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

Vitreoretinal surgery in the management of war-related open-globe injuries

BACKGROUND

Ranking among the most severe combat damages, war-related open-globe injuries (WROGIs) are not uniform, so the treatment approaches are sometimes unclear. The essential issue is to define exact indications for time- and resource-intensive vitreoretinal surgery (VRS), known to be an effective procedure for severe posterior segment injuries. We studied WROGI structure, and summarized the experience of specialized ophthalmologic care (SOC) management during local armed conflicts (LACs).

METHODS

This was a retrospective multicenter study that included case series of 203 wounded subjects (314 eyes) with WROGIs sustained during LACs treated in the hospitals of first, second and third echelons of SOC. Ocular trauma was classified according to the International Society of Ocular Trauma (ISOT) classification, and only open-globe injuries (OGI) made up two groups of study: injured eyes that underwent VRS, n = 135, and those eyes on which VRS was not performed, n = 119. Two subgroups according to stages of VRS were also included. We reviewed the demographic characteristics, the time between injury and surgery, the number of stages in which surgery was performed, and initial visual acuity (IVA) at arrival and final visual acuity (FVA), 12 months after surgery.

RESULTS

WROGI constituted 65.1 % of all eyes injured. The visual outcomes after VRS were favorable in ruptures of the eye, penetrating WROGIs, intraocular foreign body (IOFB) WROGIs, perforating WROGIs (types A, B, C, D) of grades 1-4. Those WROGIs of grade 5 had poor visual outcomes irrespective of the surgeries. In 19.1% of all cases wherein either the eye wall or eye content were extensively damaged (included types A, C, D, E of grade 5), all attempts to save the eye through reconstructive surgery were unsuccessful and led to enucleation (evisceration).

CONCLUSIONS

Medical service management in LACs demands to define groups of priority for VRS between the wounded with WROGI during triage at the first echelon of SOC. Multistage VRS determines unfavorable outcomes of the WROGI. Treatment should be determined by diagnosis, and there is a need to introduce a new category into the OGI classification--eye destruction, because only this damage determines the choice of enucleation/evisceration of the eye.

Twelve-year review of pediatric traumatic open globe injuries in an urban U.S. population

PURPOSE

To evaluate the epidemiology, anatomical characteristics, and clinical outcomes of pediatric traumatic open globe injuries and to compare the observed final visual acuity to the expected visual acuity as predicted by the Ocular Trauma Score (OTS).

METHODS

Retrospective chart review of 89 pediatric patients (89 eyes) with open globe injury presenting between 1997 and 2008.

RESULTS

Sixty-five patients (73%) were male, average age was 9.7 years, and mean follow-up was 22.6 months. The most common causes of trauma were: accidents (79%), violence (10%), and motor vehicle accidents (9%). Penetrating ocular injury was the most common trauma (54%), followed by blunt rupture (34%). Zone 1 injuries represented 49% of cases, and zones 2 and 3 represented 29% and 21%, respectively. No patient developed endophthalmitis. The average presenting and final visual acuities were logarithm of the minimum angle of resolution 1.927 and 1.401, respectively. Lens trauma was noted in 44 (49%) eyes. Twenty-eight patients (31%) had retinal detachment within 6 months of presentation. Total retinal attachment was achieved in 12 (63%) of 19 eyes undergoing repair. Enucleation was performed in 9 (10%) patients. Final visual acuities were not statistically different from visual acuities predicted by OTS (P > .05).

CONCLUSIONS

The visual prognosis in pediatric open globe injury is poor. The zone of injury may correlate with poor final visual acuity, risk of retinal detachment, and subsequent need for an enucleation. The final predicted visual acuity correlated well with the observed final visual acuity in these patients.

Case-control study of risk factors for no light perception after open-globe injury: eye injury vitrectomy study

PURPOSE

Investigate possible risk factors of no light perception (NLP) after open-globe injury. Explore whether these risk factors are predictors for an unfavorable visual outcome.

METHODS

This case-control study matched 72 eyes with NLP according to type and zone of injury to 2 controls per case with light perception or better vision. Cases were selected from the Eye Injury Vitrectomy Study database. All injured eyes in the study underwent surgical intervention.

RESULTS

Ciliary body damage (odds ratio = 2.94), closed funnel retinal detachment (odds ratio = 2.43), and choroidal damage (odds ratio = 2.80) were independent risk factors for NLP after open-globe injury. There were 67 traumatized eyes with NLP that had ≥1 of these risk factors. In 43 of the cases (64.2%), the eyes recovered light perception or better after vitreoretinal surgery. The five traumatized NLP cases without these risk factors obtained a favorable visual outcome after vitreoretinal surgery. There was no statistical significance in visual outcome between them (P = 0.162).

CONCLUSION

Ciliary body damage, closed funnel retinal detachment, and choroidal damage are independent risk factors for NLP posttrauma but not prognostic indicators for NLP visual outcome. Traumatized eyes with NLP may recover light perception or better vision if appropriate interventional measures are used for treatment of the injured ciliary body, retina, and choroid.

Prognostic factors influencing final visual acuity in open globe injuries

BACKGROUND

To investigate the factors that influence final visual acuity (VA) in open globe injuries.

METHODS

The records of patients with open globe injuries who were followed for longer than 6 months between 1998 and 2009 in two different centers were retrospectively reviewed. The data collected included patients' demographics as well as their initial VA, wound location, mechanism and type of injury, clinical findings, and final best-corrected VA. Statistical analysis was conducted using univariate analysis and multiple logistic regression analysis.

