomy within 12 h after open globe injury. Intraoperative B-scan ultrasonography was feasible in all cases and was useful for diagnosing choroidal hemorrhage (four eyes), massive subretinal hemorrhage (two eyes), and retinal detachment (five eyes). In addition, serial real-time B-scan imaging facilitated successful evacuation of the choroidal hemorrhage and massive subretinal hemorrhage by external drainage, resulting in opening of the vitreous space to allow subsequent pars plana vitrectomy without entry site-related complications. After surgery, all patients had successful retinal attachment, and there was no loss of light perception.

CONCLUSION

Intraoperative B-scan ultrasonography is technically feasible and may potentially improve the safety and efficacy of severe open globe injury repair.

Patterns of Ocular Trauma among the Elderly in a South-American Urban Area and the Association between Eye Traumas with Sleep Disorders

Aims:

Eye trauma in the older population can lead to blindness. Sleep deterioration is associated with increased risk of occupational injuries. The purpose of the study was to assess the epidemiology of ocular trauma in the elderly population and to evaluate the relationship between eye trauma and sleep quality.

Settings and Design:

This was a cross-sectional, observational hospital based study done in a Sao Paulo, Brazil.

Subjects and Methods:

Patients with ocular trauma aged 60 years who attended the Eye Trauma Service of the Santa Casa de Sao Paulo Central Hospital were included. All subjects underwent a complete eye examination and answered to the Pittsburgh Sleep Quality Index (PSQI) questionnaire. The results were compared with an age and gender matched control group.

Results:

Eighty-nine patients with ocular trauma were included in the epidemiological study, 71 (80%) were male and 18 (20%) were female. The patients’ ages ranged from 60 to 90 years (65.7 ± 7.1 years). Most accidents occurred at home and were of mild severity. The control group had a global PSQI score of 1.21 ± 1.37, whereas in the ocular trauma group the score was 3.11 ± 3.63 (P < 0.038). A post hoc analysis including only patients with severe trauma, the PSQI score was 8.80 ± 2.44 (P < 0.000).

Conclusion:

The elderly population represents an important group of ocular trauma in their own peculiar characteristics. Elderly victims of ocular trauma, particularly serious eye injury, have worse sleep quality than subjects of the same age.

Clinical profile of medicolegal cases presenting to the eye casualty in a tertiary care center in India

Purpose:

The purpose of this study was to analyze the clinical profile of medicolegal cases (MLCs) presenting to the eye casualty in a tertiary care hospital.

Materials and Methods:

Retrospective review of records. The cases were grouped according to the Ocular Trauma Classification Group classification system.

Results:

Out of 188 MLCs, 164 (87.2%) were male. Mean age (±standard deviation) was 31.6 (±12.7) years. Age ranged from 7 to 75 years. Twenty-six (13.8%) patients had bilateral involvement. The fist was the most common mode of injury, which was seen in 109 (58%) cases. A total of 27 (14.3%) patients had associated extraocular injury. No evidence of ocular or orbital trauma (malingering) could be found in 13 (7%) patients. Mechanical trauma was present in 169 (90%) patients with injury to globe in 129 (69%) patients and injury to lid or orbit without damage to the globe in 40 (21%) patients. Chemical injury was observed in 6 (3%) patients. Closed globe injury (CGI) was seen in 116 eyes and open globe injury (OGI) was noted in 29 eyes. The most common type of injury, zone, pupil, and grade of injury in CGI were Type A or contusion (79%), Zone I (72%), Pupil B (absence of relative afferent pupillary defect) in 95%, and Grade A [visual acuity (VA) ≥20/40] in 68% of the eyes, respectively. The most common type of injury, zone, pupil, and grade of injury in OGI were Type B or penetrating (48%), Zone II (38%), Pupil B (59%), and Grade D (VA 4/200-light perception) (42%), respectively.

Conclusions:

The most common form and mode of ocular injury in MLC were closed globe injury and fist, respectively. The most common type of injury in CGI and OGI was contusion and penetrating injury, respectively.

Posterior Segment Intraocular Foreign Bodies: A 10-Year Review

PURPOSE

To describe the characteristics of open-globe injuries with posterior segment intraocular foreign bodies (IOFBs).

DESIGN

Retrospective chart review study.

PARTICIPANTS

Patients treated for posterior segment IOFB injuries.

METHODS

Retrospective analysis of all patients with posterior segment IOFBs from 2003 to 2014 was conducted. Data including demographics, mechanism of injury, type of IOFB, method of diagnosis, presenting examination, medical and surgical treatment, visual outcomes, and complications were recorded.

MAIN OUTCOME MEASURES

Visual acuity (VA); anatomically successful retinal reattachment; need for additional surgery; frequency of post-traumatic complications, such as sympathetic ophthalmia (SO), endophthalmitis, and enucleations; and accuracy of Ocular Trauma Score (OTS).

RESULTS

Thirty-one patients (28 male; mean age, 36.6 years; 42% Hispanic) had posterior segment IOFB injuries, 23 (74%) of which were construction work related. Twenty-five IOFBs (81%) were metallic. Twenty-four IOFBs (77%) had Zone I entry. Computed tomography (CT) scan detected an IOFB in 21 of 22 eyes in which it was performed, with 1 scan highly suspicious for an IOFB. Average size of the IOFB was 10 mm³; size or initial VA did not have any correlation with final VA. The OTS had 60% accuracy in predicting final VA (n = 20). The majority of patients had traumatic cataract and vitreous hemorrhage (VH) on presentation (77% and 61%, respectively); 65% had a retinal tear or retinal detachment (RD), and these patients had worse final VA than those with no retinal pathology. Average time from injury to IOFB removal was 3 days because of the delay in presentation to our facility; 27 of 31 patients (87%) had IOFBs removed within 24 hours of presentation with pars plana vitrectomy (PPV) and either gas or silicone oil tamponade. Patients were admitted for an average of 4 days of intravenous antibiotics. The most common complication was recurrent RD in 11 patients (35%), which portended worse final VA. One patient (3%) developed SO. There were no cases of postoperative endophthalmitis or enucleation.

