ophthalmic trauma: risk and management update...ocular traumatologists and also to give...

Ophthalmic trauma: risk andmanagement updateExpert Rev. Ophthalmol. Early online, 1–15 (2014)

Bhaskar Gupta1,Indy Sian1 andRupesh Agrawal*2,3

1South West Peninsular Deanery, Royal

Devon and Exeter NHS Trust, Barrack

Road, Exeter, EX2 5DW, UK2Moorfields Eye Hospital, City Road,

London EC1V 2PD, UK3National Healthcare Group Eye

Institute, Tan Tock Seng Hospital,

Singapore, Singapore

*Author for correspondence:

[email protected]

Management of ocular trauma is both challenging and controversial. Using current availableevidence in literature and author experience this review aims to highlight critical issues inmanagement of ocular and orbital trauma. This review provides a working framework frominitial presentation, investigations, management principles, complications and prognosis tooutcome and controversies involved in management. The review will focus on the concept ofatraumatic repair of traumatized globe and will also give guidelines about strategic planningin ocular trauma management. Clinicians are occasionally faced with dilemmas and challengesin management of severely traumatized eyes with limited or no visual potential in view oflife-time risk of sympathetic ophthalmia and the authors aim to address the controversysurrounding it.

KEYWORDS: corneal trauma • no light perception • ocular trauma score • open globe injury • primary enucleation• ophthalmic trauma • traumatic cataract

Ocular injury is a frequent, preventable cause ofvisual impairment, with a lifetime prevalence of14.4–19.8% [1,2]. Pediatric patients account fora large proportion of these injuries and it is usu-ally accidental and uniocular [2,3]. Oculartrauma can result in a wide spectrum of injuryto the eye resulting in mild-to-severe ocularmorbidity. Mechanical injuries to the eye can beclassified into open globe injury (OGI) andclosed globe injury (CGI). OGI is defined as afull-thickness wound of the eye wall. Finalvisual results can be unpredictable and depen-dent on several variables like mechanism of theinjury, the initial post-trauma vision, presenceof relative afferent pupillary defect (RAPD),adnexal injury, wound location and size, lentic-ular damage, hyphema, vitreous hemorrhage,presence of intraocular foreign body (IOFB)and retinal detachment [4–6]. Mechanisms ofinjury can include contusion from fists, highpressure from blank cartridge [7], war injuries,golf ball [8] or sharp instrument like glass, darts,knives, forks, metal pins, slate, wire, pencils andscrewdrivers [6], etc. IOFB and object causingthe ocular trauma can be broadly grouped intovegetative or non-vegetative objects based ontheir risk of causing infection to the eye.

The conundrum of open globe injuries con-tinues to pose management dilemmas due tolack of use of standardized terminology andunawareness about principles of repair of

OGI. The standard practice worldwide inthese cases is to undertake a primary surgicalrepair to restore the structural integrity of theglobe at the earliest opportunity regardless ofthe extent of the injury and the presentingvisual acuity. This review aims to revisit thekey elements and provide updates in classifica-tion, diagnosis, investigation and managementof this complex clinical condition.

ClassificationBirmingham Eye Trauma Terminology(BETT) is the most commonly used oculartrauma terminology system and it provides aclear definition for each injury type and placesthe injury type within a comprehensiveframework (TABLE 1 & BOX 1) [9]. In practice,BETT only concerns mechanical eyeballinjury. BETT avoids any ambiguity in com-munication with regards to OGI. As a result,orbital and ocular adnexa injury cannot beclassified by BETT and other classification sys-tem have been proposed but not yet widely inuse [10]. In Classification and Regression Treeanalysis model (CART), Grant and collabora-tors have shown the significance of lid andadnexal laceration in predicting the final visualoutcome [4]. Agrawal et al. [11] also proposedto incorporate the adjacent orbital and adnexaltrauma and challenged the wisdom of using5 mm landmark to differentiate between zone

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II and zone III, but instead suggested to use anatomical land-mark: spiral of Tillaux or annulus of Zinn (ring of rectus mus-cle insertion) as the possible site to segregate two zones and tobe used in future prognostic model [11,12].