RESULTS

Of 313 patients, 73.2% were men, and the mean age was 32.01 years ± 21.04 years. Penetrating injury was the most common type of injury. Of 313 injuries, 212 were caused by sharp/projectile objects, and injuries most commonly occurred in the workplace. In a univariate analysis, the factors contributing to a final VA worse than 20/200 included being older than 50 years, injury in zone 2 or 3, blunt injury, rupture-type injury, poor initial VA, and the presence of endophthalmitis, retinal detachment, relative afferent papillary defect, hyphema, vitreous prolapse, and uveal prolapse. In a multiple logistic regression analysis in which all factors that may influence final VA were analyzed together, poor initial VA, retinal detachment, and vitreous prolapse were found to be statistically significant.

CONCLUSION

In this retrospective study, the most important factors influencing final VA were initial VA, retinal detachment, and vitreous prolapse, all of which are important with regard to informing the patient of the prognosis and determining the approach the physician will take.

Prevalence and incidence of ocular trauma in North China: the Beijing Eye Study

PURPOSE

To determine the prevalence and incidence of ocular trauma and proportion of trauma-related visual impairment in the population of Greater Beijing.

METHODS

The population-based Beijing Eye Study included 4439 subjects in 2001, of whom 3251 subjects returned for follow-up examination in 2006 (response rate: 73.3%). The subjects underwent a comprehensive ocular evaluation. Prospective information on ocular trauma and type of treatment was recorded with questionnaires in face-to-face interviews.

RESULTS

A history of ocular trauma was reported by 72 (1.6 ± 0.2%) subjects (age-standardized prevalence: 1.7 ± 0.01%). Prevalence of ocular trauma history was associated with male gender (p = 0.02), rural residence (p = 0.04) and alcohol consumption (p = 0.01). Trauma as underlying cause for visual impairment (best-corrected visual acuity < 20/60 and ≥ 20/400) was found in 4 (6.6%) eyes and as underlying cause for blindness (best-corrected visual acuity <20/400) in three eyes (4.2%). In the survey of 2006, 116 (3.6 ± 0.3%) participants had a self-reported history of ocular trauma, which was associated with male gender (p = 0.002), low income (p = 0.01) and alcohol consumption (p = 0.016). The 5-year incidence of ocular trauma was 2.6 ± 0.3%, which was associated with male gender (p = 0.02), younger age (p = 0.037) and lower income (p = 0.009).

CONCLUSIONS

In the adult population of Greater Beijing with an age of 40+ years, the prevalence of ocular trauma was 1.6 ± 0.2% and was associated with male gender, rural residence and alcohol consumption. The age-standardized ocular trauma prevalence of 1.7 ± 0.01% was comparable with figures from Caucasian populations. The 5-year incidence of ocular trauma of 2.6 ± 0.3% was associated with male gender, younger age and lower income.

Ophthalmic Evaluation and Management of Traumatic Accidents Associated with Retinal Breaks and Detachment: A Retrospective Study

Purpose

This retrospective study reviews a group of patients with retinal breaks or retinal detachment following ocular trauma.

Methods

A total of 94 patients were included in the study. They underwent closed globe injuries causing multiple retinal breaks or retinal detachment at time of presentation in the emergency department. Analysis concerned epidemiologic, clinical, and therapeutic aspects, both in short-term (1 and 3 months) and long-term (6-12 months) follow-up.

Results

A total of 85% of patients were male, involved in work-related injuries, and complaining visual function decrease. Retinal breaks were mostly singular, U-shaped, and located in the upper temporal quadrant. At presentation, visual acuity ≥5/10 and Ocular Trauma Score of 4 were the most represented. Fifty-eight patients (61.70%) underwent repair within 48 hours of the trauma, 27 (28.73%) within 7 days, and 9 (9.57%) more than 7 days after trauma. Procedures performed were photocoagulation with argon laser (52%), episcleral buckle (34.45%), or vitrectomy associated with episcleral buckle and intraoperative argon laser (13.55%). A total of 92% of patients treated within 48 hours had better or unchanged visual acuity in 6-12 months of follow-up. All patients treated more than 7 days after trauma had worse visual acuity (p<0.01 with Student t test).

Conclusions

Detailed clinical history, well-done preoperative examination, early diagnosis, and prompt parasurgical or surgical repair are significant prognostic factors for better visual outcome and lower incidence of relapse.

Epidemiological characteristics and visual outcome after open globe injuries in children

PURPOSE

To determine demographic, etiologic, clinical characteristics, visual outcome, and the factors affecting visual prognosis in children with open globe injuries.

METHODS

The medical records of 82 patients under the age of 16 years who presented with open globe injuries from January 1998 to January 2009 were retrospectively examined. Age, sex, involved eye, cause, place of injury, wound location, presenting visual acuity, clinical signs, and final visual acuity were noted. The injuries were classified by Ocular Trauma Classification Group Guidelines and Birmingham Eye Trauma Terminology.

RESULTS

Most injuries occurred in boys (54/82). The mean age was 8.4 ± 3.7 years. Most patients (37.8%) were in the 3- to 6-year age group. All patients had a minimum of 6 months' follow-up (mean, 23.9 ± 23.2 months; range, 6-114). Pointed metallic objects were found to be the main causative agents. Injuries occurred most frequently in streets (36.3%), homes (18.7%), leisure areas (15.4%), and schools (7.7%). Factors adversely affecting visual prognosis were poor presenting visual acuity, posterior wound location, low ocular trauma score, retinal detachment, afferent pupillary defect, vitreous prolapse, uveal tissue prolapse, and hyphema.