CONCLUSIONS

Open-globe injuries with posterior segment IOFBs have a guarded visual prognosis, particularly when associated with RD. Increased awareness of the importance of eye protection can help minimize the occurrence of these injuries.

Early versus late traumatic cataract surgery and intraocular lens implantation

PurposeTo determine the proper time for traumatic cataract surgery after open globe injuries.SettingFarabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran.DesignRandomized clinical trial.Patients and methodsIn a randomized clinical trial, 30 eyes with traumatic cataract after open globe injury with IOL implantation underwent early (in the first week after the trauma) and 30 eyes underwent late cataract surgery (from the first to second month after the trauma). We excluded patients who were under 12-year-old. All patients were visited at 1 week, 4 weeks, 12 weeks, and 6 months after surgery. In each visit, patients were examined regarding visual acuity, intraocular pressure (IOP), anterior chamber inflammation, IOL position, and posterior synechiae. In addition, posterior segment evaluation and fundoscopy were performed. Intraoperative complication including posterior capsular rupture, anterior vitrectomy, and zonulysis as well as the site of IOL implantation were documented and post-operative complications including raised IOP, anterior chamber inflammation, visual axis opacity, posterior synechiae, subluxation of IOL, and IOL pigment deposition were listed.ResultsBest-corrected visual acuity 6 months after surgery was not different between the two groups. Also in early cataract surgery group, the rate of posterior capsular rupture was not significantly higher than the late surgery group (P=0.069). On the other hand, zonulysis was significantly higher in the late procedure group (P=0.039). Other complications including anterior vitrectomy, raised IOP, anterior chamber inflammation, visual axis opacity, posterior synechiae, subluxation of IOL, and IOL pigment deposition were not different in the two groups.ConclusionsEarly and late traumatic cataract surgery and IOL implantation after open globe injuries, have no significant difference regarding the post-surgical BCVA and prominent intraoperative and post-operative complications.

The impact of ocular trauma during the Nepal earthquake in 2015

Background

Nepal was struck by a massive earthquake on the 25th April 2015 and major aftershock on the 12th of May 2015, resulting in widespread devastation with a death toll in the thousands. The burden of ocular trauma resulting from the recent earthquakes in Nepal has not been described thus far. The aim of this study was to determine the types of ocular injuries sustained in the earthquake in Nepal and its management in Tilganga Institute of Ophthalmology (TIO) in Gaushala, Kathmandu.

Methods

This is a hospital-based retrospective study of patients presenting to TIO following repeated earthquake. Variables that were recorded included patients’ presenting symptoms and time to presentation, visual acuities at presentation and at follow-up, diagnosis of ocular injury and surgery performed.

Results

There were 59 cases of earthquake victims visiting TIO, Gaushala, Kathmandu from April 2015 to July 2015, with 64 affected eyes due to 5 cases of bilateral involvement. The majority of patients were from the district Sindhupalchowk (14 cases, 23.7%), which was the epicenter of the main earthquake. The average duration between the earthquake and presentation was 13 · 9 days (range 1–120 days). Closed globe injury was most frequent (23 cases), followed by open globe injuries (8 cases). While 24 patients (38%) initially presented with a visual acuity <3/60 in their affected eye, 15 patients (23%) had a visual acuity of <3/60 on follow-up. A variety of surgical treatments were required including anterior and posterior segment repair.

Conclusions

Immediate management of ocular trauma is critical in order to prevent blindness. Characterizing the burden of earthquake-related ocular trauma will facilitate planning for service provision in the event of a future earthquake in Nepal, or in countries, which are similarly at risk of having natural disasters.

Electronic supplementary material

The online version of this article (doi:10.1186/s12886-017-0429-z) contains supplementary material, which is available to authorized users.

A Possible Regression Equation for Predicting Visual Outcomes after Surgical Repair of Open Globe Injuries

Background. To analyze the effects of factors other than the ocular trauma score parameters on visual outcomes in open globe injuries. Methods. Open globe injuries primarily repaired in our hospital were reviewed. The number of surgeries, performance of pars plana vitrectomy (PPV), lens status, affected tissues (corneal, scleral, or corneoscleral), intravitreal hemorrhage, intraocular foreign body, glaucoma, anterior segment inflammation, loss of iris tissue, cutting of any prolapsed vitreous in the primary surgery, penetrating injury, and the time interval between the trauma and repair were the thirteen variables evaluated using linear regression analysis. Results. In total, 131 eyes with a mean follow-up of 16.1 ± 4.7 (12–36) months and a mean age of 33.8 ± 22.2 (4–88) years were included. The regression coefficients were 0.502, 0.960, 0.831, −0.385, and −0.506 for the performance of PPV, aphakia after the initial trauma, loss of iris tissue, penetrating injury, and cutting of any prolapsed vitreous in the primary surgery, respectively (P < 0.05 for these variables). Conclusions. The performance of PPV, aphakia after the initial trauma, and loss of iris tissue were associated with poor visual outcomes, whereas cutting any prolapsed vitreous in the primary repair and penetrating-type injury were associated with better visual outcomes.

Surgical Outcomes of Ahmed or Baerveldt Tube Shunt Implantation for medically Uncontrolled Traumatic Glaucoma

Aim

To describe postoperative surgical success of either Ahmed or Baerveldt tube shunt implantation for eyes with medically uncontrolled traumatic glaucoma.

Materials and methods

A review was carried out to identify patients with traumatic glaucoma that required tube shunt implantation between 2009 and 2015 at Rutgers University in Newark, New Jersey, USA. Seventeen eyes from 17 patients met inclusion criteria, including at least 3-month postoperative follow-up. The main outcome measure was surgical success at 1-year follow-up after tube implantation.

