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

Corneal Opacity in the United States: An American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight) Study

PURPOSE

Vision loss associated with opacification of the cornea is one of the leading causes of blindness globally. However, the epidemiological data pertaining to the demographics, associated etiological causes and reduced vision in corneal opacity patients continue to be sparse. This study assesses the case frequencies, underlying etiologies, and vision outcomes in patients diagnosed with corneal opacity, in the United States.

DESIGN

Retrospective cohort study PARTICIPANTS: Patients in the IRIS® Registry (Intelligent Research in Sight) who were diagnosed with corneal opacity between January 1st, 2013, and November 30th, 2020.

METHODS

The IRIS Registry contains demographic and clinical data of 79,887,324 patients who presented to eye clinics during the study period. We identified patients with corneal opacity using International Classification of Disease (ICD) codes (ICD-9, and -10) of "371" (corneal scar) and "H17" (corneal opacity), respectively. The analyzed data included demographic parameters included age, sex, race, ethnicity, and geographical location. We evaluated clinical data including laterality, etiology, disease descriptors, and best-corrected visual acuity (VA) up to 1 year before the onset (± 30 days), at the time of diagnosis, and at one year following diagnosis (± 30 days).

MAIN OUTCOME MEASURES

Case frequencies, etiology, and vision outcomes in patients diagnosed with corneal opacity.

RESULTS

We identified 5,220,382 patients who were diagnosed with corneal opacity and scars using H17 (ICD-10) and 371.0 (ICD-9) codes over seven years. The case frequency of corneal opacity during the study period was 6,535 cases per 100,000 patients (6.5%). The mean age of the patients was 63.36±18.14 years and the majority were female (57.6%). In the cohort, 38.39% and 30.00% of patients had bilateral and unilateral corneal opacity, respectively. Most of the patients were White (69.13%), followed by Black or African American (6.84%), Asian (2.45%), American Indian or Alaska Native(0.34%), Native Hawaii or other Pacific Islander(0.19%). Among the patients with corneal opacity, 7.34% had Hispanic or Latino ethnicity. The primary etiologies associated with corneal opacity included corneal dystrophies (64.66%) followed by edema (18.25%), ulcer (7.78%), keratoconjunctivitis (7.18%), degeneration (5.62%), neovascularization (6.27%), and trauma (5.28%). Visual acuity of the patients significantly worsened due to corneal opacity (0.46±0.74 logMAR; ∼20/58 in Snellen) and did not improve to the baseline (0.37±0.68 logMAR, ∼20/46 in Snellen) post-management (0.43±0.77 logMAR, ∼20/54 in Snellen). The multiple linear regression analysis showed worse vision outcomes in females (compared to males), and Asian, Black or African American, and American Indian or Alaska Native (compared to White) patients. Additionally, worse vision outcomes were observed in patients with opacity associated with corneal malformation, degenerative disorders, edema, injury, and ulcer compared to those with hereditary corneal dystrophy.

CONCLUSIONS

Our study shows that the corneal opacity was diagnosed in 6.5% of the patients in the IRIS Registry and it was primarily associated with corneal dystrophies. The final vision outcomes in corneal opacity patients were significantly worse compared to baseline. The worse vision outcomes were associated with sociodemographic differences that might be associated with disparities in access, utilization, and care patterns.

All about traumatic cataracts: narrative review

Ocular trauma is an important cause of monocular blindness worldwide. Injury to the lens after blunt or penetrating trauma is common and can result in vision impairment. Selecting the most appropriate therapeutic approaches depends on factors such as patients' age, mechanism of trauma, and underlying clinical conditions. Early management, especially within childhood, is essential because of the difficulties involved in examination; anatomical variations; as well as accompanying intraocular inflammation, amblyopia, or vitreoretinal adhesions. The objective of this study was to provide a comprehensive review of the epidemiology and clinical management of traumatic cataract, highlighting the significance of accurate diagnosis and selection of the optimal therapeutic approach.

Early versus Delayed Vitrectomy for Open Globe Injuries: A Systematic Review and Meta-Analysis

Background

Open globe injuries (OGIs) are a leading cause of monocular blindness worldwide and require prompt intervention to prevent proliferative vitreoretinopathy (PVR) and endophthalmitis when serious intraocular damage occurs. The management of OGIs involves initial wound closure within 24 hours, followed by vitrectomy as a secondary surgery. However, there is a lack of consensus regarding the optimal timing of vitrectomy for maximizing visual outcomes. This meta-analysis aimed to investigate whether early or delayed vitrectomy leads to better outcomes in patients with OGIs.

Methods

This review was conducted based on PRISMA guidelines. The Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases were searched (October 23, 2023). Clinical studies that used vitrectomy to manage OGIs as early (within 7 days) or delayed (8-14 days) interventions were included. Randomized controlled trials (RCTs) and non-RCTs were appraised using the Cochrane risk of bias and JBI tools, respectively.

Results

Eleven studies met the inclusion criteria and were included in the quantitative analyses. There were 235 patients with OGIs who received early intervention and 211 patients who received delayed intervention. The retina was reattached in 91% and 76% of the patients after early and delayed intervention, respectively. Traumatic PVR was present in 9% and 41% of the patients in the early and delayed groups, respectively. The odds of retinal reattachment after vitrectomy were greater in the early group (OR = 3.42, p = 0.010, 95% CI=1.34-8.72), and the odds of visual acuity ≥ 5/200 were 2.4 times greater in the early group. The incidence of PVR was significantly greater in the delayed surgery group (OR = 0.16, p < 0.0001; 95% CI=0.06-0.39), which also required more than one vitrectomy surgery.

Conclusion

Early vitrectomy results in better postoperative visual acuity, a greater proportion of retinal reattachment, and a decreased incidence of PVR.

Comparison of the effectiveness of different corneal curvature measurement methods for IOL implantation in traumatic aphakic eyes with corneal injury

BACKGROUND/AIM

To assess the refractive outcomes of secondary intraocular lenses (IOL) in patients with traumatic aphakic eyes with corneal penetrating injury and compare different corneal curvature measurement methods.

METHODS

Patients with unilateral penetrating eye injuries underwent corneal wound repair and cataract extraction, followed by secondary IOL implantation. Corneal curvature measurements were taken on the contralateral healthy eye (Group A), from the affected eye before removing corneal sutures (Group B), or after suture removal (Group C). The refractive outcomes were compared among the three groups.

RESULTS

The study included 261 eyes. The Mean Absolute Error (MAE) in Group C (0.99 ± 0.85 D) was significantly smaller than that in Group A (1.87 ± 1.71 D) and Group B (1.37 ± 1.20 D) (both P < 0.001). Moreover, the percentage of eyes with IOL prediction errors within ± 0.50 D in Group C (40%) was higher than that in group A (21.7%) (OR = 2.364, 95%CI: 1.272-4.392, P = 0.006) and group B (28.0%) (OR = 1.714, 95%CI: 0.948-3.099, P = 0.073), and the percentage of eyes with IOL prediction errors within ± 1.0 D in Group C (90.9%) was higher than that in group A (67.9%) (OR = 4.758, 95%CI: 2.131-10.626, P < 0.001) and group B (75.0%) (OR = 3.370, 95%CI: 1.483-7.660, P = 0.003) as well.

CONCLUSIONS

In traumatic aphakic eyes with corneal sutures, IOL power calculation based on the corneal curvature of the injured eye after removing the corneal sutures yields the best refractive outcomes.

Demographics, Presenting Features, and Outcomes of Adult Patients with Ocular Trauma

Introduction

Ocular trauma is a common cause of permanent vision loss in adults. The combination of an accurate clinical examination and imaging offers the best prognostic indicators for patients and helps to navigate treatment modalities. This is a retrospective chart review of examination and imaging findings for ocular trauma and how they correlate with treatment course and visual acuity (VA) outcomes.

Methods

Adult patients with ocular trauma presenting to a single institution between January 2013 and December 2020 were evaluated. Initial examination and imaging findings were compared for associations with each other and with VA outcomes.

Results

136 ocular traumas on 134 patients were included. The median presenting logMAR VA was 2.7 (interquartile range (IQR) 1.2-3.7) with 62% open globe injuries. The most commonly reported finding on initial CT scan was globe deformity (30%), on B-scan was choroidal detachment (20%), and on ultrasound biomicroscopy was intraocular foreign body, ciliochoroidal effusions, or angle recession (21% each). Worse vision was observed for patients positive for retinal detachment on initial B-scan compared to those negative for this finding at 6-month (median logMAR 2.7 vs. 0.5; P < 0.0001) and at final post-injury evaluation (median logMAR 3.7 vs. 0.4; P < 0.0001). Similarly, worse VA was observed for patients with choroidal detachment on initial B-scan compared to those without this finding at 6-month (median logMAR 1.4 vs. 0.5; P = 0.002) and at final post-injury evaluation (median logMAR 2.0 vs. 0.4; P < 0.0001). If positive conjunctiva/sclera examination findings were identified, 66% had positive findings on B-scan, whereas if the conjunctiva/sclera examination findings were absent, 41% had positive findings on B-scan (P = 0.005). If anterior chamber (AC) examination findings were positive, 59% had positive findings on B-scan, whereas if the AC examination findings were absent, 37% had positive findings on B-scan (P = 0.03). Discussion. The predictive value of examination findings in this study may offer insight as to long-term visual prognosis. Positive B-scan or CT findings should increase suspicion for open globe injuries.