CONCLUSIONS

Open globe injuries in children occur most frequently in preschool boys. Prognosis is determined by presenting visual acuity, trauma score, and wound severity and location.

An overview of penetrating ocular trauma with retained intraocular foreign body

Penetrating trauma is one of the common causes of ocular morbidity world wide. Violation of the globe integrity, also known as a ruptured globe is an ocular emergency that universally threatens vision. Prompt recognition and management is prudent. Here we report a case of a 26-year-old-female, university teacher, who presented with pain and sudden loss of vision in the left eye of 2 h duration subsequent to a test tube blast in the chemical laboratory. Examinations revealed a ruptured globe with vitreous haemorrhage and an intraocular glass foreign body in the left eye. Primary repair was done with good post operative visual recovery. We report this case to emphasize that protective measures should be taken to prevent such eye traumas.

Prognostic indicators for no light perception after open-globe injury: eye injury vitrectomy study

PURPOSE

To describe ocular characteristics, surgical interventions, and anatomic and visual outcomes of traumatized eyes with no light perception (NLP) following open-globe injury and to investigate prognostic predictors for NLP cases after open-globe injury.

DESIGN

Interventional case series study.

METHODS

Thirty-three traumatized eyes with NLP were selected from the Eye Injury Vitrectomy Study database, a hospital-based multicenter prospective cohort study. Inclusion criteria were NLP cases following open-globe injury with outcomes of anatomic restoration, phthisis bulbi, or enucleation. Exclusion criteria were cases with missing records, undergoing vitrectomy after injury at nonparticipating hospitals, direct optic head injury, endophthalmitis, and hypotonous or silicone oil-sustained eyes. All cases underwent vitreoretinal surgery or enucleation after exploratory surgery and were followed up for at least 6 months. Two outcomes were assessed: favorable outcome (anatomically restored eye globes with light perception [LP] or better vision) and unfavorable outcome (NLP, phthisis bulbi, or enucleation).

RESULTS

The following 7 risk factors were significant between the 2 groups: rupture (P = .021); open globe III (P = .046); scleral wound ≥10 mm (P = .001); ciliary body damage (P < .001); severe intraocular hemorrhage (P = .005); closed funnel retinal detachment or retinal prolapse (P = .005); and choroidal damage (P = .001).

CONCLUSIONS

These 7 risk factors are possible predictors of poor prognosis. Traumatized eyes with NLP can be anatomically restored with LP or better vision if vitreoretinal surgery is attempted, and a favorable anatomic and visual outcome is increased by having a decreased number of these risk factors.

Ocular injuries from improvised explosive devices

PURPOSE

To document the characteristics, treatments, and anatomical and functional outcomes of patients with ocular trauma from improvised explosive devices (IEDs).

METHODS

Retrospective review of ocular injuries caused by IEDs, admitted to our tertiary referral centre.

RESULTS

In total, sixty-one eyes of the 39 patients with an average age of 24 years (range, 20-42 years) were included in the study. In total, 49 (80%) eyes of the patients had open-globe and 12 (20%) had closed-globe injury. In eyes with open-globe injury, intraocular foreign body (IOFB) injury was the most frequently encountered type of injury, observed in 76% of eyes. Evisceration or enucleation was required as a primary surgical intervention in 17 (28%) of the eyes. Twenty-two (36%) eyes had no light perception at presentation. Patients were followed up for an average of 6 months (range, 4-34 months). At the last follow-up, 26 (43%) of 61 eyes had no light perception. Postoperative proliferative vitreoretinopathy (PVR) developed in 12 (50%) of the 24 eyes that underwent vitreoretinal surgery, and four of these eyes became phthisical. There were no cases of endophthalmitis. The presence of open-globe injury and presenting visual acuity worse than 5/200 were significantly associated with poor visual outcome (<5/200, P<0.05). In eyes with open-globe injury, the presence of an IOFB was not associated with poor visual outcome (P>0.05).

CONCLUSION

Ocular injuries from IEDs are highly associated with severe ocular damage requiring extensive surgical repair or evisceration/enucleation. Postoperative PVR is a common cause of poor anatomical and visual outcome.

Clinical pattern of pediatric ocular trauma in fast developing country

BACKGROUND

Ocular trauma is a significant problem in pediatric patients. Also, leads to visual loss throughout the world there are no data of pediatric ocular trauma in Arabian Gulf Countries in the current literature.

AIM

To study the epidemiology, mechanism, causes and outcome of serious ocular trauma requiring hospital admission, in children below 16years of age.

STUDY DESIGN

A retrospective cohort study.

SUBJECTS

All pediatric patients (up to 16years of age) presenting with ocular injuries to a tertiary care pediatric ophthalmology and Pediatric Accident Emergency Department 1 January 2005 to 30 December 2009.

METHODS

Each file was studied to find out the demographic data, mechanism and cause of injury. The definitions and classifications of ocular trauma in our study were modified from the Ocular Trauma Classification Group guidelines and Birmingham Eye Trauma Terminology Presenting and final visual acuity were recorded along with details of anterior and posterior segment evaluation.