Results

Mean preoperative intraocular pressure (IOP) was 34.1 ± 8.2 mm Hg on 3.1 ± 1.6 ocular hypotensive medications. Nine eyes (53%) sustained closed globe injury. Ten eyes (59%) received an Ahmed valve shunt and seven eyes (41%) received a Baerveldt tube shunt. Surgical success rate at 1 year postoperatively was 83%. Compared to preoperative, the mean postoperative IOP was significantly lower (16.1 ± 3.5 mm Hg, p < 0.001) on significantly fewer ocular hypertensive medications (1.3 ± 1.6, p = 0.001) at a mean follow-up of 10 months. Mean IOP reduction at last follow-up was 49%. There were three cases of surgical failures: One case of hypotony, one case of tube extrusion with subsequent explan-tation, and one case requiring second tube insertion for IOP control.

Conclusion

Implantation of an Ahmed or Baerveldt tube shunt provided successful control of IOP in patients with medically uncontrollable traumatic glaucoma.

How to cite this article

Yadgarov A, Liu D, Crane ES, Khouri AS. Surgical Outcomes of Ahmed or Baerveldt Tube Shunt Implantation for medically Uncontrolled Traumatic Glaucoma. J Curr Glaucoma Pract 2017;11(1):16-21.

Validation of the Retinal Detachment after Open Globe Injury (RD-OGI) Score as an Effective Tool for Predicting Retinal Detachment

PURPOSE

The Retinal Detachment after Open Globe Injury (RD-OGI) Score is a clinical prediction model that was developed at the Massachusetts Eye and Ear Infirmary to predict the risk of retinal detachment (RD) after open globe injury (OGI). This study sought to validate the RD-OGI Score in an independent cohort of patients.

DESIGN

Retrospective cohort study.

PARTICIPANTS

The predictive value of the RD-OGI Score was evaluated by comparing the original RD-OGI Scores of 893 eyes with OGI that presented between 1999 and 2011 (the derivation cohort) with 184 eyes with OGI that presented from January 1, 2012, to January 31, 2014 (the validation cohort).

METHODS

Three risk classes (low, moderate, and high) were created and logistic regression was undertaken to evaluate the optimal predictive value of the RD-OGI Score. A Kaplan-Meier survival analysis evaluated survival experience between the risk classes.

MAIN OUTCOME MEASURES

Time to RD.

RESULTS

At 1 year after OGI, 255 eyes (29%) in the derivation cohort and 66 eyes (36%) in the validation cohort were diagnosed with an RD. At 1 year, the low risk class (RD-OGI Scores 0-2) had a 3% detachment rate in the derivation cohort and a 0% detachment rate in the validation cohort, the moderate risk class (RD-OGI Scores 2.5-4.5) had a 29% detachment rate in the derivation cohort and a 35% detachment rate in the validation cohort, and the high risk class (RD-OGI scores 5-7.5) had a 73% detachment rate in the derivation cohort and an 86% detachment rate in the validation cohort. Regression modeling revealed the RD-OGI to be highly discriminative, especially 30 days after injury, with an area under the receiver operating characteristic curve of 0.939 in the validation cohort. Survival experience was significantly different depending upon the risk class (P < 0.0001, log-rank chi-square).

CONCLUSIONS

The RD-OGI Score can reliably predict the future risk of developing an RD based on clinical variables that are present at the time of the initial evaluation after OGI.

Better Visual Outcome by Intraocular Lens Ejection in Geriatric Patients with Ruptured Ocular Injuries

Ocular trauma is one of the leading causes of visual impairment worldwide. Because of the popularity of cataract surgeries, aged individuals with ocular trauma commonly have a surgical wound in their eyes. The purpose of this study was to evaluate the visual outcome of cases that were coincident with intraocular lens (IOL) ejection in the eyes with ruptured open-globe ocular injuries. Consecutive patients with open-globe ocular injuries were first reviewed. Patients’ characteristics, corrected distance visual acuities (CDVAs) over 3 years after the trauma, causes of injuries, traumatic wound patterns, and coexistence of retinal detachment were examined. The relationships between poor CDVA and the other factors, including the complications of crystalline lens and IOL ejection, were examined. A total of 105 eyes/patients [43 eyes with rupture, 33 with penetrating, 28 with intraocular foreign body (IOFB), and 1 with perforating injuries] were included. Rupture injuries were common in aged patients and were mostly caused by falls, whereas penetrating and IOFB injuries were common in young male patients. CDVAs of the eyes with rupture injuries were significantly worse than those of the eyes with penetrating or IOFB injuries. CDVA from more than 50% of the ruptured eyes resulted in no light perception or light perception to 20/500. CDVA of the ruptured eyes complicated by crystalline lens ejection was significantly worse than that of those complicated by IOL ejection. The wounds of the ruptured eyes complicated by IOL ejection were mainly located at the superior corneoscleral limbus, whereas those of the eyes complicated by crystalline lens ejection were located at the posterior sclera. There were significant correlations between poor CDVA and retinal detachment and crystalline lens ejection. These results proposed a new trend in the ocular injuries that commonly occur in aged patients; history of cataract surgery might affect the final visual outcome after open-globe ocular injuries.

Surgical Management of Traumatic Retinal Detachment with Primary Vitrectomy in Adult Patients

Purpose. To evaluate functional and anatomical results of pars plana vitrectomy (PPV) in the retinal detachment (RD) followed by severe eye trauma. Methods. Retrospective analysis of medical records of forty-one consecutive patients treated with 23-gauge PPV due to traumatic RD. Age, gender, timing of PPV, visual acuity, and presence of intraocular foreign body (IOFB) and proliferative vitreoretinopathy (PVR) were included in the analysis. Results. Mean age of patients was 47 years; the majority of patients were men (88%). Closed globe injury was present in 21 eyes and open globe injury in 20 eyes (IOFB in 13 eyes, penetration injury in 4 eyes, and eye rupture in 3 eyes). Mean follow-up period was 14 months; mean timing of PPV was 67 days. Twenty-seven (66%) eyes had a functional success; 32 eyes (78%) had anatomical success. As a tamponade silicone oil was used in 33 cases and SF6 gas in 8 cases. Conclusions. Severe eye injuries are potentially devastating for vision, but vitreoretinal surgery can improve anatomical and functional outcomes. Among analysed pre- and intra- and postoperative factors, absence of PVR, postoperative retinal attachment, and silicone oil as a tamponade were related to significantly improved visual acuity.