Variations in Management of Zone 1 Open Globe Injuries Across Corneal Specialists

PURPOSE

The aim of this study was to describe variations in practice patterns for the management of zone 1 open globe injuries among corneal specialists worldwide.

METHODS

This cross-sectional study was performed using an online survey distributed to members of The Cornea Society. Responses were collected between September 9, 2021, and September 30, 2021.

RESULTS

Of 94 responses included in analysis, respondents averaged 18.2 ± 14.5 years of postfellowship experience. Among respondents, 53 (56.4%) were affiliated with an academic institution and 41 (43.6%) with private practice. Ophthalmologists practicing in the United States were significantly more likely to use an eye shield preoperatively (98.5% vs. 85.7%, P = 0.03) and less likely to perform primary lensectomy in cases of lens involvement (40.9% vs. 75.0%, P = 0.002) compared with those practicing outside the United States. Ophthalmologists in practice fewer than 10 years were more likely to administer preoperative systemic antibiotics (91.4% vs. 66.1%, P = 0.006) and tetanus prophylaxis (88.6% vs. 67.8%, P = 0.03), and to obtain preoperative computed tomography scans (85.7% vs. 54.2%, P = 0.002) compared with more senior physicians. Ophthalmologists at academic institutions were more likely to perform preoperative B-scan (30.2% vs. 9.8%, P = 0.02), use general anesthesia (90.6% vs. 70.7%, P = 0.03), and admit for postoperative antibiotics (28.3% vs. 9.8%, P = 0.04), and were less likely to perform surgery overnight (45.3% vs. 70.7%, P = 0.02) compared with private practice physicians.

CONCLUSIONS

There is significant variation in the practice patterns for the management of zone 1 open globe injuries among corneal specialists, which presents an opportunity to investigate whether certain treatment options lead to better outcomes in these injuries.

Visual outcomes and prognostic factors of early pars plana vitrectomy for open globe injury

OBJECTIVES

To identify the clinical features and outcomes of early vitrectomy in patients with open globe injury (OGI) and the prognostic factors for visual outcome.

METHODS

This retrospective observational case series included 390 eyes in 389 patients diagnosed with OGI receiving vitrectomy within four days after injury. Preoperative parameters included the injury types, wound locations, consequent tissue damages, initial visual acuity (VA), and ocular trauma score. Postoperative outcome measures included surgical procedures, retinal (re)attachment, complications, and final VA. The logistic analysis evaluated the prognostic factors for visual outcome.

RESULTS

Intraocular foreign bodies (59.2%) and penetrating injuries (28.7%) were the most common injury types. Among the 165 eyes with retinal detachment (RD), 121 (73.3%) had retinal reattachment during early primary vitrectomy, and 32 (19.4%) were repaired during a second or subsequent surgery. Thirteen eyes (3.3%) were enucleated. The final VA improved from the initial level in 207 eyes (55.2%), remained unchanged in 123 (32.8%), and decreased in 45 (12.0%). Multivariable regression revealed that the injury zone, initial VA, RD, and endophthalmitis were associated with poor visual outcomes (P < 0.05).

CONCLUSIONS

Higher zone injury, low initial VA, RD, and endophthalmitis are predictors of poor visual outcome in eyes undergoing early vitrectomy for OGI.

Retinal Detachments after Open-Globe Injury: Risk Factors and Outcomes

PURPOSE

To identify risk factors for retinal detachment (RD) after open-globe injury (OGI) and evaluate outcomes of RD repair after OGI.

DESIGN

Case-control study.

PARTICIPANTS

Overall, 769 patients presented with 786 OGIs, which were surgically managed with ≥ 30 days of follow-up. Of the 786 eyes, 223 developed RD, the other 551 served as controls, and RD status of 12 eyes was unknown.

METHODS

A retrospective chart review was performed of all OGIs presented to the University of Michigan between 2000 and 2022. Multivariable regression identified risk factors for RD after OGI and predictors of poor vision after RD repair. Kaplan-Meier analysis estimated time from OGI to RD.

MAIN OUTCOME MEASURE

Predictors of visual outcome after RD repair after OGI.

RESULTS

After OGI, 223 (28.4%) of 786 eyes were diagnosed with RD, with > 73% diagnosed within a month. Predictors of RD include posterior injury (zone II vs. I odds ratio [OR], 1.60 [95% confidence interval {CI}, 1.04-2.46]; P = 0.0331; zone III vs. I OR, 2.29 [1.53-3.41]; P < 0.0001), vitreous hemorrhage (OR, 2.29 [1.54-3.1]; P < 0.0001), and presenting acuity worse than count fingers (CFs) (OR, 2.65 [1.69 - 4.16]; P < 0.0001). Retinal detachment repair took place in 142 of 223 eyes. The mean logarithm of minimal angle of resolution visual acuity (VA) improved from 2.3 ± 0.8 to 1.7 ± 0.9 after RD repair at 6-month follow-up, with 51.2% of eyes achieving CF or better vision. Single surgery anatomic success rate was 69.7% and final anatomic success was 88%. Predictors of vision worse than CF include history of ocular surgery (OR, 0.32 [0.11-0.94]; P = 0.039), proliferative vitreoretinopathy (PVR; OR, 0.39 [0.16 - 0.92]; P = 0.032), aphakia (OR, 0.25 [0.08 - 0.77]; P = 0.016), and redetachment (OR, 0.26 [0.1 - 0.63]; P = 0.003).

CONCLUSIONS

Most RD occur within the first month after OGI. Patients with posterior injuries, vitreous hemorrhage, or poor presenting VA were more likely to develop RD after OGI. Anatomic success was achieved in the majority, as was final VA of CF vision or better. History of ocular surgery, PVR at time of repair, aphakia, and redetachment were risk factors for a poor outcome.

FINANCIAL DISCLOSURE(S)

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

Effect of Oral Prednisone on the Prevention and Management of Proliferative Vitreoretinopathy After Open-Globe Injury

Purpose: To determine the impact of oral prednisone on the final visual acuity (VA) and prevention of proliferative vitreoretinopathy (PVR) in patients having pars plana vitrectomy (PPV) for globe injuries. Methods: A retrospective chart review was performed of all globe injuries with an initial repair and subsequent PPV between 2009 and 2018. Data included the initial VA, zones of injury, initial closure date, time to secondary intervention (PPV), oral prednisone (1 mg/kg/day) use, the final VA, and enucleation rate. Multivariable regression models were used to assess the impact of oral prednisone use on anatomic and functional outcomes. Results: The mean (±SD) patient age was 46.25 ±18.56 years (range, 13-92); 131 (83.9%) were men. Oral prednisone intake was recorded in 81 patients (52.3%). The prednisone group had significantly more zone 3 involvement (P = .001), worse initial VA (2.28 vs 1.92 logMAR; P = .003), and a greater mean number of surgeries (P = .020) than the no-steroids (control) group but an equivalent final logMAR VA (1.57 vs 1.52; P = .881). The prednisone group had significant VA improvement (P = .025); however, oral prednisone use did not predict the development of PVR (29.23% vs 12.90%; odds ratio [OR], 2.81; 95% CI, 0.89-8.85) or retinal detachment (27.27% vs 29.58%; OR, 0.59; 95% CI, 0.23-1.56). Conclusions: Despite a worse initial clinical presentation, patients who received oral prednisone had significant visual improvement compared with the control group. However, oral prednisone (1 mg/kg/day) use at the time of injury did not decrease the PVR rate.

Zone 1 trauma: wound dehiscence compared to primary trauma

PURPOSE

The study aims to assess if Zone 1 globe injuries hold a favorable prognosis for all situations, including wound dehiscence, or just primary traumatic injuries.

METHODS

Retrospective cross-sectional chart review of patients who underwent open globe repair from 1/1/2019 to 12/1/2020 at an urban hospital setting was evaluated for final visual outcomes, associated ocular pathology, long-term complications, and need for further surgeries.

RESULTS

Fifty-eight eyes were identified-38 primary trauma and 20 dehisced wounds (11 penetrating keratoplasties, five clear corneal incisions, one laceration, one extracapsular cataract extraction, one radial keratotomy, and one tectonic graft). Dehisced wounds had more posterior segment pathology vs primary trauma, i.e., hemorrhagic choroidal, vitreous hemorrhage, retinal detachment, choroidal effusion (all 20% vs 2.63%, 5.26%, 5.26%, and 0%, respectively), vitreous prolapse (20% vs 2.63%), and uveal prolapse (80% vs 36.84%). Dehisced wounds had more traumatic aphakia (40% vs 0%) and dislocated lenses (15% vs 0%). Primary trauma was more likely to have traumatic cataracts (55.26% vs 10%) or no lens changes (44.74% vs 25%). About 10% dehisced wounds required enucleation (0% primary trauma). Cataract/secondary intraocular lens surgery was performed in 34% of the primary traumas (10% in dehisced wounds). Primary traumas achieved 20/40 vision or better in 44.74% (10% dehisced wounds). About 7.89% of patients with wound dehiscence ended with no light perception (none in primary trauma).