RESULTS

Hundred and six files of the children admitted to ophthalmology ward with the diagnosis of ocular trauma between 2005 and 2009 were reviewed. Majority were boys (77.4%). The mean age at admission was 6.63years. A higher incidence of ocular trauma was noted in children above 5years than those below (58.5%). Most number of trauma occurred at home (42.5%, n=45) followed by street (35.8% n=34), school (12.3%, n=13), sporting area (5.7%, n=6). Also, eight patients (8.5%) involved in Road Traffic Accidents (RTA). Closed globe injury occurred more frequently than open globe injury (59.4% vs. 40.6%). Initial visual acuity was more than 6/60 in (55.6%) patients of closed globe while in open globe injury was (37.3%). Final visual acuity was more than 6/18 in (82.5%) patients of closed globe injury group and in (63%) patients of open globe injury group. Severe impairment of vision was found in (11.6%) and blindness (4.7%) only in open globe injury group.

CONCLUSION

Most eye injuries in children are preventable so this reflects the importance of health education, adult supervision and application of appropriate measures that is necessary for reducing the incidence and severity of trauma.

Anatomical and functional outcomes in contusion injuries of posterior segment

PURPOSE

To evaluate the clinical features, and anatomical and visual outcomes in patients with closed-globe contusion injury involving the posterior segment.

METHODS

Retrospective review of posterior segment contusion injuries admitted to our tertiary referral center.

RESULTS

In all, 115 patients (115 eyes) with complete data were reviewed. Surgery had been performed in 79 (69%) patients. The mean follow-up period was 6 months (range, 2-34 months). Retinal detachment, in 31% of eyes, was the most frequently encountered posterior segment pathology. The presence of retinal detachment was associated with poor visual outcome (<20/100), (P<0.001). Coexisting (five patients, 4%) and postoperative proliferative vitreoretinopathy (PVR) (two patients, 2%) was the main cause of failure in these cases. A significant positive correlation was obtained between initial and final visual acuity levels in both the medical treatment group and the surgical treatment group (P<0.05). The presenting visual acuity of <20/400 was associated with poor visual outcome (P<0.05 for both groups). Poor visual outcome in 13 patients with successful repair of retinal detachment was due to the macular lesions and the optic atrophy.

CONCLUSION

Retinal detachment was the most frequently encountered posterior segment pathology subsequent to closed-globe contusion injuries. In addition to macular scarring and optic nerve damage, development of PVR has prognostic significance in these eyes.

Epidemiology of penetrating eye injury in ibadan: a 10-year hospital-based review

PURPOSE

To assess risk factors associated with the occurrence of penetrating ocular injuries among patients presenting to an eye hospital at Ibadan, Nigeria.

MATERIALS AND METHODS

All cases of penetrating ocular injury presenting over a 10 - year period, were identified by retrospective chart review. All current cases of penetrating ocular injury identified were included. All information was obtained retrospectively from the medical records.

RESULTS

The cohort consisted of 135 cases. The follow-up was for an average period of 24.6 weeks (range, 12-312 weeks). Injuries were most likely to occur at home, in a domestic setting (58%). The most common mechanism of injury was projectile missiles hitting the eye. The age range for injuries was 9 months to 70 years. Penetrating ocular injury was most frequent in the 20-29 years group (31.9%) followed by the 0-9 years age group (31.1%). Males were more frequently involved than females (ratio 4:1). The final acuity was better than 6/18 in 14.8% and less than 3/60 in 59.3% of cases.

CONCLUSIONS

Penetrating ocular injury occurs, most frequently, in a domestic setting and mostly as a result of working with sharp objects. Preventive measures are recommended to reduce visual disabilities due to ocular injuries.

A new ocular trauma score in pediatric penetrating eye injuries

PURPOSE

To assess the prognostic value of a new ocular trauma score (OTS) in pediatric penetrating injuries.

METHODS

Children ≤ 15 years of age that presented to the emergency room with penetrating eye injuries between April 2007 and August 2008 were evaluated prospectively. All patients were reviewed on the basis of age, gender, time of injury and how it happened, time of admission, time of surgery, type of penetrating injury, initial and final visual acuity (VA), and concomitant eye pathology. Injuries were classified based on a new OTS, and we assessed the relationship with final VA and the new OTS.

RESULTS

In total, 30 eyes in 29 patients (41.38% female, 58.62% male) with a mean age of 6.83 ± 4.00 years (range: 1-15 years) were included in the study. Initial VA, which was evaluated in 22 patients, was as follows: no light perception (NLP) in 2 (9.09%) patients, light perception (LP) to hand motion (HM) in 8 (36.36%) patients, counting fingers in 6 (27.27%) patients, 0.1-0.5 in 4 (18.18%) patients, and ≥ 0.6 in 2 (9.09%) patients. Final VA, which was evaluated in 27 patients, was as follows: NLP in 3 (11.11%) patients, LP to HM in 3 (11.11%) patients, counting fingers in 2 (7.41%) patients, 0.1-0.5 in 11 (40.74%) patients, and ≥ 0.6 in 8 (29.63%) patients. The relationship between initial VA and final VA was statistically significant (P < 0.001).

CONCLUSIONS

The new OTS calculated at initial examination may be of prognostic value in children with penetrating eye injuries.

Visual outcome after open globe injury and its predictive factors in Korea

BACKGROUND

To determine visual outcomes and prognostic factors of open globe injury in Korea and to assess the prognostic power of Ocular Trauma Score (OTS) model.

METHODS

The medical records of 194 consecutive patients (194 eyes) with open globe injury were reviewed. Data including demographics, mechanisms of injuries, wound sizes and locations, initial visual acuities, presence of intraocular damage and adjacent tissue injuries, and final visual acuities, which was defined as visual acuities at 1 year, after injury were collected and analyzed. Comparison of final visual acuities with those of the OTS study was also performed.