Prevalence and risk factors associated with work-related eye injuries in Bosnia and Herzegovina

BACKGROUND

Eye injuries are a prevalent workplace injury and cause substantial disability when vision is impaired.

OBJECTIVE

To examine work-relatedness of demographic, injury, and clinical characteristics of eye injuries in a large clinic in Bosnia and Herzegovina.

METHODS

We performed a nine-year retrospective study of patients admitted with an eye injury to the Canton Hospital in Zenica, Bosnia and Herzeogvina. Controlling for age and sex, we used logistic regression to examine the influence of work-relatedness on patient and injury characteristics and clinical outcomes.

RESULTS

Of 258 patients, 71 (27.5%) had work-related and 180 (69.8%) had non-work-related eye injuries. Work-related eye injury was associated with age, education, occupation, and injury type. Agricultural workers were eight times more likely to experience work-related eye injury (95%CI = 1.21-152.0) compared to manual workers. Work-relatedness of injury did not predict final visual acuity or length of hospital stay.

CONCLUSION

Promotion of eye safety is needed countrywide. Occupational eye protection is a priority due to the relatively proportion of eye injuries and the workplace being a relatively controlled environment.

Timing of Pars Plana Vitrectomy in Management of Gunshot Perforating Eye Injury: Observational Study

The aim of this study is to report the difference in either anatomical or functional outcome of vitreoretinal intervention in cases of gunshot perforating eye injury if done 2–4 weeks or after the 4th week after the original trauma. Patients were treated with pars plana vitrectomy and silicon oil. Surgeries were performed in the period from February 2011 until the end of December 2014. 253 eyes of 237 patients were reviewed. 46 eyes were excluded. 207 eyes of 197 patients were analyzed. The included eyes were classified based on the timing of vitrectomy in relation to the initial trauma into two groups: 149 eyes (the first group) operated on between the 3rd and the 4th week and 58 eyes (the second group) operated on after the 4th week after the trauma. Following one surgical intervention, in the first group, attached retina was achieved in 93.28% of patients. In the second group, attached retina was achieved in 96.55% of patients. All RD cases could be attached by a second surgery. Visual acuity improved in 81.21% of patients, did not change in 15.43% of patients, and declined in 3.35% of patients. In the second group, visual acuity improved in 81.03% of patients, did not change in 12.06% of patients, and worsened in 6.89% of patients. There was no statistically significant difference between the two groups in either anatomical or functional results. We recommend interfering before the 5th week after the trauma as retinal detachment is encountered more in cases operated on after the 4th week. The visual outcome depends on the site of entry and exit (the route of gunshot).

COMPARISON BETWEEN PARS PLANA VITRECTOMY WITH VERSUS WITHOUT A 360° EPISCLERAL BAND IN THE MANAGEMENT OF GUNSHOT PERFORATING EYE INJURY

PURPOSE

To evaluate whether omitting the use of the 360° episcleral band in combination with pars plana vitrectomy and silicone oil tamponade had an effect on either anatomical or functional success in cases of perforating eye injury due to gunshot.

METHODS

A retrospective consecutive interventional study from medical records. Surgeries were performed in the period from January 2011 until the end of December 2013. Patients with perforating eye injury due to gunshots were treated with pars plana vitrectomy and silicone oil tamponade with or without the addition of a 360° scleral band.

RESULTS

Two hundred and thirteen eyes of 210 patients were reviewed of which 17 patients were excluded, 5 patients because the vision had no light perception and 12 patients because of the short follow-up period (less than 6 months). The remaining 196 eyes of 193 patients were analyzed. All surgeries were performed by 1 surgeon. The included eyes have been classified into 2 groups; 101 eyes in the first group (360° band was used), and 95 eyes in the second group (without 360° band). The included patients were followed up at least 6 months after the last surgery. By first surgery, anatomical success was achieved in 93 eyes (92.08%) in Group 1, and retinal detachment developed in 8 eyes (7.92%). In Group 2 anatomical success was achieved in 91 eyes (95.78%), and retinal detachment developed in 4 eyes (4.21%). All cases with retinal detachment were reattached by second surgery. In the first group, visual acuity improved in 80 eyes (79.2%), unchanged in 14 eyes (13.86%), and was less than that of preoperative value in 7 eyes (6.93%). In the second group visual acuity improved in 78 eyes (82.1%), unchanged in 13 eyes (13.68%) and less than that of preoperative value in 4 eyes (4.21%). No statistically significant difference was found between the two groups (P = 0.943) in anatomical or functional results. None of the operated eyes developed phthisis bulbi.

CONCLUSION

The abundant use of the 360° scleral band in combination with pars plana vitrectomy and silicone oil tamponade did not change the anatomical or the functional outcomes in the management of perforating eye injury due to gunshots.

Visual outcome after emergency surgery for open globe eye injury in Japan

Background

Most patients with open globe eye injury are brought to hospital as emergency patients and usually require admission for emergency surgery. We analyzed the visual outcome in patients with open globe eye injury at our hospital over a 4-year period.

Patients and methods

This study reviewed 40 eyes of 40 patients with open globe eye injury who were presented to Juntendo University Shizuoka Hospital and required emergency surgery during the 4 years from January 2010 to December 2014. Retrospective evaluation of the visual outcome was performed using data from the medical records, including assessment of the influence of sex, side of the eye injury, cause of injury, and site/severity of injury.