CONCLUSION

Zone 1 open globe injuries due to wound dehiscence may exhibit worse prognosis compared to primary trauma open globe injury. More important than the zone of injury may be the source.

Management of scleral tears with concurrent intraocular foreign bodies and factors affecting outcomes

AIM

To report the clinical settings and factors predicting outcomes in scleral tears with concurrent retained intraocular foreign bodies METHODS: All cases with scleral and corneoscleral wounds with retained intraocular foreign bodies (RIOFB) from January 2014 to January 2021 were retrospectively analysed. Favourable anatomic outcome was defined as presence of globe integrity, attached retina, absence of hypotony and active inflammation at last visit. Favourable functional outcome was defined as final visual acuity (VA) > 20/200.

RESULTS

Total 139 eyes were included. Mean age was 30.66 ± 13.32 years (median 29 years, IQR 17). Penetrating trauma accounted for 87.1%, rupture for 5.8%, perforation for 7.2%. In 5.8% of the eyes the injury involved zone I extending till Zone II while in 66.9% it involved Zone II and in 27.3% in Zone III. Snellen visual acuity at presentation was logMAR 2.97 ± 1.01 and at last visit was logMAR 2.38 ± 1.45 (p < 0.0001). Time between presentation and repair was 13.93 ± 19.56 h (median 7.6 h, IQR 17.17). Favourable functional outcome was seen in 34.5% eyes and 2/3rd achieved favourable anatomic outcome. Absence of endophthalmitis (OR = 6.25, p = 0.003) and ability to remove the foreign body (OR = 7.05, p = 0.003) were associated with a favourable anatomic outcome. Better presenting Snellen visual acuity (OR = 2.77, p = 0.003), manifest scleral tear (OR = 3.36, p = 0.04), and absence of endophthalmitis (OR = 50, p = 0.0009) were associated with a favourable functional outcome.

CONCLUSION

A third of the cases achieved favourable visual outcome while 2/3rd achieved favourable anatomic outcome. Absence of endophthalmitis is an important factor predicting both.

Characteristics of pediatric open globe injuries in preschool-aged and school-aged children

OBJECTIVE

To evaluate the characteristics and outcomes of pediatric open globe injuries in preschool- and school-aged children.

METHOD

Medical records of 93 children were reviewed. Patients were categorized in 2 groups: preschool-aged group (0-7 years) and school-aged group (8-15 years). Demographic data, characteristics of trauma, Ocular Trauma Score (OTS), and initial and final best-corrected visual acuity (BCVA) were recorded and compared between groups.

RESULTS

The preschool-aged group consisted of 54 patients (mean age 4.6 ± 1.8 years), and the school-aged group consisted of 39 patients (mean age 11.5 ± 2.7 years). Most of the injuries were penetrating and caused by nonmetalic sharp objects in both groups. A corneal injury was detected in 45 patients (83.3%) in the preschool-aged group and 29 patients (74.4%) in school-aged group. Localization of the corneal wound was mostly central (46.7%) in the preschool-aged group and peripheral (48.3%) in school-aged group (p = 0.045). Mean corneal wound length was significantly longer in the preschool-aged group (p = 0.018). Most of the cases in the preschool-aged group were OTS group 2 (50%), whereas most of the cases in the school-aged group were OTS group 3 (38.5%). Poor visual outcome was significantly correlated with the following factors in both groups: lower OTS, worse initial BCVA, central corneal wound, longer corneal and total wound length, and presence of lens damage, retinal detachment, and hypotonia (p < 0.05 for all). Poor final BCVA also was significantly correlated with a longer scleral wound in the school-aged group and the presence of vitreous hemorrhage and uveal tissue prolapse in the posterior segment in the preschool-aged group (p < 0.05).

CONCLUSIONS

Localization and length of the corneal wound is closely associated with visual outcome in children with open globe injuries. Especially in preschool-aged children, mostly central localization of a corneal wound can be a challenging factor for visual rehabilitation.

Use of Yamane technique for secondary intraocular lens implantation following open globe injury

A woman in her 50s presented with suspected open globe injury (OGI) of the right eye after being hit with a high velocity piece of plastic. Visual acuity at the time of presentation was counting fingers in the affected eye. Slit lamp examination revealed a full thickness laceration of the cornea and a traumatic cataract. Primary corneal repair was performed and the patient was left aphakic after cataract removal. Secondary intraocular lens placement was deferred for 2 years, after which time a scleral-fixated intraocular lens was implanted using the Yamane technique. Postoperative visual acuity of 20/50 was achieved, with the vision limited by persistent diabetic macular oedema. Thus, this case of successful implantation of a secondary lens using the Yamane technique in a patient with prior corneal laceration and traumatic cataract highlights that the Yamane technique can result in visual improvement in patients with prior OGI.

Discrepancy of eye injuries in mechanism, clinical features, and vision prognosis by different causative sports

Objective

To investigate the epidemiological and clinical characteristics of sports-related eye injuries in China, as well as how they differ depending on the sport or other specific factor that caused them.

Methods

Consecutive medical records from 2015 to 2019 of sports-related eye injuries from a standardized database in nine tertiary referral hospitals in China were retrospectively reviewed and analyzed.

Results

A total of 377 eyes in 376 inpatients (mean age, 22.5 ± 7.3 years; men:women 15.4:1) were included. Soccer (46.8%), basketball (27.1%), and badminton (16.8%) were the top three sports that caused injury. Ball strikes (74.7%), physical collision (13.8%), and racket/equipment beating (9.0%) were the common specific causes of injury. Blunt force injuries (95.8%) and close globe injuries (95.1%) accounted for the majority of injuries. Open globe injuries occurred more in basketball (8.3%) than in other sports, mainly due to physical collision (12.8%) and racket/equipment beating (11.8%). Basketball (13.4%) or physical collision (21.3%) caused Zone I injuries more frequently than other sports. Soccer (60.5%) and basketball (54.6%) caused more injuries to the posterior segment of the eyeball than other sports, mainly due to ball strikes (96.6%). Badminton (69.8%) and racket beating (61.8%) caused more Zone II globe injuries than other sports. In badminton, the percentage of hyphema (85.7%), the most typical symptom of eye damage, and ultimate visual acuity (VA) ≥20/40 (88.9%) was the greatest. A final low vision score of (≤4/200) was observed in 10.6% of all participants, including three participants who had an eye removed due to rupturing. The final VA was positively correlated with the presenting VA (r = 0.421).

Conclusion

Sports can lead to high proportions of ocular contusion injury and low vision. VA prognosis is closely related to initial VA following ocular sports trauma, which is directly determined by the causative sports and/or the specific causes. Effective eye protection is imperative to avoid or reduce visual impairments of sports participants.

Double Reverse Overlapping Scleral Trapdoor (DROST) Technique for the Removal of Juxtalenticular Intraocular Foreign Body

We describe the double reverse overlapping scleral trapdoor (DROST) technique, a novel minimally invasive technique for the removal of very anterior intraocular foreign bodies without the need of pars plana vitrectomy. [Ophthalmic Surg Lasers Imaging Retina 2023;54:600-602.].

Long-term functional and structural outcomes after large chorioretinectomy for ruptured globe following blunt trauma

BACKGROUND

The purpose of this study was to present a modified surgical technique involving pars plana vitrectomy with large chorioretinectomy for eyes with rupture of the globe due to severe ocular blunt trauma.

METHODS

This retrospective study included consecutive patients with rupture of the globe due to blunt trauma who were treated at the King Khaled Eye Specialist Hospital (Riyadh, Saudi Arabia). All patients underwent 25-gauge pars plana vitrectomy with large chorioretinectomies involving all the tissue around the posterior scleral wounds. Outcome measures included best-corrected visual acuity (BCVA), anatomical success and globe survival, rates of complications.

RESULTS

15 eyes of 15 patients were included. Mean BCVA was 2.88 ± 0.13 logMAR at presentation, and significantly improved to 0.83 ± 0.28 logMAR (P < 0.001), with 10 patients (67%) achieving a final BCVA ≥ 20/200. Anatomical success and globe survival were achieved in 11 (73%) and 15 (100%) of eyes, respectively. Postoperative complications included retinal detachment in 6 eyes (40%), epiretinal membrane in 6 (40%), hypotony in 4 (26%), PVR in 2 (13%).

CONCLUSIONS

Pars plana vitrectomy with large chorioretinectomy is an effective treatment for globe rupture following severe blunt trauma, yielding good visual outcomes and anatomical success rates.