RESULTS

The study group consisted of 160 (82.5%) male and 34 (17.5%) female subjects. The average age was 38.2 ± 17.8 years (range, 2-91 years). One year after injury, visual acuity of light perception or better was attained in 78.4% of the patients, and 20/200 or better in 58.2%. In multivariate analysis, poor initial visual acuity, presence of retinal detachment and relative afferent papillary defect, and larger wound (>10 mm) were related to poor final visual acuities. Final visual acuities assessed using OTS categories were similar to those of OTS study in OTS category 3, 4, and 5, and more favorable in OTS category 1 and 2.

CONCLUSION

We have identified prognostic factors of open globe injury including initial visual acuity, presence of retinal detachment, relative afferent papillary defect, and wound length. OTS may have prognostic value in open globe injuries in Asian patients.

Ophthalmic injuries in British Armed Forces in Iraq and Afghanistan

AIM

British military ophthalmologists have not been deployed in support of operations since 2003. Eye injuries in British forces receive definitive treatment on return to the United Kingdom. We report the injury patterns, management strategies, and outcomes for eye injuries in British Armed Forces in Iraq and Afghanistan.

METHODS

Retrospective consecutive case series of eye injuries in British Armed Forces in Iraq or Afghanistan from July 2004 to May 2008. Outcomes assessed by final best-corrected visual acuity (VA; few patients lost to follow-up), rates of endophthalmitis, and proliferative vitreoretinopathy (PVR).

RESULTS

There were 630 cases of major trauma, 63 sustained eye injuries (10%), and 48 sustained significant eye injuries. There were 21 open-globe injuries: 9 ruptures and perforating injuries, of which 7 were enucleated/eviscerated; 11 intraocular foreign body (IOFB) injuries, of which 1 was eviscerated. Primary repair was combined with posterior segment reconstruction in 9/11 cases with IOFB. Mean time to primary repair was 1.9 days (range 0-5). Intravitreal antibiotics were given at primary repair in five cases. All cases received early broad-spectrum systemic antibiotics. Median final VA was logMAR 0.25 excluding evisceration/enucleations. There were two cases of PVR and none of endophthalmitis.

CONCLUSIONS

The number of eye injuries as a proportion of all casualties is lower than recently reported. The injuries are more severe than in civilian practise. The outcomes were comparable with previous reports, this demonstrates that, in certain cases, primary repair can be safely delayed beyond 24 h in the patient's best interests, in order to optimise the conditions for treatment.

Outcomes of vitreoretinal surgery in patients with closed-globe injury

PURPOSE

To evaluate the clinical features, visual outcomes, and prognostic factors in patients who underwent vitreoretinal surgery after closed-globe injury.

METHODS

Retrospective review of patients with closed-globe injuries who underwent vitreoretinal surgery between January 2003 and December 2007.

RESULTS

The study cohort included 46 eyes from 46 patients who underwent vitreoretinal surgery for posterior segment injury. Retinal detachment was the most frequent indication for the surgery, in 33 eyes (72%). After surgery, final visual acuity of 20/400 or better was achieved in 35 eyes (76%), while 11 eyes (24%) had visual acuity less than 20/400 (poor visual outcome). The most frequent reason for poor outcome was proliferative vitreoretinopathy (PVR) (6 eyes), followed by macular complications (3 eyes) and optic atrophy (2 eyes). Two cases with PVR became phthisical following repeated vitreoretinal procedures and also lost light perception. Prognostic factors associated with poor outcomes included delayed presentation, presenting visual acuity of less than 20/400, the presence of initial macular detachment, and the need for additional surgical intervention (p<0.05). No statistical difference was found in final visual acuity between eyes with or without retinal detachment (p>0.05). Also, the presence of damage to the anterior segment was not significantly associated with poor visual outcome (p>0.05).

CONCLUSIONS

In patients with posterior segment pathology caused by closed-globe trauma, retinal detachment was the most common reason for vitreoretinal surgery and PVR was the main cause of surgical failure. The poor visual outcomes associated with delayed presentation suggest that patients need to be referred for further management.

Descriptive study on ocular survival, visual outcome and prognostic factors in open globe injuries

A prospective observational study was done to assess ocular survival, visual outcome and prognostic factors of open globe injury. Eighty eyes of penetrating trauma between 2004 and 2006 were categorized according to the ocular trauma classification system. Primary repair was done and outcomes were assessed at one, three and six months. The final vision was categorized as per World Health Organization classification of visual impairment. Factors at presentation were evaluated for prognostic value towards visual outcome. Sixty-nine eyes with minimum one month follow-up were included for analysis. Statistical analysis was done using Univariate and Multivariate analysis. We found Grade IV visual acuity (<5/200) at presentation (64%) as the most important factor contributing to poor visual outcome. Statistically insignificant factors were time since injury, cataract, and presence of intraocular foreign body. Ocular survival was 97%. We concluded that initial visual acuity, hyphema, zone and length of injury, retinal detachment and vitreous hemorrhage are statistically significant factors affecting outcome in open globe injuries.

The influence of surgery and intraocular lens implantation timing on visual outcome in traumatic cataract

PURPOSE

To compare the visual outcome of primary versus secondary traumatic cataract extraction and primary versus secondary intraocular lens (IOL) implantation.

METHODS

The medical charts of consecutive patients who developed cataract following open and closed-globe injuries and were referred to our institute were reviewed. The best-corrected visual acuity of the patients who underwent primary and secondary cataract extraction and those with primary and secondary IOL implantation was assessed at presentation and at the end of the follow-up.