Results

The mean age (SD) at the time of the injury was 58.9 years (±25.1 years). There were 28 males (70.0%) and 12 females (30.0%). Statistically significant improvement in visual acuity after treatment was noted in the males (P=0.0015, Wilcoxon test), but not in the females. Twenty-five patients had injury to the right eye (62.5%) and 15 had injury to the left eye (37.5%). A significant improvement in visual acuity was achieved after treatment of injury to the right eye (P=0.021), but not the left eye (P=0.109). The most frequent cause of injury was an accident (15 eyes; 37.5%). The second most frequent cause was work-related injury (14 eyes; 35.0%), which only occurred in males, and the third cause was accident due to negligence (eleven eyes; 27.5%). Two patients developed sympathetic ophthalmia and one patient developed postoperative endophthalmitis.

Conclusion

The majority of patients with open globe eye injury were male workers in Japan. The visual outcome of work-related injury was better than that of injury due to other causes. The visual outcome was also better if the right eye was injured compared with the left eye. Patients with injuries due to negligence were older than the other groups, and this finding might be characteristic of an aging society.

OUTCOMES OF RETINAL DETACHMENT REPAIR AFTER POSTERIOR OPEN GLOBE INJURY

PURPOSE

To report outcomes of retinal detachment (RD) repair following posterior open globe injury.

METHODS

This retrospective, consecutive case series examined patients who underwent RD repair following Zone II and/or III open globe injury repair between January 1, 2007 and October 31, 2013. Patients with <3 months of follow-up since their last vitreoretinal surgery, and those who underwent pars plana vitrectomy (e.g., for intraocular foreign body) during their initial open globe injury repair were excluded.

RESULTS

Of 30 patients who met inclusion criteria, reattachment of the retina was achieved in 25 (83%) during the first vitreoretinal surgical procedure and 5 (17%) were deemed inoperable intraoperatively. Ten patients (30%) developed recurrent RD, and 8 underwent additional surgery. At last follow-up, reattachment was observed in 4 of these 8. The overall rate of final reattachment was 63% (19 patients). The mean number of surgeries for RD was 1.5 (range, 1-3). Fifteen patients (50%) achieved final visual acuity of counting fingers or better. Mean follow-up from the last vitreoretinal surgery was 23 months (range, 3-52).

CONCLUSION

Although RD following posterior open globe injury confers a grave prognosis, successful anatomic reattachment of the retina was achieved in the majority of patients in this series, with half achieving ambulatory vision.

Clinical characteristics and prognostic factors of scleral rupture due to blunt ocular trauma

PurposeTo describe and identify ocular and wound characteristics, and prognostic factors associated with final visual acuity (VA) in patients with scleral rupture due to blunt ocular trauma.MethodsThe medical records of 61 patients with globe rupture due to blunt ocular trauma who underwent primary repair were reviewed retrospectively. The data recorded included demographic characteristics, initial and final VA, ocular signs, wound characteristics, and surgeries. Initial VA, ocular signs, wound characteristics, and surgeries were analyzed to determine the association with the final VA.ResultsForty three women and 18 men with a mean age of 43.6±23.5 years were included in the study. The locations of scleral wounds were mostly in the superonasal quadrant (41.0%) and zone 2 (75.4%). In eyes with hyphema (P=0.009), vitreous hemorrhage (P=0.001), and retinal detachment (P=0.004), final VA was statistically worse than eyes without these signs. A moderate positive correlation was found between the initial and final VA (P<0.001). Final VA was statistically worse in eyes with horizontal midline wounds than in eyes with vertical midline wounds (P=0.002). A moderate negative correlation was found between scleral wound length and final VA (P<0.001). Patients who underwent cataract surgery had statistically better final VA (P=0.002).ConclusionsScleral rupture was detected mostly in females, superonasal quadrant and zone 2. Poor final VA was significantly associated with poor initial VA, longer wound length, horizontal midline wound, presence of hyphema, vitreous hemorrhage and retinal detachment at presentation, and cataract surgery not performed during follow-up period. Scleral ruptures have different demographic, ocular and wound characteristics than other open globe injuries.

Prognostic Factors for Visual Outcome in Traumatic Cataract Patients

Purpose. To investigate the prognostic factors for visual outcome in traumatic cataract patients. Methods. The demographic features of traumatic cataract patients in Central China were studied. The factors that might influence the visual outcome were analyzed. The sensitivity and specificity of OTS (ocular trauma score) in predicting VA were calculated. Results. The study enrolled 480 cases. 65.5% of patients achieved VA at >20/60. The factors associated with the final VA were initial VA, injury type, wound location, the way of cataract removal, and IOL implantation. The sensitivities of OTS in predicting the VA at NLP (nonlight perception), LP/HM (light perception/hand motion), and ≥20/40 were 100%. The specificity of OTS to predict the final VA at 1/200-19/200 and 20/200-20/50 was 100%. Conclusion. The prognostic factors were initial VA, injury type, wound location, cataract removal procedure, and the way of IOL implantation. The OTS has good sensitivity and specificity in predicting visual outcome in traumatic cataract patients in long follow-up.

Glaucoma After Open-globe Injury at a Tertiary Care University Hospital: Cumulative Causes and Management

PURPOSE

To investigate causes and treatment modalities of traumatic glaucoma after open-globe injury (OGI).

MATERIALS AND METHODS

The medical records of all patients with postrepair follow-up of OGI at a tertiary care university hospital from January 1996 to December 2010 were reviewed. These patients had persistent elevated intraocular pressure (IOP) of >21 mm Hg at 2 consecutive visits, with or without optic disc damages.