Bilateral Angle Recession and Chronic Post-Traumatic Glaucoma: A Review of the Literature and a Case Report

Ocular trauma affects millions of people worldwide and is a leading cause of secondary glaucoma. Angle recession is the main cause of post-traumatic glaucoma after blunt eye trauma, and it is usually unilateral. The aim of this paper is to investigate the possible causes of angle recession with a bilateral presentation. Airbag activation during traffic accidents is a likely cause to be ruled out, along with repeated head or eye trauma, due to contact sports or a history of physical abuse. These aspects can aid in early detection, appropriate management, and improved outcomes for patients with ocular trauma. Finally, we report the case of a 75-year-old Caucasian man who developed a bilateral angle recession after an airbag impact, with advanced glaucoma in the right eye and ocular hypertension in the left eye. To our knowledge, this is the first case in the literature of chronic post-traumatic glaucoma probably caused by an airbag.

Evolving Use of Regional versus General Anesthesia for the Surgical Repair of Open Globe Injuries

PURPOSE

The purpose of the current study is to report outcomes with the evolving use of regional anesthesia with monitored anesthesia care (RA-MAC) vs general anesthesia (GA) in the repair of open globe injuries.

DESIGN

Retrospective, consecutive, comparative, nonrandomized clinical study.

METHODS

The study includes 507 eyes of 507 patients with open globe injuries treated with either RA-MAC or GA at a tertiary referral center between 2015 and 2020. There was no predetermined protocol for selection of anesthesia method. However, based on experience and findings of prior research by this group, regional anesthesia with monitored anesthesia care was typically selected initially and changed to general anesthesia if warranted after evaluation of the patient and discussion with the surgeon. The main outcome measure was visual acuity at last follow-up. Results were compared to previously published study groups between 1995 and 2014.

RESULTS

Primary closure of open globe injury was performed under RA-MAC anesthesia in 462 patients (91%) and under GA in 45 patients (9%). Zone 1, 2, and 3 injuries were recorded in 251, 170, and 86 patients, respectively. Zone 1 (96%, 240 of 251 patients) or zone 2 (92%, 156 of 170 patients) (P < .001) were more likely to be repaired under RA-MAC vs zone 3 injuries (76%, 65 of 86 patients). The improvement from presenting visual acuity was similar for the 2 anesthesia groups, 0.52 logMAR and 0.46 logMAR for RA-MAC and GA, respectively (P = .68, CI -0.3 to 0.2). The use of RA-MAC anesthesia for open globe injuries has increased at our institution from 64% in 1995-1999 to 91% in the present study, 2015-2020 (P < .00001).

CONCLUSION

The current study demonstrates that with anesthesiologists experienced in ophthalmic regional anesthesia techniques, and appropriate case selection, RA-MAC can be safely used as an alternative to general anesthesia for open globe repair. Considerations when employing RA-MAC include a patient's ability to cooperate, position, and communicate for the duration of the globe repair.

Clinical characteristics and prognostic factors of open globe injuries in a North Spain population: a 10-year review

OBJECTIVES

To describe the epidemiologic and clinical characteristics of open globe injuries (OGIs) treated in a tertiary hospital and analyse predictors of visual outcome.

METHODS

This retrospective observational study included all patients with OGIs admitted to Cruces University Hospital between 2010 and 2020. The descriptive analysis included demographic data, type of injury classified as "rupture", "penetration", "perforation", or "intraocular foreign body", trauma mechanism and setting, injury zone, Ocular Trauma Score, delay to surgery, length of hospital stay, antibiotic prophylaxis, initial and final best corrected visual acuity (BCVA), complications and further surgery. Univariate analysis and logistic regression were performed to identify prognostic factors, based on final BCVA.

RESULTS

Overall, 207 OGI cases were reported. The most common type of injuries were ruptures caused by domestic falls. Notably, 44.4% of eyes developed phthisis bulbi. In the univariate analysis, the following variables were significantly linked to visual outcome: age > 60 years, "rupture", "fall", posterior and/or combined zones of injury, lens damage, retinal/choroidal detachment, initial BCVA of no light perception, and Ocular Trauma Score ≤ 2 (p < 0.001). Delay to surgery, length of stay and further surgery did not have prognostic value. In the logistic regression, initial BCVA of no light perception (p < 0.001) and injury zone III (p = 0.005) remained significant predictors of poor outcome.

CONCLUSIONS

In the population studied, most OGIs were caused by domestic falls usually affecting elderly patients with comorbidities. Visual outcome depended on patients´ specific characteristics and the nature of the trauma itself, whereas environmental factors failed to show any prognostic value.

Case report: Bilateral eye injuries in members of one family due to a cluster munition in Ukraine

The aim of the study was to report the effects of surgical treatment of three victims of a cluster munition in Ukraine. A 32-year-old woman and her sons-6-year-old male twins-presented in Poland after 18 days of delay in treatment. All ocular injuries were bilateral. One of the boys presented with total retinal detachment and a post-traumatic cataract as well as corneal sutures in one eye and a post-traumatic cataract in the other eye. The other boy had already developed atrophy in one eye and a vitreous hemorrhage in the other eye. The woman suffered from bilateral post-traumatic cataract with multiple glass intraocular foreign bodies (IOFBs). The surgical treatment included cataract surgery with intraocular lens implantation in three eyes, removal of IOFBs in one eye, and enucleation of the atrophic eye with implantation of an ocular prosthesis preventing constriction of face tissues. The eye with retinal detachment underwent pars plana vitrectomy, and the vitreous hemorrhage resolved itself. Postoperatively, visual acuity improved significantly in four of six eyes. Only in the eye with an open-globe injury and persistent retinal detachment, the final visual acuity was still poor. In conclusion, cluster munition may lead to bilateral ocular trauma with IOFBs, open-and close-globe injuries, and severe vision loss if left untreated. Modern ophthalmic surgery leads to vision with IOL improvement and solving the eyes after severe combat injury.

Outcomes of Zone 3 Open Globe Injuries by Wound Extent: Subcategorization of Zone 3 Injuries Segregates Visual and Anatomic Outcomes

PURPOSE

Open globe injuries (OGIs) are categorized by zone, with zone 3 (Z3) comprising wounds > 5 mm beyond the limbus. Outcomes of Z3 OGIs are highly heterogeneous. Open globe injuries with far posterior Z3 (pZ3) wounds were hypothesized to have worse visual and anatomic outcomes.

DESIGN

Single-center retrospective cohort study.

PARTICIPANTS

A total of 258 eyes with Z3 OGIs.

METHODS

A retrospective review of Z3 OGIs treated at a tertiary center over 12 years. Wounds ≥ 10 mm posterior to the limbus were defined as pZ3. Outcomes were compared between pZ3 and anterior Z3 (aZ3) eyes.

MAIN OUTCOME MEASURES

Visual acuity on a logarithm of the minimum angle of resolution (logMAR) scale. Secondary outcomes included anatomic outcomes, development of retinal detachment and proliferative vitreoretinopathy, and the number of secondary surgeries.

RESULTS

A total of 258 Z3 OGI eyes with > 30 days follow-up were assessed; 161 (62%) were pZ3. At 3-month follow-up, pZ3 OGIs were more likely to exhibit no light perception (pZ3: 38%; aZ3: 17%; P < 0.003), lack count fingers vision (pZ3: 72%; aZ3: 43%; P < 0.002), and fail to read a letter on the eye chart (pZ3: 83%; aZ3: 64%; P < 0.001). The visual acuity distribution at 3 months was significantly worse for pZ3 compared with aZ3 injuries (P < 0.004). Similar results were found at final follow-up. Multiple linear regression showed that pZ3 location was independently associated with worse visual acuity (β = 0.29, 95% confidence interval [CI], 0.09-0.50, P < 0.006) in addition to presenting acuity, age, vitreous hemorrhage, uveal prolapse, and afferent pupillary defect. Far posterior wounds injuries were more likely to develop retinal detachments (pZ3: 87%; aZ3: 71%; P < 0.01) and proliferative vitreoretinopathy (pZ3 66%; aZ3 47%; P < 0.03). Patients with pZ3 OGIs were significantly more likely to reach poor anatomic outcome (phthisis, enucleation, need for keratoprosthesis) compared with patients with aZ3 OGI (pZ3: 56%; aZ3: 40%; P < 0.03).

CONCLUSIONS

Posterior OGI extension independently portends worse visual and anatomic outcomes. The effect on visual outcome was durable and clinically relevant compared with established predictors of OGI outcomes. Application of these findings improves the prognostic precision and will guide future research efforts to optimize surgical decision-making in severe OGI cases.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Occult intraocular aluminium foreign body causing rhegmatogenous retinal detachment: a case report

BACKGROUND

Ocular trauma is complex and varied, and some occult intraocular foreign bodies (IOFBs) can lead to uncommon symptoms and signs. We report a case of rhegmatogenous retinal detachment (no obvious wound, no pain, no intraocular infection or other symptoms) caused by an occult intraocular aluminium foreign body, which could have been easily missed.

CASE PRESENTATION

A 42-year-old male presented to the outpatient department of our hospital complaining of fluttering black dots and decreased vision in his left eye that began 3 months earlier. He was diagnosed with "floaters" at a community hospital. He denied a history of ocular trauma or previous surgery. The cornea and lens of the left eye were clear. A small patch of pigmentation was noted in the temporal sclera. Fundoscopy revealed macula-off retinal detachment. After mydriasis, elliptical holes were seen in the peripheral retina at 2:30, and a suspicious hyperreflective strip was found under the anterior lip of the retina by Goldmann three-mirror contact lens examination; the strip was confirmed to be an IOFB by orbital CT. The IOFB was removed through pars plana vitrectomy without any complications.