Model to prognostic outcome in OGIThere are two models to predict final visual outcome followingOGI, the ocular trauma score (OTS) (TABLE 2) [13] and theCART (FIGURE 1) [4]. Wound location is defined according to theOcular Trauma Classification Group [14]. The OTS is calcu-lated by assigning certain numerical raw points to six variables:initial visual acuity, globe rupture, endophthalmitis, perforating

injury, retinal detachment and an RAPD. The scores are strati-fied into five categories that give the probabilities of attaining arange of visual acuities post-injury (TABLE 2). Higher OTS scorestend to indicate a better prognosis. In CART classification tree,the presence of an RAPD and poor initial visual acuity are themost predictive of visual loss; the presence of lid laceration andposterior wound location also predicted poor visual outcome.In a study by Wai and Steel [15], the OTS had higher prognos-tic accuracy comparing OTS and CART models in the man-agement of OGI. The OTS score can also be calculated on theUS Eye Injury website [16]. The OTS provides both patient andophthalmologist with realistic estimates of the visual potentialand is a useful tool in patient counseling and management [15].OTS has been validated in several small and large series [17] andhelps to eliminate ambiguity in clinical communication amongocular traumatologists and also to give evidence-based prognos-tic outcome to trauma patient and family.

Model to prognosticate outcome in pediatric OGIOTS is also widely used and accepted in pediatric oculartrauma [18,19], but a new pediatric ocular trauma score (POTS)has been proposed (TABLE 3) [20]. POTS also takes into account thepatient’s age and the wound location, from which a similar sub-traction is performed with an expanded series of proposed nega-tive factors (TABLE 3). In pediatric population, it is often difficultto obtain initial visual acuity, this method hence describes anadditional equation that includes various assumptions to predictoutcomes. There is no convincing agreement between the OTSand POTS and the POTS produced a skewed distribution andconsistently produced a lower score compared with OTS [21].

First contact management with ocular trauma patientHistory

The mechanisms, timing and circumstances surrounding theinjury should be thoroughly documented in a clear, legiblehandwriting as it may become significant piece of medico-legalevidence in future. Any history of using protective eye wear,previous eye surgery or amblyopia should be recorded. Persongiving the information or bystander details should also berecorded. Every attempt should be made during this step torule out any associated life-threatening injury by asking relevantleading questions including loss of consciousness.

Systemic assessment

Ophthalmologist should take a step back and rule out any life-threatening injury before approaching any patient with oculartrauma in emergency settings. The patient should be examinedfor evidence of obvious signs and symptoms of serious systemicand life-threatening injuries. In severe injuries, basic andadvanced life support is the primary objective until the patient isstabilized. If neurosurgical concerns prevent pupillary dilation, acomprehensive evaluation of the posterior sclera, retina, choroid,ciliary body and optic nerve head may be compromised.Eye injuries should be covered immediately by a simple cartellaeye shield and any pressure including the pressure patch should

Table 1. Terminology of ocular trauma [9].

Terminology Definition/explanation

BETT Birmingham Eye Trauma Terminology

OGI Open globe injury

CGI Closed globe injury

Penetrating Full-thickness corneoscleral wound with

no exit wound

Perforating Full-thickness corneoscleral wound with

an exit wound

IOFB Intraocular foreign body retained in the globe

Box 1. Open globe injury classification [23].

Type

A. Rupture

B. Penetrating

C. Intraocular foreign body

D. Perforating

E. Mixed

Grade

Visual activity

1. ‡20/402. 20/50 to 20/100

3. 19/100 to 5/200

4. 4/200 to light perception

5. No light perception

Pupil

Positive: relative afferent pupillary defect present in affected

eye

Negative: relative afferent pupillary defect absent in

affected eye

Zone

I. Isolated to cornea (including the corneoscleral limbus)

II. Corneoscleral limbus to a point 5 mm posterior into the

sclera

III. Posterior to the anterior 5 mm of sclera

Review Gupta, Sian & Agrawal

doi: 10.1586/17469899.2014.931808 Expert Rev. Ophthalmol.