PARTICIPANTS

Sixty-nine eyes of 69 patients developed cataract after being involved in ocular trauma. Forty-five eyes had open-globe injury and 24 had closed-globe injury. The right eye was involved in 26 injuries and the left in 43.

RESULTS

Best-corrected visual acuity (BCVA) of 20/40 or better was not statistically associated with the type of cataract extraction (extracapsular versus phacoemulsification) (in open-globe injury p = 0.181 and in all p = 0.662) and placement of anterior or posterior IOL (in open-globe injury p = 0.196 and in all p = 0.114). The timing of surgery (as immediate surgery or later as a second surgery) and the timing of intraocular lens implantation (during the extraction of the cataract or later in a secondary procedure) were not statistically associated with BCVA of 20/40 or better (in open-globe injury p = 0.322 and 0.381 in all p = 0.460 and 0.450, respectively). Irreversible amblyopia in children was a statistically significant factor for this visual acuity both in patients with open-globe injury (p = 0.036) and in all patients (p < 0.001).

CONCLUSIONS

In traumatic cataract, the visual outcome did not differ between primary and secondary cataract extraction and between primary and secondary IOL implantation in adults. In the amblyogenic age, primary surgery with IOL implantation should be preferred.

Cataract surgery in the setting of trauma

PURPOSE

To review the changes in the surgical techniques used for cataract removal in the setting of trauma and their postoperative outcome.

RECENT FINDINGS

Primary cataract removal with intraocular lens (IOL) implantation is the commonly followed procedure for penetrating injuries with cataract. IOL implantation has evolved through various techniques namely 'in the bag', 'in the sulcus', epilenticular implantation, anterior chamber IOL, scleral fixated IOL and recently glued IOL.

SUMMARY

Certain lacerating injuries of the anterior segment are particularly amenable to cataract extraction and IOL implantation at the time of primary laceration repair. This approach obviates additional operative and anesthetic risks, while affording timelier visual rehabilitation. Secondary lens removal may also be indicated in cases of severe corneal injury and marked edema, which may interfere with intraocular visualization.

Chorioretinectomy for perforating or severe intraocular foreign body injuries

BACKGROUND

To report the outcomes of chorioretinectomy versus non-chorioretinectomy in combat ocular injuries where a foreign body penetrated the choroid or perforated the globe.

METHODS

Retrospective, comparative, consecutive interventional case series of 32 perforating or severe intraocular foreign body combat ocular trauma injuries sustained by United States military soldiers and treated at a single institution from March 2003 to March 2009. Final best-corrected visual acuity (BCVA) in 19 non-chorioretinectomy-treated eyes was compared to 13 chorioretinectomy-treated eyes. The chorioretinectomy group was repaired with a 20 gauge three-port pars plana vitrectomy (PPV) by removing the choroid and/or retina at the impact or perforation site of the foreign body following evacuation from a combat zone. The main outcome measures were best-corrected visual acuity and rates of globe survival, retina reattachment and proliferative vitreoretinopathy.

RESULTS

Thirty-two eyes of 31 patients with a mean age of 29 +/- 9 years (range, 19-53 years) were followed for a median of 463 +/- 226 days (range, 59-1022 days). The mean time of injury to the operating room in the chorioretinectomy group was 12.6 +/- 9.8 days, compared to that of the non-chorioretinectomy group of 22.1 +/- 16.4 days (P = 0.05) Final BCVA > or =20/200 occurred in seven of 13 (54%) of the chorioretinectomy group, compared to two of 19 (11%) in the non-chorioretinectomy group (P = 0.04). Globe survival rates were higher in the chorioretinectomy group [11 of 13 (85%) vs 9 of 19 (45%); P = 0.06], as well as the final retinal reattachment rate [8 of 13 (62%) vs 8 of 19 (42%); P = 0.47]. The proliferative vitreoretinopathy rate was eight of 13 (62%) in the chorioretinectomy group, compared to 14 of 19 (74%) in the non-chorioretinectomy group (P = 0.70). Graft failure occurred in five of six eyes (83%) of non-chorioretinectomy cases, requiring temporary keratoprosthesis and penetrating keratoplasty.

CONCLUSION

Chorioretinectomy is a surgical option that may improve final BCVA and increase globe survival rates when a foreign body penetrates the choroid or perforates the globe.

Intravitreal crystalline drug delivery for intraocular proliferation diseases

PURPOSE

A long-lasting, slow-release, crystalline antiviral drug delivery system was initially reported using ganciclovir and cyclic cidofovir as the prototype compounds. The present study was undertaken to investigate the feasibility of applying this system to antiproliferative small molecules.

METHODS

The crystalline lipid prodrugs of hexadecyloxypropyl-arabinofuranosylguanine 5'-monophosphate (HDP-P-AraG), hexadecyloxypropyl 5-fluoro-2'-deoxyuridine cyclic 3',5'-monophosphate (HDP-cP-5-F-2dUrd), and hexadecyloxypropyl 5-fluoro-2'-deoxyuridine 5'-monophosphate (HDP-P-5-F-2dUrd) were synthesized from their parent compounds arabinofuranosylguanine (AraG) and 5-fluoro-2'-deoxyuridine (5-F-2dUrd). All three compounds were tested at escalating doses in rabbit eyes. Only one eye of each animal was injected with test compound, and the fellow eye was injected with 5% dextrose as the control. The injected eyes were monitored by slit lamp, a handheld tonometer, indirect ophthalmoscopy, electroretinography (ERG), and histology. The selected doses were used for efficacy study with the rat CNV model or the rabbit PVR model.