CONCLUSION

Unlike iron and copper IOFBs, aluminium IOFBs are more inert and more likely to be missed. For people with special occupations (construction workers, mechanics, etc.), when abnormal pigmentation of the sclera is found, the possibility of foreign bodies in the eye should be considered. In the process of disease diagnosis and treatment, it is necessary to ask for a detailed history, including occupation history and practice, and perform careful physical and targeted examinations. Such comprehensive analysis regarding the above information will minimize the chance of missed diagnosis.Awareness of occult IOFB in high risk occupations and prompt referral to a retinal surgeon is of outmost importance.

Clinical and Social Features of Patients with Eye Injuries Admitted to a Tertiary Hospital: A Five-Year Retrospective Study from Crete, Greece

Eye injuries are a major cause of visual disability worldwide and may present a burden to both quality of life of the sufferers and healthcare services. The aim of this study was to extract and triangulate information on the demographic, clinical, and social features of eye-injured adult patients admitted to a tertiary hospital in Greece. The design was a five-year retrospective study of eye-injured adult patients, admitted to the General University Hospital of Heraklion, Crete (GUHH), the single tertiary referral hospital on the island. Drawing the profile of eye-injured patients may add to future health planning. Data collected from 1 January 2015 to 31 December 2019, such as sociodemographic features and clinical information, were extracted. One hundred twenty-eight patients were included. Of those, there was no available information on activity during injury for 6 patients, 78 (60.9%) had work-related ocular injuries, and 44 (34.4%) had non-work-related ocular injuries. Patients with no current formal employment, those who were retired, and formally unemployed and manual force workers had the higher rates of work-related injuries. The most common work-related injuries were closed globe injuries, specifically contusions, while ruptures and penetrating wounds were the most frequent of the open globe injuries. Within the univariate analyses, work-related eye injuries were significantly associated with male gender, middle age, and the place related to daily work activity. Determinants of poor final visual acuity (VA) were the initial VA, the type of injury (p < 0.0001), the distance of the place of residence from the hospital, and the time to hospital admission (p < 0.013). In a multivariate analysis, referred patients and those with open globe injuries arrived at hospital after a two-hour interval compared with those who were not referred and those with closed globe injuries (p ≤ 0.05). A reduction in the time to hospital admission deserves further attention. The interconnection of community and health system services through a capacity increase and networking needs further research in order to obtain targeted and viable access for eye-injured patients.

The Association Between Computerized Tomography Findings and Ocular Trauma Score in Open Globe Injury: The Prognostic Value of Imaging

PURPOSE

The aim of this study was to evaluate the association between CT findings and Ocular Trauma Score (OTS) in open globe injury.

METHODS

In 182 eyes with open globe injury, CT findings were categorized into 5 major types: scleral irregularity with decreased globe volume, dislocation of the crystalline lens, abnormal vitreous density, thickening of the chorioretinal layer, and intraocular foreign body/air. Association between different types and number of CT findings with OTS stages were evaluated through a multivariate analysis.

RESULTS

Mean age of the patients was 38 ± 8.5 years. The most common CT findings were severe scleral irregularity or globe collapse (71.9%) and abnormal vitreous density (56%). The most common OTS stages were II (44.5%) and I (30.7%). In multivariate analysis, abnormal vitreous density (odds ratio [OR] = 2.11, p < 0.001), chorioretinal thickening (OR = 1.89, p < 0.001), and intraocular foreign body/air (OR = 1.58, p = 0.001) were associated with more advanced OTS stages (I or II). Mean OTS in eyes with 1, 2, and 3 CT findings were 66 (stage III), 47 (stage II), and 37 (stage I), respectively ( p value = 0.008). Presence of 2 (OR = 2.46, p < 0.001) and 3 (OR = 2.92, p < 0.001) CT findings were associated with more advanced OTS stages (I or II).

CONCLUSIONS

The type and number of CT findings may help to predict the OTS stage and visual prognosis in eyes with open globe injury.

Characteristics and Outcomes of Electric Bicycle-Related Open-Globe Injuries in a Tertiary Hospital in North China

BACKGROUND

The aim was to describe the characteristics and outcomes of patients treated for electric bicycle-related open-globe injuries (OGIs).

METHODS

A retrospective chart review of all patients who presented with electric bicycle-related OGIs was performed at the Hebei Eye Hospital in North China between January 2012 and December 2018. Demographic data, injury type, presenting clinical examination findings, best-corrected visual acuity (BCVA), secondary ocular complications, necessary surgical procedures and long-term outcome data were recorded.

RESULTS

Twenty-six patients with electric bicycle-related OGIs met the inclusion criteria and were enrolled in the study. Eighteen of the 26 patients (69.2%) were males. the average age of these patients was 44.0 years old. The injuries peaked in winter in the hour between 15:00 and 20:00. Among the patients, 23 (88.5%) were farm workers, 2 (7.7%) were industrial workers, 1 (3.8%) was student. The types of OGIs were 23 ruptures (88.5%), 3 penetrating injuries (11.5%). Data on zone of injuries included 1 zone I injuries (3.8%), 12 zone II injuries (46.2%), 13 zone III injuries (50.0%). Nine eyes (34.6%) had traumatic cataract, 24 eyes (92.3%) had vitreous hemorrhage, 20 eyes (79.9%) had retinal detachment, 19 eyes (73.1%) had choroidal detachment. Ten eyes (38.4%) had hand motion or worse vision at final follow-up. four eyes (15.4%) which had injuries involving all 3 zones resulted in enucleation or evisceration. With respect to BCVA, the initial BCVA was 2.7±0.3 and the final BCVA was 2.0±0.7, indicating that the patients' BCVA was significantly improved by surgery ( t =4.3, P <0.001).

CONCLUSIONS

Electric bicycle-related OGIs may have severe consequences. Modern surgical techniques can increase the rate of globe salvage although final vision remains poor. Therefore, increased awareness, proposed policies and suggestions should focus on regulating the use of electric bicycles and reinforcing laws and regulations to improve safety and prevent injuries.

Ocular trauma, visual acuity related to time of referral and psychosocial determinants, during COVID‑19 pandemic: A prospective study

The aim of the present study was to explore the associations between visual outcomes of ocular injury patients in a tertiary hospital unit with clinical and demographic variables and to evaluate the psychosocial impact of the injury on the patients. An 18-month prospective study of 30 eye-injured adult patients was conducted in the General University Hospital of Heraklion, Crete, a tertiary referral hospital. All severe eye injury case information was prospectively collected between February 1, 2020 and August 31, 2021. Best corrected visual acuity (BCVA) was labelled not poor (>0.5/10 or >20/400 on the Snellen scale, <1.3 in LogMAR scale) and poor (≤0.5/10 or ≤20/400 on the Snellen scale, ≥1.3 on the LogMAR equivalent). Data regarding participants' perceived stress levels, by using Perceived Stress Scale 14 (PSS-14), were collected prospectively, one year after study end. Out of 30 ocular injury patients selected, 76.7% were men and most of them were self-employed and private or public sector workers (36.7%). Not poor final BCVA was related to not poor initial BCVA [odds ratio (OR) 1.714; P=0.006]. No statistical associations were found between visual outcome and demographic or clinical factors, but not poor final BCVA was associated with improved self-reported psychological condition of the sufferers, as examined by a questionnaire sheet developed to collect information for study purpose (8.36/10 vs. 6.40/10; P=0.011). No patient reported job loss or changed work status following the injury. Not poor initial BCVA was a significant predictor for not poor final visual outcomes (OR 1.714; P=0.006). Patients with not poor final BCVA expressed higher levels of positive psychology (8.36/10 vs. 6.40/10; P=0.011) and less fear of eye injury repetition (64.0 vs. 100.0%; P=0.286). Not poor final BCVA was associated with low PSS-14 scores one year after study end (77.3 vs. 0.0%, P=0.003). Collaboration between ophthalmologists, mental health professionals and primary care team may be important in order to help patients to cope with the psychosocial burden sequel to eye trauma.

High risk and low prevalence diseases: Open globe injury

INTRODUCTION

Open globe injury (OGI) is a rare but serious condition that carries with it a high rate of morbidity.

OBJECTIVE

This review highlights the pearls and pitfalls of OGI, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

OGI refers to full-thickness injury to the layers of the eye. OGI can be caused by blunt or sharp trauma, and subtypes include penetration, perforation, intraocular foreign body (IOFB), globe rupture, or mixed types. OGI is more common in males and usually secondary to work-related injury, but in women it is most commonly associated with falls. Emergency clinicians should first assess for and manage other critical, life-threatening injuries. Following this assessment, a thorough eye examination is necessary. Computed tomography (CT) may suggest the disease, but it cannot definitively exclude the diagnosis. While point-of-care ultrasound (POCUS) is highly sensitive and specific for some findings in OGI, its use is controversial due to potential globe content extrusion. Management includes protecting the affected eye from further injury, preventing Valsalva maneuvers that could extrude ocular contents, updating tetanus vaccination status, administering broad-spectrum antibiotics, and ophthalmology consultation for surgical intervention to prevent the sequelae of blindness and endophthalmitis.