RESULTS

Over the 14-year study period, 41 eyes of 41 patients with repaired OGI that developed glaucoma were identified. In the early stage (within 1 mo), high IOP levels occurred owing to the presence of unremoved lens particles in 11 patients (26.8%), inflammation in 6 patients (14.6%), and hyphema in 3 patients (7.3%). In the intermediate stage (2 to 6 mo), the IOP increased owing to the presence of synechial angle closure in 9 patients (21.9%) and ghost cells in 3 patients (7.3%). In the late stage (>6 mo), the IOP rose owing to the presence of unremoved lens particles in 2 patients (4.8%), angle recession in 4 patients (9.7%), and synechial angle closure in 3 patients (7.3%). Surgical interventions included trabeculectomy in 9 eyes (22%), lens aspiration in 9 eyes (22%), cyclophotocoagulation (CPC) in 5 eyes (12.2%), anterior chamber washout in 3 eyes (7.3%), and tube surgery in 2 eyes (4.9%).

CONCLUSIONS

Traumatic glaucoma is not uncommon long-term complication after OGI. It is important to inspect the association between the initial cause and achieving a successful treatment. Surgical intervention may be crucial in the majority of cases.

Risk factors for poor outcomes in patients with open-globe injuries

Purpose

The aim of this study was to identify the risk factors that are predictive of poor outcomes in penetrating globe trauma.

Patients and methods

This retrospective case series evaluated 103 eyes that had been surgically treated for an open-globe injury from 2007 to 2010 at the eye clinic of the University of Virginia. A total of 64 eyes with complete medical records and at least 6 months of follow-up were included in the study. Four risk factors (preoperative best-corrected visual acuity [pre-op BCVA], ocular trauma score [OTS], zone of injury [ZOI], and time lapse [TL] between injury and primary repair) and three outcomes (final BCVA, monthly rate of additional surgeries [MRAS], and enucleation) were identified for analysis.

Results

Pre-op BCVA was positively associated with MRAS, final BCVA, and enucleation. Calculated OTS was negatively associated with the outcome variables. No association was found between TL and ZOI with the outcome variables. Further, age and predictor variable-adjusted analyses showed pre-op BCVA to be independently positively associated with MRAS (P=0.008) and with final BCVA (P<0.001), while the calculated OTS was independently negatively associated with final BCVA (P<0.001), but not uniquely associated with MRAS (P=0.530).

Conclusion

Pre-op BCVA and OTS are best correlated with prognosis in open-globe injuries. However, no conventional features reliably predict the outcome of traumatized eyes.

An Important Cause of Blindness in Children: Open Globe Injuries

Objective. Our aim was to present and evaluate the predictive factors of visual impairment and blindness according to WHO criteria in pediatric open globe injuries. Methods. The medical records of 94 patients younger than 18 years who underwent primary repair surgery were reviewed retrospectively. The initial and final visual acuity, anterior and posterior segment findings, and zone of injury were noted. The patients were classified as blindness in one eye or visual impairment in one eye. Results. Of 412 patients who presented with open globe injury, 94 (23%) were under 18 years old. Fifty-four (16 females, 38 males) children were included. The mean age of the children was 7.1 ± 4.1 years. According to WHO criteria, 19 of 54 patients (35%) had unilateral blindness and 8 had unilateral visual impairment (15%). There was no significant relationship between final visual acuity and gender and injured eye. In visually impaired and blind patients, presence of preoperative hyphema, retinal detachment, and zone 2 and zone 3 injuries was significantly higher. Conclusion. Presence of hyphema and zone 2 and zone 3 injuries and retinal detachment may end up with visual impairment and/or blindness in children.

Traumatic open globe injury in young pediatric patients: characterization of a novel prognostic score

BACKGROUND

Open globe injury is a common cause of monocular blindness in children. Current formulas to predict outcomes of open globe injury often rely heavily on visual acuity and presence of an afferent pupillary defect, examination elements that are difficult to assess in young children. We aimed to analyze the features of open globe injuries in children aged 0-6 years to facilitate development of a novel algorithm for predicting visual outcomes in this age group.

METHODS

The medical records of patients 0-6 years of age presenting at a single institution with open globe injury from 2000 to 2013 were retrospectively reviewed. Epidemiology, physical examination, and intervention data were used to develop a prognostic algorithm.

RESULTS

A total of 28 patients were included. Mean age at presentation was 4.2 years (range, 1.9-6.7). Glass was the most common mechanism of injury. Associated findings included uveal prolapse (93%), choroidal detachment (39%), hyphema (32%), and retinal detachment (11%). In addition to primary repair, 43% patients required a lensectomy, and 7% underwent surgery to repair retinal detachment. Complicating cataract (P < 0.005) and a wound >6 mm (P < 0.05) were associated with a final visual acuity worse than 20/40. A novel algorithm for predicting visual outcome was devised with a sensitivity of 81% and a specificity of 92%.

CONCLUSIONS

Patients 0-6 years of age with open globe injuries present unique risk factors for poor outcome. The trauma score generated by our algorithm is not reliant on presenting visual acuity and may be useful in predicting prognosis in very young children.

Conjunctival pedicle flap in management of open globe injury with corneal tissue loss

Accidental injury with scissors led to an open globe injury with iris prolapse and corneal tissue loss in the right eye of a 15-year-old girl. Attempts to suture the laceration normally, led to persistent aqueous leak, and tight suturing was leading to unacceptable distortion of the corneal contour. In the absence of donor tissue or tissue glue, a bulbar conjunctival pedicle flap was used to augment sutures placed without undue tension, and watertight closure of the globe was achieved. Postoperatively, the flap retracted, and excellent tectonic, cosmetic and refractive outcomes were achieved. A conjunctival pedicle flap can be a useful adjunct in the armamentarium of the corneal surgeon while dealing with open globe injuries with corneal tissue loss.

Causes of combat ocular trauma-related blindness from Operation Iraqi Freedom and Enduring Freedom

BACKGROUND

The incidence of eye injuries in military service members is high in the combat setting. This is the first study that identifies the primary reason for poor visual acuity (worse than 20/200).