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be avoided to reduce the risk of infection. In the patients whohad either polytrauma or are unconscious or disoriented, briefophthalmic examination should be performed and documentedin medical records highlighting the reason for not able to performcomplete visual acuity examination. It is also essential that imme-diate relatives or caretakers are updated about the status of theeye and prognosis is these unconscious or disoriented patients.

Visual acuity

Visual acuity should be recorded in each eye. If distance visioncannot be recorded, efforts should be done to do near visionusing Jagger chart. If no letters on vision chart can be readthen efforts should be done to record for any counting finger,hand moment or accurate projection in all quadrants and per-ception of light (PL). To accurately record accurate projectionin all quadrants and PL vision, bright uniform source of lightlike from indirect ophthalmoscope should be used. However,caution should be exercised as PL is not a reliable test in thepresence of severe media opacity, even when the bright light ofan indirect ophthalmoscope is used. The absence of light per-ception is not an indication for enucleation, and the globe maybe salvageable [22]. If for some reason, it is not feasible to assessvisual acuity, the reason should be clearly documented in notes.

Ophthalmic assessment

The presence of an open-globe injury is determined by clinicalexamination and if there is inability to examine the globe, com-puted tomography (CT) can be resorted to examine the integ-rity of globe. In severe open globe injuries, there is often limitedview of the globe and fundus due to severe periorbital swellingand ecchymosis, hyphema, traumatic cataract and vitreous hem-orrhage. Every effort should be made to carry out thoroughsystematic examination of the lids andadnexa, cornea and sclera using brightlight and on slit lamp followed by fundusexamination with indirect ophthalmo-scope. It is imperative that the visual acu-ity should be recorded as the first step inapproaching patient with ocular traumadue to both management and medicolegalreasons. Photographic documentation ordiagrammatic representation of type andextent of injury should be done in allcases. It is advised to use freehand draw-ing to document the examination finding(FIGURE 2). An attempt should be made toclassify mechanical OGI as per interna-tional classification system laid down byPieramici et al. to prevent any furtherambiguity among the team [23]. In caseswhere OGI is suspected, but adequateexamination is not possible (e.g., pediatrictrauma), examination under anesthesia iswarranted to rule out disintegrity inthe globe.

Ocular signs

TABLE 4 gives an overview of the scope of globe injuries as perdifferent zones [24].

Pupillary reaction

Both direct and consensual light reflex should be checked andany RAPD should be documented. In cases with badly trauma-tized eye where the pupil may be distorted and invisible, theconsensual reflex in the fellow eye should be looked for tocheck for the integrity of optic nerve in the injured eye. Simi-larly, presence of RAPD in cases of blunt ocular trauma maybe the only clinical indicator of traumatic optic neuropathybesides subnormal visual acuity. Caution should always be

Table 2. Summation of raw points to calculate theocular trauma score [13].

Initial visual factor Raw points

Initial visual acuity No light perception 60

Light perception/hand

movements

70

1/200 to 19/200 80

20/200 to 20/50 90

>20/40 100

Globe rupture -23

Endophthalmitis -17

Perforating injury -14

Retinal detachment -11

Afferent pupillary defect -10

No

RAPD

Yes

No Yes

Initial vision

6/6 to HMLP

Lid laceration

Wound location

Zones 1 and 2 Zone 3

NPL

Vision (96.9%)No vision (3.1%)






Figure 1. The classification and regression tree model for open globe injury:visual survival (light perception or better) vs no visual survival [4].HM: Hand moment; LP: Light perception; NPL: No light perception; RAPD: Relativeafferent pupillary defect.

Ophthalmic trauma Review

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exercised in using presence of RAPD as a prognostic indicatorfor final outcome as it can be falsely positive in the presence ofsevere hyphema or subretinal vitreous hemorrhage and may dis-appear after reabsorption of hemorrhage [22,25,26].

Sequential assessment should be carried out and followingsigns can be illustrated in case of trauma as listed in TABLE 5 toexamine the various signs of ocular trauma.