CONCLUSION

An understanding of OGI can assist emergency clinicians in diagnosing and managing this sight-threatening traumatic process.

Open Globe Injury in a Tertiary Hospital of Northern Thailand: No Vision Survival and Ocular Trauma Score

Purpose

To determine characteristics and factors associated with no vision survival (included no light perception, enucleation, and evisceration) following open globe injury (OGI) and to correlate the proportion of final vision to predictive values of ocular trauma score (OTS).

Patients and Methods

The medical records of consecutive patients diagnosed as OGI between January 2015 and December 2020 were retrospectively reviewed. Data collected included demographics, mechanisms and modes of injuries, ophthalmic presentations, managements, and visual outcomes at the final visit.

Results

Three hundred and seventy-one patients with a mean (standard deviation, SD) age of 44.0 (17.4) years were included. Male with workplace injury was the most frequent scenario. High-velocity metallic objects were the predominant causative materials. Following treatments, fifty-six eyes (14.9%) obtained no vision survival. Factors associated with no vision survival following OGI were low presenting vision, globe perforation, larger wound, presence of relative afferent pupillary defect, retinal detachment, and vitreous hemorrhage. Compared to OTS predictive values, eyes in OTS categories 1 and 2 had a lower proportion of no vision survival.

Conclusion

This study identified the importance of workplace injuries. Overall, there were comparable final visions between OTS and this study. However, a reduced proportion of no vision survival among severely injured eyes signifies the challenges of OGI management.

Explosive eye injuries: characteristics, traumatic mechanisms, and prognostic factors for poor visual outcomes

BACKGROUND

Explosions can produce blast waves, high-speed medium, thermal radiation, and chemical spatter, leading to complex and compound eye injuries. However, few studies have comprehensively investigated the clinical features of different eye injury types or possible risk factors for poor prognosis.

METHODS

We retrospectively reviewed all consecutive records of explosive eye injuries (1449 eyes in 1115 inpatients) in 14 tertiary referral hospitals in China over 12 years (between January 2008 and December 2019). Data on demographics, eye injury types, ocular findings, treatments, and factors affecting visual prognosis were extracted from a standardized database of eye injuries and statistically analyzed.

RESULTS

Mechanical ocular trauma accounted for 94.00% of explosion-related eye injuries, among which intraocular foreign bodies (IOFBs) resulted in 55.17% of open globe injuries (OGIs) and contusion caused 60.22% of close globe injuries (CGIs). Proliferative vitreous retinopathy (PVR) was more common in perforating (47.06%) and IOFB (26.84%) than in penetrating (8.79%) injuries, and more common with laceration (24.25%) than rupture (9.22%, P < 0.01). However, no difference was observed between rupture and contusion. Ultimately, 9.59% of eyes were removed and the final vision was ≤ 4/200 in 45.82% of patients. Poor presenting vision [odds ratio (OR) = 5.789], full-thickness laceration of the eyeball ≥ 5 mm (OR = 3.665), vitreous hemorrhage (OR = 3.474), IOFB (OR = 3.510), non-mechanical eye injury (NMEI, OR = 2.622, P < 0.001), rupture (OR = 2.362), traumatic optic neuropathy (OR = 2.102), retinal detachment (RD, OR = 2.033), endophthalmitis (OR = 3.281, P < 0.01), contusion (OR = 1.679), ciliary body detachment (OR = 6.592), zone III OGI (OR = 1.940), and PVR (OR = 1.615, P < 0.05) were significant negative predictors for poor visual outcomes.

CONCLUSIONS

Explosion ocular trauma has complex mechanisms, with multiple eyes involved and poor prognosis. In lethal level I explosion injuries, eyeball rupture is a serious condition, whereas contusion is more likely to improve. In level II injuries, IOFBs are more harmful than penetrating injuries, and level IV represents burn-related eye injuries. PVR is more associated with penetrating mechanisms than with OGI. Identifying the risk predictors for visual prognosis can guide clinicians in the evaluation and treatment of ocular blast injuries.

International Globe and Adnexal Trauma Epidemiology Study (IGATES): Visual outcomes in open globe injuries in rural West India

BACKGROUND/OBJECTIVES

To evaluate the factors influencing final visual outcome after surgical repair of open globe injuries (OGIs) in a rural population using the International Globe and Adnexal Trauma Epidemiology Study (IGATES) online registry.

SUBJECTS/METHODS

Retrospective cohort study of patients with OGI. OGIs were identified from the IGATES database at a tertiary referral eye care centre in rural West India over a period of 12 years. Patient demographics, clinical and pre-operative factors affecting final visual outcome was evaluated.

RESULTS

A total of 791 eyes with OGIs were included in data analysis. 11 eyes that were lost to follow-up and 12 eyes with incomplete data were excluded. Most of the patients were male (559, 70.6%) and mean age of all patients was 23.9 years ± 19.4 years. Occupational hazards (including domestic housework) (307, 38.8%) and leisure play (324, 41.0%) were the leading causes of OGI. The most common mechanism of injury was being struck by a wooden stick (250, 31.6%). Univariate analysis of pre-operative variables showed initial visual acuity (VA), zone of injury, size of wound, structures involved in the injury and presence of infection were significant prognostic factors for worse final visual outcome (p < 0.001). Multivariate analysis showed VA ≤ 3/60 or worse at presentation had statistically significantly higher odds ratio of ending up with worse visual outcomes (p < 0.012).

CONCLUSIONS

Males in working age groups suffer from OGIs more frequently, usually from agricultural and pastoral activities. Initial VA, zone 3 injuries, corneoscleral wound, large wound size and presence of post-traumatic infections are significant prognostic factors.

Clinical Findings Predicting Posttraumatic Endophthalmitis after Repair of Open Globe Injuries

BACKGROUND

To evaluate risk factors for developing endophthalmitis after repair of open globe injuries.

METHODS

Retrospective chart analysis of 1303 patients from May 1996 till December 2019.

RESULTS

All patients received prophylactic intravenous broad-spectrum antibiotics for 5-7 days. Endophthalmitis was clinically suspected in 37 (2.8%) eyes and was culture proven in 14 of these eyes (1.1%). Univariate analysis identified poor initial visual acuity at presentation, rural setting of injury, contaminated wound and lens injury as significant predictors for the development of clinically suspected endophthalmitis. Intravitreal antibiotics at the time of primary repair in eyes with high-risk characteristics decreased risk of developing endophthalmitis (OR: 2.28;95% CI,1.07-4.86; p = .033).

CONCLUSIONS

Poor initial visual acuity, rural setting of injury, contaminated wound, and lens injury increased risk of suspected posttraumatic endophthalmitis. Prophylactic intravitreal antibiotics at the time of primary repair in eyes with high-risk characteristics reduced the risk of posttraumatic endophthalmitis.

Ophthalmic trauma: the top 100 cited articles in Ophthalmology journals

OBJECTIVES

To analyze the top 100 cited papers on ophthalmic trauma.

METHODS

A literature search of Ophthalmology journals within the ISI Web of Science database for the most cited papers related to ophthalmic trauma.

RESULTS

The most cited articles were published between 1943 and 2013, the greatest number being published in 2000. Ophthalmology (45), Archives of Ophthalmology (17), and the American Journal of Ophthalmology (15) published most of the articles. The institutions with the highest number of publications were Wilmer Eye Institute (10) and Massachusetts Eye and Ear Infirmary (7). Sixty-seven percent of the articles originated from the USA. The most common type of trauma studied was non-open-globe injuries and the most frequent topic studied were pathological conditions secondary to trauma (34), particularly endophthalmitis (8), and optic neuropathy (6). Articles presenting a standardized classification system for eye injury received the highest average of citations per publication. Types of research most frequently cited were observational clinical studies (62) and epidemiological studies (30); the least frequent were clinical trials (2).

CONCLUSION

This bibliographic study provides a historical perspective of the literature and identifies trends within the most highly influential papers on ophthalmic trauma. Many of these articles emerged within the past three decades and came from Ophthalmology journals that remain high impact to this day. Clinical trials have been difficult to conduct and are lacking, reflecting a critical need in ophthalmic trauma research, as most of our understanding of ophthalmic trauma comes from observational and epidemiological studies.

Prognosis of Open Globe Injuries at a Tertiary Referral Center: The Modified Florida Ocular Trauma Score

PURPOSE

To analyze vision outcomes after open globe injury and propose modifications to the ocular trauma score to offer more specific vision prognoses.

DESIGN

Validity and reliability analysis.

METHODS

Patients presenting to the University of Florida with a new open globe injury from October 2015 to January 2021 with subsequent follow-up were included in the study. Demographics, ophthalmic history, trauma details, timeline, imaging, operative findings, and ocular examinations were collected from the medical record. Z tests, χ² test, Fisher exact test, receiver operating characteristic curve, and ordinal correlation were used. A weighted logistic model was optimized to predict vision outcomes. Measured outcomes included the best-corrected visual acuity, Ocular Trauma Score category, and performance of vision prognosis scores.