METHODS

This is a retrospective, noncomparative, interventional case series analyzing US Operation Iraqi and Enduring Freedom members who were evacuated from the theater of operations to Walter Reed Army Medical Center from 2001 through 2011. Primary outcome measures were the length of follow-up, globe survival, and anatomic causes of blindness. Secondary outcome measures included surgical procedures performed, use of eye protection, nonocular injuries, incidence of traumatic brain injury, source of injury, visual outcomes, and predictability of Ocular Trauma Score (OTS) on visual outcome. Univariate analysis was performed using χ and Fisher's exact test. A p < 0.01 was considered significant because of the multiple hypotheses tested.

RESULTS

There were 265 eyes of 239 patients who had final best-corrected visual acuity of worse than 20/200. The average age was 27.4 years (range, 19-53 years). Of the patients, 97.5% were male, and 28.9% had documented use of eye protection. The average follow-up was 350.19 days (range, 3-2,421 days). There were 128 right-eye and 133 left-eye injuries, with a total of 26 bilateral injuries. There were 206 open-globe and 56 closed-globe injuries, which were further subdivided into zones. Open-globe Zone III injuries (81.6%) were the number one cause of blindness, and most injuries were caused by improvised explosive devices (64.2%). Enucleation was the most common surgery performed (40.6%) and therefore the leading cause of blindness, followed by a multifactorial cause and direct traumatic optic neuropathy.

CONCLUSION

Ocular trauma is common among combat injuries. Close to a third of service members that experience an ocular trauma become legally blind. Further research is needed to focus on strategies to prevent injury and improve visual outcomes.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level V.

Wide-Field Landers Temporary Keratoprosthesis in Severe Ocular Trauma: Functional and Anatomical Results after One Year

Purpose. To evaluate longitudinal functional and anatomical results after combined pars plana vitrectomy (PPV) and penetrating keratoplasty (PKP) using a wide-field Landers intraoperative temporary keratoprosthesis (TKP) in patients with vitreoretinal pathology and corneal opacity due to severe ocular trauma. Material and Methods. Medical records of 12 patients who had undergone PPV/PKP/KP due to severe eye trauma were analyzed. Functional (best-corrected visual acuity) and anatomic outcomes (clarity of the corneal graft, retinal attachment, and intraocular pressure) were assessed during the follow-up (mean 16 months). Results. Final visual acuities varied from NLP to CF to 2 m. Visual acuity improved in 7 cases, was unchanged in 4 eyes, and worsened in 1 eye. The corneal graft was transparent during the follow-up in 3 cases and graft failure was observed in 9 eyes. Silicone oil was used as a tamponade in all cases and retina was reattached in 92% of cases. Conclusions. Combined PPV and PKP with the use of wide-field Landers TKP allowed for surgical intervention in patients with vitreoretinal pathology coexisting with corneal wound. Although retina was attached in most of the cases, corneal graft survived only in one-fourth of patients and final visual acuities were poor.

Pediatric open globe injury: A review of the literature

Open globe injury (OGI) is a severe form of eye trauma estimated at 2-3.8/100,000 in the United States. Most pediatric cases occur at home and are the result of sharp object penetration. The aim of this article is to review the epidemiology, diagnosis, management, and prognosis of this condition by conducting a systematic literature search with inclusion of all case series on pediatric OGI published between 1996 and 2015. Diagnosis of OGI is based on patient history and clinical examination supplemented with imaging, especially computed tomography when indicated. Few prospective studies exist for the management of OGI in pediatric patients, but adult recommendations are often followed with success. The main goals of surgical management are to repair the open globe and remove intraocular foreign bodies. Systemic antibiotics are recommended as medical prophylaxis against globe infection, or endophthalmitis. Other complications are similar to those seen in adults, with the added focus of amblyopia therapy in children. Severe vision decline is most likely due to traumatic cataracts. The ocular trauma score, a system devised to predict final visual acuity (VA) in adults, has proven to be of prognostic value in pediatric OGI as well. Factors indicating poor visual prognosis are young age, poor initial VA, posterior eye involvement, long wound length, globe rupture, lens involvement, vitreous hemorrhage, retinal detachment, and endophthalmitis. A thorough understanding of OGI and the key differences in epidemiology, diagnosis, management, and prognosis between adults and children is critical to timely prevention of posttraumatic vision loss early in life.

Automated Perimetry and Visual Dysfunction in Blast-Related Traumatic Brain Injury

PURPOSE

To evaluate feasibility and results of automated perimetry in veterans with combat blast neurotrauma.

DESIGN

Prospective, longitudinal, observational case series.

PARTICIPANTS

Sixty-one patients in a Veterans Affairs Polytrauma Center diagnosed with traumatic brain injury (TBI) from combat blast exposure.

METHODS

Study participants underwent automated perimetry at baseline (median interval, 2 months after injury) (Humphrey Field Analyzer, Carl Zeiss Meditec, Dublin, CA, Swedish Interactive Threshold Algorithm 30-2 Standard or Fast), and 36 of them were followed up (median interval, 10 months after baseline). Presence of significant mean deviation and pattern standard deviation was determined for testing with reliability indices ≤20% for fixation loss, 15% for false-positives, and 33% for false-negatives. Test-retest stability of global visual field indices was assessed for tests with these cutoffs or with elevated fixation loss. Associations between global visual field defects and predictors were examined.

MAIN OUTCOME MEASURES

Global visual field indices (mean deviation and pattern standard deviation).

RESULTS

Among 61 study participants (109 study eyes) with baseline testing, a field that met reliability cutoffs was obtained for 48 participants (79%) and 78 eyes (72%). Fixation loss was found in 29% of eyes in initial testing. Nine study participants (15%) demonstrated hemianopia or quadrantanopia, and an additional 36% had an abnormal global visual field index. Global indices were relatively stable at follow-up testing for tests meeting fixation-loss cutoffs and tests that did not. Visual scotomas due to post-chiasmal lesions were associated with moderate to severe TBI or penetrating head injury, but other visual field deficits were prevalent across the range of mild to severe TBI. Ocular injury to the retina or choroid, poorer visual acuity, and pupillary defect were associated with visual field defects. Participants with depressed visual field sensitivity reported lower visual quality of life.