RESULTS

The highest nontoxic dose for HDP-P-AraG was 75 microg/eye, and was 70 and 210 microg/eye for HDP-P-5-F-2dUrd and HDP-cP-5-F-2dUrd, respectively. All compounds demonstrated a localized depot of crystalline aggregate in the vitreous with a clear view of vitreous and retina elsewhere. The drug depot of HDP-P-AraG was visible for 4 to 5 weeks; HDP-P-5-F-2dUrd, 8 to 10 weeks; and HDP-cP-5-F-2dUrd longer than 14 weeks. The treatment study showed HDP-P-AraG led to 33% reduction in CNV in the rat (P = 0.015), and HDP-cP-5-F-2dUrd provided 100% prevention of trauma-induced PVR in the rabbit (P = 0.046). The pretreatment study demonstrated a significant protection against intraocular proliferation compared with the 5-FU in a parallel study (P = 0.014).

CONCLUSIONS

The intravitreous injectable lipid prodrugs of AraG and 5-fluoro-2'-deoxyuridine could be long-lasting, slow-release, antiproliferative compounds to treat unwanted intraocular proliferation.

Prognostic factors in posterior open globe injuries (zone-III injuries)

PURPOSE

The aim of this study is to describe and identify clinical characteristics, prognostic factors and visual outcome in a group of patients with posterior open globe injuries (zone III injury).

METHODS

A retrospective review was made of all cases of open globe injuries that were examined at the Ophthalmology Department of Soroka Medical Center, Beer-Sheva, Israel, from 1995 to 2005. One hundred and eight consecutive patients diagnosed with open globe injuries were reviewed. Of these, 21 eyes from 21 patients with zone III injuries were analysed and are the subject of this study. We assessed the relationship of presenting visual acuity, cause and extent of injury, as well as the number of surgical procedures, postoperative complications with the final outcome.

RESULTS

The study group comprised 95% male subjects with a mean age of 35.8 years (range 20-60 years). The median follow up was 21.2 months (range 6-66 months). In 72.7% of the cases metal was the causative factor. Clinical signs associated with an adverse outcome included poor-presenting acuity, eyelid injury, cornea lamellar lacerations or abrasions, iris deformity, lens damage, ocular hypotony, coexisting injuries and a low ocular trauma score. No cases presented with post-traumatic endophthalmitis.

CONCLUSIONS

From this study we determined the most important prognostic factor in zone III open globe injuries is the presenting acuity. Other prognostic factors associated with a poor final outcome are eyelid injury, iris deformity, lens damage, ocular hypotonia, coexisting injuries and low ocular trauma score (< or =2). Posterior open eye injuries were most commonly owing to metal entering the eyes of young men.

Traumatic brain injury associated with combat ocular trauma

PURPOSE

To determine the impact of traumatic brain injury (TBI) on visual outcomes in combat ocular trauma (COT) and determine the association between TBI severity and types of ocular injuries.

PARTICIPANTS

One hundred fifty-two US casualties sustained 207 globe/oculoplastic combat injuries.

METHODS

Retrospective, hospital-based cross-sectional study of US service members injured during Operations Iraqi Freedom and Enduring Freedom were treated by the Ophthalmology Service at Walter Reed Army Medical Center and screened for TBI by the Defense and Veterans Brain Injury Center from August 2004 to October 2006.

MAIN OUTCOME MEASURES

The main outcome measure was best-corrected visual acuity (BCVA). Secondary outcome measures included the severity and frequency of TBI with globe, oculoplastic, and/or neuro-ophthalmic injury.

RESULTS

The frequency of COT with positive TBI screening was 101 of 152 cases (66%) in comparison with negative TBI screening, which was 51 of 152 (34%) cases. The Defense and Veterans Brain Injury Center found TBI with concomitant ocular trauma in 101 of 474 (21%) consecutive casualties. Explosive fragmentary munitions accounted for 79% of TBI-associated COT. The median follow-up was 185 days. Traumatic brain injury severity did not correlate with worse final BCVA (Spearman coefficient, r = 0.12). The odds that BCVA worse than 20/200 was present with TBI was not statistically significant (OR: 1.5; 95% CI, 0.9-2.6; P = .10). The presence of TBI in COT was not associated with worse visual outcome (Mann-Whitney U test, P = .10). Globe injuries were more common than oculoplastic or neuro-ophthalmic injury. Closed-globe injuries were more likely to have TBI than open-globe injuries (OR: 2.17; 95% CI, 1.12-4.21; P = .03). Traumatic brain injury severity associated with COT included mild TBI (31%), moderate TBI (30%), severe TBI (25%), and penetrating TBI (14%). Severe TBI is more frequently associated with COT.

CONCLUSION

Traumatic brain injury occurs in two thirds of all COT and ocular trauma is a common finding in all TBI cases. Closed-globe injuries are at highest risk for TBI while TBI does not appear to lead to poorer visual outcomes. Every patient with COT needs TBI screening. Those service members who are screened TBI positive need a referral to a TBI rehabilitation specialist.

Penetrating needle injury of the eye

This retrospective case series reviews the characteristics, complications and epidemiology of penetrating needle eye injury treated at a referral eye centre in Tehran, over 5 years. The medical records of 27 patients were evaluated. Mean age of patients was 17.41+/-18.69 years; 63% were less than 12 years old. Accident was the cause of 61.5% of injuries, and 55% of injuries occurred at home. Endophthalmitis ensued in 22.2% and cataract in 51.9% of cases. Pars plana vitrectomy was performed for 25.9% of patients. There was no association between endophthalmitis and iris prolapse, zonal involvement, vitreous haemorrhage, traumatic cataract or visual acuity >20/200 on admission, but endophthalmitis was associated with absence of hyphaema at presentation. Families and children should be educated about the dangers of needles.