RESULTS

A total of 162 eyes were identified from chart review. Eighty percent of the Ocular Trauma Score categories were accurate. Only the absence of orbital fractures was associated with a significant weight in the logistic model, which produced more accurate prognoses for 59 patients, and less accurate prognoses for 30 patients compared to the Ocular Trauma Score. Kendall Tau-B was 0.639 for the logistic model and 0.582 for the Ocular Trauma Score.

CONCLUSIONS

The Ocular Trauma Score accurately estimates vision prognosis after open globe injury. We propose inclusion of orbital fracture status in our Modified Florida Ocular Trauma Score. This addended score is more correlated with final vision outcome and provides more specific prognoses for severe open globe injuries. Prospective, multicenter validation is needed to refine and confirm the use of this new scoring system.

Active shape model registration of ocular structures in computed tomography images

Purpose. The goal of this work is to create an active shape model segmentation method based on the statistical shape model of five regions of the globe on computed tomography (CT) scans and to use the method to categorize normal globe from globe injury. Methods. A set of 78 normal globes imaged with CT scans were manually segmented (vitreous cavity, lens, sclera, anterior chamber, and cornea) by two graders. A statistical shape model was created from the regions. An active shape model was trained using the manual segmentations and the statistical shape model and was assessed using leave-one-out cross validations. The active shape model was then applied to a set of globes with open globe injures, and the segmentations were compared to those of normal globes, in terms of the standard deviations away from normal. Results. The active shape model (ASM) segmentation compared well to ground truth, based on Dice similarity coefficient score in a leave-one-out experiment: 90.2% ± 2.1% for the cornea, 92.5% ± 3.5% for the sclera, 87.4% ± 3.7% for the vitreous cavity, 83.5% ± 2.3% for the anterior chamber, and 91.2% ± 2.4% for the lens. A preliminary set of CT scans of patients with open globe injury were segmented using the ASM and the shape of each region was quantified. The sclera and vitreous cavity were statistically different in shape from the normal. The Zone 1 and Zone 2 globes were statistically different than normal from the cornea and anterior chamber. Both results are consistent with the definition of the zonal injuries in OGI. Conclusion. The ASM results were found to be reproducible and accurately correlated with manual segmentations. The quantitative metrics derived from ASM of globes with OGI are consistent with existing medical knowledge in terms of structural deformation.

Outcomes of Penetrating Keratoplasty After Open Globe Injury

PURPOSE

The purpose of this study was to investigate the clinical features, surgical outcomes, and prognostic factors of penetrating keratoplasty (PKP) after open globe injury (OGI).

METHODS

A retrospective review of all patients treated for OGI between January 2000 and July 2017 was conducted. Demographic, preoperative, perioperative, and postoperative data were collected for those who underwent PKP after OGI. The predictive value of each preoperative variable on graft failure was assessed using univariate and multivariable Cox proportional hazards models, and the predictive value of variables on post-PKP visual outcome was assessed using both univariate and multivariable logistic regression models. All eyes that underwent PKP after OGI were included unless they had less than 365 days of follow-up.

RESULTS

Forty-six eyes that underwent PKP met inclusion criteria. The median age was 46 years (interquartile range = 23.00-61.25), median follow-up was 78.5 months (interquartile range = 38.63-122.02), and 37 of 46 subjects (80.4%) were male. The observed 1- and 5-year graft survival estimates were 80.4% and 41.7%, respectively. Factors statistically associated with graft failure in multivariable analyses were rejection episode, hazard ratio (HR) = 3.29; retinal detachment (RD), HR = 3.47; and endophthalmitis, HR = 6.27. Fifteen of 42 eyes (35.7%) regained ambulatory vision (20/200 or better). The strongest predictors of vision worse than 20/200 at the last follow-up were RD, odds ratio (OR) = 43.88; graft rejection, OR = 12.42; and injury outside the workplace, OR = 25.05.

CONCLUSIONS

Despite a high graft survival at 1 year, most of the patients did not regain ambulatory vision. Graft rejection, RD, and endophthalmitis were risk factors for graft failure. These factors should be considered when counseling patients regarding PKP after OGI.

Predictors of Long-term Ophthalmic Complications after Closed Globe Injuries Using the Intelligent Research in Sight (IRIS®) Registry

Purpose

To identify clinical factors associated with the need for future surgical intervention following closed globe ocular trauma.

Design

Retrospective cohort study.

Subjects Participants and/or Controls

Patients in the American Academy of Ophthalmology Intelligent Research in Sight (IRIS®) Registry with a diagnosis of closed globe ocular trauma occurring between 2013 and 2019, identified using International Classification of Disease, 10th Revision and Systematized Nomenclature of Medicine codes.

Methods

Diagnosis codes were used to identify multiple concomitant diagnoses present on the date of closed globe ocular trauma. Survival analyses were performed for each outcome of interest, and linear regression was used to identify clinical factors associated with the risk of surgical intervention.

Main Outcome Measures

Outcomes included retinal break treatment, retinal detachment (RD) repair, retinal break treatment or RD repair, glaucoma surgery, and cataract surgery.

Results

Of the 206 807 patients with closed globe ocular trauma, 9648 underwent surgical intervention during the follow-up period (mean, 444 days): 1697 (0.8%) had RD repair, 1658 (0.8%) had retinal break treatment, 600 (0.3%) had glaucoma surgery, and 5693 (2.8%) had cataract surgery. Traumatic cataract was the strongest risk factor for cataract surgery (hazard ratio, 13.0; 95% confidence interval, 10.8-15.6), traumatic hyphema showed highest risk for glaucoma surgery (7.24; 4.60-11.4), and vitreous hemorrhage was the strongest risk factor for retinal break treatment and detachment repair (11.01; 9.18-13.2 and 14.2; 11.5-17.6, respectively) during the first 60 days after trauma date. Vitreous hemorrhage was a risk factor for cataract surgery at > 60 days after trauma date only. Iris-angle injury was the strongest risk factor for glaucoma surgery > 60 days after trauma, while vitreous hemorrhage remained the strongest factor for retinal break treatment and detachment repair at > 60 days. Traumatic hyphema was a risk factor for all surgical outcomes during all follow-up intervals.

Conclusions

Diagnosis of concomitant traumatic cataract, vitreous hemorrhage, traumatic hyphema, and other risk factors may increase the likelihood of requiring surgical intervention after closed globe ocular trauma.

Risk Factors for Enucleation Following Open Globe Injury: A 17-Year Experience

Purpose

At the time of open globe injury (OGI), it may be difficult for clinicians to predict which eyes are at highest risk for requiring enucleation. We performed a 17-year retrospective cohort study to report outcomes and risk factors for enucleation following open globe injuryto better aid clinicians counseling patients at OGI diagnosis.

Methods

A retrospective cohort study of all patients who presented to the University of Michigan with open globe injury (OGI) and were surgically managed between January 2000 and July 2017 was conducted. At least 30 days of follow-up was required. All eyes that ultimately underwent enucleation following OGI were identified and their clinical course analyzed. The main outcome measured was the rate of enucleation after OGI.

Results

There were 587 eyes meeting inclusion criteria. The mean patient age was 40.75 ± 25.1 (range 1–91). 441/585 (75.4%) patients were male. Average follow-up time was 1029.9 ± 1285.9 days. 116/587 eyes (19.8%) required enucleation after OGI, with 81.9% undergoing enucleation less than 30 days from injury. In enucleated eyes, the mean presenting logMAR vision was 2.91 ± 0.47 (Snellen equivalent between hand motion and light perception). The most common mechanism of injury requiring enucleation was globe rupture, 89/116 (76.7%), with 14/116 (12.1%) penetrating injuries and 13/116 (11.2%) perforating injuries. The mean age of patients that underwent enucleation was 45.6 ± 22.5 (range 3–91).

Conclusion

Open globe injuries are often visually devastating and a significant number of cases ultimately require enucleation. Despite emergent closure within 24 hours, 19.8% of eyes managed for OGI at our institution required eventual enucleation. 81.2% of these eyes required enucleation within 30 days of injury. Wound length greater than 10 mm, uveal prolapse, higher zone of injury, IOFB, and RAPD were identified as risk factors that predict future need for enucleation.

Risk Factors for Development of Endophthalmitis after Open Globe Injury in Children: A Case-Control Study

AIM

To identify risk-factors for developing endophthalmitis following open globe injury (OGI) in children.

METHODS

Retrospective, single-center, case-control study of children aged <18 years who sustained OGI.

RESULTS

Our cohort of 93 eyes consisted of 30 cases (Group A- endophthalmitis) and 63 controls (Group B- no endophthalmitis). Twenty-four eyes (80%) diagnosed with endophthalmitis presented after 24 hours of injury. The presence of central corneal zone-1 injuries (Odd ratio [OR]: 6.64, p= 0.001) and vitreous in wound (OR: 3.53) were associated with the risk of developing endophthalmitis. (p= < 0.05) Additionally the presence of iris prolapse (OR: 4.76) and posterior capsular rupture (PCR) (OR: 5.80) increased the risk of developing endophthalmitis.(p <0.05) . Streptococci was isolated in 15 eyes, Pseudomonas in 3 eyes, and Candida in 1 eye. The visual outcomes at three months were significantly worse in Group A (LogMAR 1.77±1.06) compared to Group B (LogMAR 0.65±0.68)(p<0.05).