CONCLUSIONS

Reliable automated perimetry can be accomplished in most patients with TBI from combat blast exposure and reveals high rates of visual field deficits, indicating that blast forces may significantly affect the eye and visual pathways.

Impact of surgeon subspecialty training on surgical outcomes in open globe injuries

Purpose

The purpose of this study was to evaluate whether subspecialty training of the initial treating surgeon affects visual acuity and surgical outcomes in patients with open globe injuries.

Design

This study is a single-institution, retrospective case series.

Methods

The charts of adult patients with open globe injuries requiring surgical repair at the Wilmer Eye Institute between July 1, 2007 and July 1, 2012 were retrospectively reviewed. Clinical findings at presentation were recorded, and details of initial repair and follow-up surgeries were analyzed. Differences in visual acuity and surgical outcomes were compared based on subspecialty training of the initial surgeon.

Results

The charts of 282 adult patients were analyzed, and 193 eyes had at least 6 months of follow-up for analysis. Eighty-six eyes (44.6%) required follow-up surgery within the first year, and 39 eyes (20.2%) were enucleated. Eyes initially treated by a vitreoretinal (VR) surgeon were 2.3 times (P=0.003) more likely to improve by one Ocular Trauma Score (OTS) visual acuity category and 1.9 times (P=0.027) more likely to have at least one more follow-up surgery at 6 months compared to eyes treated by non-VR surgeons. Patients with more anterior injuries treated by a VR surgeon were more likely to improve by one OTS visual acuity category compared to those treated by non-VR surgeons (P=0.004 and 0.016 for Zones I and II, respectively). There was no difference in visual acuity outcomes for eyes with posterior injuries (P=0.515 for Zone III).

Conclusion

Eyes initially treated by a VR surgeon are more likely to improve by one OTS visual acuity category than those initially treated by a non-VR surgeon. However, patients initially treated by a VR surgeon also undergo more follow-up surgical rehabilitation, and improvement in visual acuity is more likely for anterior (Zone I and II injuries) than posterior (Zone III) injuries.

Clinical features and outcomes of vitrectomy in pediatric ocular injuries-eye injury vitrectomy study

Context:

Severe pediatric ocular injury remains a frequent and difficult problem. Vitrectomy is a major technique that has been used to manage severely damaged eyes. However, limited follow-up studies exist currently.

Aims:

To evaluate the clinical features and predictive factors of visual and anatomic outcomes in Eye Injury Vitrectomy Study (EIVS).

Settings and Design:

Retrospective, consecutive, interventional case series.

Materials and Methods:

Reviewing and analyzing records of children, aged 15 years or younger, who had undergone vitrectomy for eye injuries in EIVS database between January 1997 and December 2009.

Statistical analysis used:

Descriptive analyses and multiple Logistic regressions were employed for all variables using SPSS software (version 17.0, SPSS Inc.).

Results:

Eighty-seven children (89 eyes) with more than 6 months follow-up and complete records identified in EIVS were included in this study. Average follow-up was 12.7 months. The mean age was 9.4 ± 3.8 years. Seventy-seven eyes (86.5%) had open globe injuries, and 12 (13.5%) had closed globe injuries. Seventeen eyes (19.3%) presented with endophthalmitis. Seventy-five eyes (88.2%) presented with visual acuity of 4/200 or worse; however, 42 eyes (47.7%) achieved 4/200 or better vision with anatomical restoration after vitrectomy. Multiple analysis showed that choroidal damage, large scleral wound, and endophthalmitis were significantly associated with unfavorable outcome, the OR values were 16.7 (95% CI: 2.7-102.4, P = 0.002), 10.9 (95% CI: 1.7-71.6, P = 0.013), and 6.6 (95% CI: 1.0-42.4, P = 0.048), respectively.

Conclusions:

Vitrectomy intervention resulted in favorable visual and anatomic outcomes in almost half of the injured eyes. Choroidal damage, large scleral wound, and endophthalmitis were the prognostic indicators of unfavorable outcome.

Incidence and risk factors for traumatic intraocular pressure elevation and traumatic glaucoma after open-globe injury

PURPOSE

To examine traumatic intraocular pressure (IOP) elevation and glaucoma after open-globe injury.

DESIGN

Retrospective, observational case series.

METHODS

Review of patients with open-globe repair at the University of Washington from May 1997 through July 2010. Traumatic IOP elevation and glaucoma were defined respectively as intraocular pressure (IOP) ≥22 mm Hg at >1 visit or need for glaucoma medication, and long-term (at least 3 months) glaucoma medication use or glaucoma surgery.

RESULTS

We included 515 eyes (515 patients). The mean follow-up was 12.6±20.1 months. One hundred twenty eyes (23.3%) developed traumatic IOP elevation, of which 32 (6.2%) developed glaucoma; six eyes (1.2%) required glaucoma surgery. The mean time to development of traumatic IOP elevation was 1.5±3.4 months (range 1 day to 2 years). Kaplan-Meier 6- and 12-month estimates for development of traumatic IOP elevation were 27.2 and 32.4%, respectively, and for development of traumatic glaucoma were 7.1 and 11.0%, respectively. Multivariate regression revealed associations between traumatic IOP elevation and older age, and traumatic glaucoma and prior penetrating keratoplasty, initial vitreous hemorrhage, Zone II injury, and penetrating keratoplasty after open-globe repair. Traumatic glaucoma was controlled (IOP <22 mm Hg) in 78.1% of eyes at final follow-up, with mean IOP of 18.2 mm Hg on 1.7 medications.

CONCLUSIONS

Traumatic IOP elevation and glaucoma were common after visually salvageable open-globe injury. Most cases developed within 6 months, although longer follow-up remains important for case detection. Penetrating keratoplasty before or after repair, and vitreous hemorrhage were notable risk factors.