Scheimpflug imaging of pediatric posterior capsule rupture

We report a case of an 11-year-old boy who presented two days after blunt trauma to the left eye with a slingshot. On examination his best corrected visual acuity (BCVA) was 20/20 in the right eye and 20/400 in the left eye. Slit-lamp examination of the left eye revealed a Vossius ring, traumatic cataract, traumatic posterior capsule tear (PCT). The contour of the posterior capsule bulge corresponded to the edges of the PCT. Rotating Scheimpflug imaging (Pentacam 70700:Oculus, Wetzlar Germany) confirmed the traumatic cataract in the region of the PCT visualized as increased lens density at the cortex-vitreous interface. The extent of the PCT in the greatest and least dimensions was documented before and after intraocular lens (IOL) implantation. Intra-operatively, the PCT was evident and phaco-emulsification with an IOL implant was performed. Postoperatively, his BCVA improved to 20/20 in the left eye with a well-centered in-the-bag IOL as found on slit-lamp and Scheimpflug images.

Ocular Trauma Score in childhood open-globe injuries

BACKGROUND

To assess prognostic value of the Ocular Trauma Score (OTS) in childhood open-globe injuries.

METHODS

This retrospective, interventional case series included 61 children with open-globe injuries. Certain numerical values rendered to the OTS variables (visual acuity, rupture, endophthalmitis, perforating injury, retinal detachment, afferent pupillary defect) at presentation were summated and converted into OTS categories; the likelihood of the final visual acuities in the OTS categories were calculated, and compared with those in the OTS Study.

RESULTS

Age ranged from 3 years to 14 years (mean, 8.0 years). Forty-two boys and 19 girls were included. Follow-up ranged from 6 months to 56 months (mean, 18 months). The likelihood of the final visual acuities (no light perception, light perception/hand motion, 1/200-19/200, 20/200-20/50, and > or = 20/40) in the OTS categories (1 through 5) in this group were similar to those in the OTS Study group.

CONCLUSIONS

OTS calculated at initial examination may provide prognostic information in children with open-globe injuries.

Combat ocular trauma visual outcomes during operations iraqi and enduring freedom

OBJECTIVE

To report the visual and anatomic outcomes as well as to predict the visual prognosis of combat ocular trauma (COT) during Operations Iraqi and Enduring Freedom.

DESIGN

Retrospective, noncomparative, interventional, consecutive case series.

PARTICIPANTS

Five hundred twenty-three consecutive globe or adnexal combat injuries, or both, sustained by 387 United States soldiers treated at Walter Reed Army Medical Center between March 2003 and October 2006.

METHODS

Two hundred one ocular trauma variables were collected on each injured soldier. Best-corrected visual acuity (BCVA) was categorized using the ocular trauma score (OTS) grading system and was analyzed by comparing initial and 6-month postinjury BCVA.

MAIN OUTCOME MEASURES

Best-corrected visual acuity, OTS, and globe, oculoplastic, neuro-ophthalmic, and associated nonocular injuries.

RESULTS

The median age was 25+/-7 years (range, 18-57 years), with the median baseline OTS of 70+/-25 (range, 12-100). The types of COT included closed-globe (n = 234; zone 1+2, n = 103; zone 3, n = 131), open-globe (n = 198; intraocular foreign body, n = 86; perforating, n = 61; penetrating, n = 32; and rupture, n = 19), oculoplastic (n = 324), and neuro-ophthalmic (n = 135) injuries. Globe trauma was present in 432 eyes, with 253 eyes used for visual acuity analysis. Comparing initial versus 6-month BCVA, 42% of eyes achieved a BCVA of 20/40 or better, whereas 32% of eyes had a BCVA of no light perception. Closed-globe injuries accounted for 65% of BCVA of 20/40 or better, whereas 75% of open-globe injuries had a BCVA of 20/200 or worse. The ocular injuries with the worst visual outcomes included choroidal hemorrhage, globe perforation or rupture, retinal detachment, submacular hemorrhage, and traumatic optic neuropathy. Additionally, COT that combined globe injury with oculoplastic or neuro-ophthalmologic injury resulted in the highest risk of final BCVA worse than 20/200 (odds ratio, 11.8; 95% confidence interval, 4.0-34.7; P<0.0005). Nonocular injuries occurred in 85% of cases and included traumatic brain injury (66%) and facial injury (58%). Extremity injuries were 44% (170 of 387 soldiers). Amputation is a subset of extremity injury with 12% (46 of 387) having sustained a severe extremity injury causing amputation.

CONCLUSIONS

Combat ocular trauma has high rates of nonocular injuries with better visual outcomes in closed-globe compared with open-globe trauma. The OTS is a valid classification scheme for COT and correlates the severity of injury with the final visual acuity and prognosis. Globe combined with oculoplastic or neuroophthalmologic injuries have the worst visual prognosis.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Orbital foreign body penetrating from the cheek

This study emphasizes the importance of diagnostic first aid procedures to avoid the consequences of trauma due to foreign body. A 20-year-old man referred to our hospital with a history of having a sharp penetrating injury to his right eye. Computed tomography evaluation reported right globe perforation and intraorbital glass foreign body measuring 4 x 7 cm was removed. Perforated eye was repaired and traumatic cuts were sutured. Orbital and ocular injuries are common, and delays in management may lead to complication. A team approach is the best technique for these patients.