CONCLUSION

Central corneal involvement, vitreous/ iris incarceration and PCR were important risk factors for development of PTE in children.

Guideline for the treatment of no light perception eyes induced by mechanical ocular trauma

Severe mechanical ocular trauma with no light perception (NLP) predicts a poor prognosis of visual acuity and enucleation of the eyeball. Since the innovative treatment concept of exploratory vitreoretinal surgery has developed and treatment technology has advanced, the outcomes of severe ocular trauma treatment in NLP patients have greatly improved. However, there remains a lack of unified standards for the determination, surgical indication, and timing of vitrectomy in NLP eye treatment. To address these problems, we aimed to create evidence-based medical guidelines for the diagnosis, treatment, and prognosis of mechanical ocular trauma with NLP. Sixteen relevant recommendations for mechanical ocular trauma with NLP were obtained, and a consensus was reached. Each recommendation was explained in detail to guide the treatment of mechanical ocular trauma associated with NLP.

Clinical spectrum and functional outcome of firearm pellet-related eye injuries: A prospective follow-up study

PURPOSE

To determine the prognostic significance of various clinical features and surgical techniques concerning anatomical and visual outcomes in shotgun pellet-inflicted ocular trauma.

METHODS

This prospective follow-up study was done at a tertiary care institute in Kashmir, India. Six hundred sixty-four eyes of 643 patients with firearm pellet-related ocular trauma were followed up for 6 months.

RESULTS

Ocular injury involved one eye in 622 (96.7%) patients and both eyes in 21 (3.3%) patients. Open globe injury (OGI) occurred in 451 (67.9%) eyes with perforating injury being the commonest type (248 eyes, 54.9%). For perforating injuries, entry wounds in the cornea and limbus had the worst prognosis. Closed globe injury (CGI) occurred in 213 (32.1%) eyes. An anatomical success rate of 66.3% (n = 250) was achieved for 56.8% (377/664) eyes requiring an average of 2.8 (SD 0.5) surgeries per eye. OGI was associated with poor outcomes in 259 (57.4%) and CGI with good outcomes in 200 (93.9%) eyes. The visual outcome had a significant association with grade and zone of injury both in OGI and CGI, and with the type of injury in OGI (p < .0001 each). Ocular trauma score (OTS) had a significant association with the degree of vision impairment (p < .0001). WHO category 0 visual impairment was seen in 270 (40.7%) eyes, category 1 in 85 (12.8%), category 2 in 35 (5.3%), category 3 in 30 (4.5%), category 4 in 172 (25.9%), and category 5 in 72 (10.8%) eyes irrespective of type of injury at 6 months post-treatment.

CONCLUSIONS

The perforating injury was the commonest type of injury caused by shotgun pellets. The site of the entry wound in perforating injury had prognostic significance. The outcome was generally poor in OGI and good in CGI.

Globe and Adnexal Trauma Terminology Survey

Importance

Ocular trauma terminology should be periodically updated to enable comprehensive capturing and monitoring of ocular trauma in clinical and research settings.

Objective

To update terminology for globe and adnexal trauma.

Design, Setting, and Participants

A 2-round modified Delphi survey was conducted from January 1 to July 31, 2021, using an expert panel, including 69 ophthalmologists identified through their membership in ophthalmology (globe and adnexal trauma) societies. Consensus was defined as at least 67% expert agreement. A steering committee developed questions after identifying gaps in the current terminology via a targeted literature review. Round 1 sought consensus on existing and newly proposed terminology, and round 2 focused on unresolved questions from round 1. Experts included ophthalmologists who had managed, on average, 52 globe or adnexal trauma cases throughout their careers and/or published a total of 5 or more globe or adnexal trauma-related peer-reviewed articles.

Main Outcomes and Measures

Expert consensus on ocular and adnexal terms.

Results

A total of 69 experts participated in and completed round 1 of the survey. All 69 participants who completed round 1 were asked to complete round 2, and 58 responses were received. Consensus was reached for 18 of 25 questions (72%) in round 1 and 4 of 7 questions (57%) in round 2. Existing Birmingham Eye Trauma Terminology system terminology achieved consensus of 84% (58 of 69 experts) in round 1 and 97% (56 of 58 experts) in round 2. Experts agreed on the need for further refinement of the definition of zones of injury (55 of 69 [80%]), as the zone affected can have a substantial effect on visual and functional outcomes. There was consensus that the mechanism of injury (52 of 69 [75%]) and status of the lacrimal canaliculi (54 of 69 [78%]), nasolacrimal ducts (48 of 69 [69%]), lens (46 of 58 [80%]), retina (42 of 58 [73%]), and central and paracentral cornea (47 of 58 [81%]) be included in the revised terminology.

Conclusions and Relevance

There was consensus (defined as at least 67% expert agreement) on continued use of the existing Birmingham Eye Trauma Terminology system definitions and that additional terms are required to update the current ocular trauma terminology.

A modified pediatric ocular trauma score for predicting visual outcome post open globe injury

PURPOSE

To construct a new pediatric ocular trauma score for predicting visual outcome after open globe injuries (OGI) and to compare it to the ocular trauma score (OTS) and pediatric ocular trauma score (POTS).

METHODS

This is a retrospective chart review study. For each case, the following data were collected: demographics, mechanism of the injury, initial ophthalmologic findings, presented and last follow-up visual acuity (VA), ocular treatments, and final ocular findings. We then analyzed the risk factors for the poor visual outcome (VA ≤ 20/200), and a modified pediatric ocular trauma score (MPOTS) was constructed accordingly and compared to the OTS and POTS for predicting poor outcome. Finally, a different cohort of pediatric OGIs was used for score validation.

RESULTS

Forty-five cases were included, significant predicting factors for poor visual outcome were initial VA ≤ 20/200, zone 2-3 locations of injury, presence of retinal detachment, vitreous hemorrhage, hyphema, and iris prolapse at initial presentation. The calculated Spearman correlation coefficients between each system score and poor visual outcome were OTS 0.56, POTS 0.57, and MPOTS 0.64 (P < 0.001 for all). A total of 71 new cases were used as validation cohort, and calculated Spearman correlation coefficients between each system score and poor visual outcome were: OTS 0.50, POTS 0.51, and MPOTS 0.53 (P < 0.001 for all).

CONCLUSIONS

We suggest a new scoring system for predicting poor final visual outcomes after OGI's in children, which is simpler and more clinically suitable for this study population. It was found to be a better predictor of visual outcome in this scenario compared with existing scoring systems.

Treatment of Mechanical Corneal Wounds Emergencies during the COVID-19 Pandemic: Absorbable 10-0 Vicryl (Polyglactin 910) Sutures as a Suitable Strategy

Background—The COVID-19 pandemic has changed our standard practices: operating rooms were only available for functional emergencies and outpatient visits were drastically reduced in favor of telemedicine. Aim: To report the personalized “one-shot” surgery using absorbable 10-0 Vicryl (V10-0) or polyglactin 910 monofilament in mechanical corneal injuries from February 2020 to December 2021. Methods—Prospective case series with at least 12-months’ follow-up, in a French university hospital. Among the overall population of open or closed-globe emergencies (n = 40), non-penetrating corneal lamellar lacerations (long axis > 2 mm) in zone 1 (OTC group) were treated with V10-0 suture(s) (n = 10), replacing traditional non-absorbable 10-0 nylon suture(s) or medical options in first line. The outpatient visits were performed on day (D)10, month (M)2, M6 then every six months. One interim visit by phone teleconsultation was scheduled between D10 and M2, and other(s) as needed. The main outcome was best-corrected visual acuity (BCVA) at M6. Secondary outcomes included mainly corneal astigmatism (CA) at M6 complications. Results—Among the ten corneal wounds, there were three children (30%), eight domestic accidents (80%), three eyes with metallic foreign bodies (30%), four open-globe injuries (40%), and nine eyes that received high-speed projectiles or sharp objects (90%). The complete V10-0 suture(s) absorption occurred in all eyes between D10 and M2. At M6, mean far and near BCVA decreased from 0.680 ± 0.753 and 0.490 ± 0.338 preoperatively to 0.050 ± 0.071 and 0.220 ± 0.063 logMAR (p = 0.019 and p = 0.025 respectively), mean CA decreased from 4.82 ± 3.86 preoperatively to 1.15 ± 0.66 diopters (p = 0.008). BCVA and CA were unchanged thereafter. No serious adverse event nor repeated surgery occurred. The mean number of teleconsultations was 1.20 ± 0.63 without an additional nonscheduled outpatient visit. Conclusions—The absorbable V10-0 sutures might be a safe and effective alternative for eligible corneal wounds, while reducing the number of outpatient visits, especially for children (no suture removal). The COVID-19 pandemic highlighted that they are ideally suited to logistical challenges.