Ancillary investigationsImaging

Common modalities for imaging the orbit and eye includeradiography, ultrasonography (USG), MRI and CT. Radiogra-phy is relatively sensitive to fractures of the orbit, while havinglow sensitivity for soft tissue injuries.

B-scan

USG can be very useful for evaluating the eye and its contentsincluding status of lens, presence of any vitreous inflammation/hemorrhage and retinal detachment in presence of media opac-ity; however, USG is contraindicated if an OGI is suspectedand one of the major limitations of ultrasound is that it isoperator- and interpreter-dependent. As ultrasound is a contacttechnique, it is imperative if it at all done on an open globedue care has to be exercised to prevent applying excess pressureon the open globe as it can further traumatize the globe andresult in expulsion of the intraocular contents. Caution shouldbe exercised in interpreting findings in eyes with trauma.Extensive vitreous strands and their focal attachment at discseen in such eyes may mimic focal retinal detachment. Simi-larly thick incomplete posterior vitreous detachment may bemistaken as retinal detachment, due to blood staining of theposterior hyaloid. Also, there can be presence of massive cho-roidal effusion due to low intraocular pressure (IOP) on ultra-sound scan, which usually resolves after repair of open globeinjury [27].

Computed tomography/MRI

A thorough ophthalmic examination, with particular attentiondirected toward the likelihood of ocular penetration, andincluding gonioscopy (where appropriate) and detailed dilatedfundoscopy remains the mainstay of management of ophthal-mic patients exposed to high-velocity particles [28]. Radiologistshould be provided with detailed history with regards to mech-anisms and circumstances surrounding trauma to facilitateselection of best imaging modality. CT scan is the main modal-ity of investigation for precise localization of the IOFB andalso in eyes with possibility of multiple intraocular foreignbodies and in orbital trauma. The sensitivity of CT forfractures is higher than that of radiography, and 3D reforma-tions after image acquisition can sometimes help to guidesubsequent surgical treatment. In patients with orbitaltrauma, CT scan 1–2 mm cuts axial and coronal slices, with3D reconstruction or orbital helical CT, should be requested.The advantages of helical CT over conventional CT include:much shorter scanning time (5 minwith traditional protocol); reduced motion artifacts; muchlower radiation exposure; much more sensitive in detectingsoft tissue entrapment, especially in pediatric patients. Thebest protocol is to obtain thin-section axial CT scans, then

Table 3. Summation of raw points to calculate thepediatric ocular trauma score [20].

Variables Raw points

Initial visual acuity

NLP 10

LP/HM 20

Counting fingers 30

0.1–0.5 40

0.6–1.0 50

Age of the pediatric patients (years)

0–5 10

6–10 15

11–15 25

Wound location

Zone I 25

Zone II 15

Zone III 10

Concomitant eye pathologies

Iris prolapse -5

Hyphema -5

Organic/unclean injury -5

Delay of surgery (>48 h) -5

Traumatic cataract -10

Vitreous hemorrhage -20

Retinal detachment -20

Endophthalmitis -30

HM: Hand moment; LP: Light perception; NLP: No light perception.

Limbal involvement Type of laceration

Site of laceration

Involving visualaxis

Dimensions

Depth

Shape

Clarity of the cornea

Foreign body entry site

Siedel’s test

Figure 2. Diagrammatic representation of corneal injury.



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to perform multiplanar reformation. When evaluating apatient with an orbital injury, the radiologist should do thefollowing: evaluate the bony orbit for fractures, note any her-niation of orbital contents and pay particular attention to theorbital apex; evaluate the anterior chamber; evaluate the posi-tion of the lens (the lens may be displaced, and it may beeither completely or partially dislocated); evaluate the poste-rior segment of the globe; look for bleeds or abnormal fluidcollections; evaluate for radiopaque or radiolucent foreignbodies and evaluate the ophthalmic veins and the optic nervecomplex, especially the orbital apex [29].

Utility of the imaging modalities can be user dependent, andability to accurately diagnose and locate IOFB depends on the

size and nature of suspected material. The sensitivity of CT fordetecting clinical occult open-globe injuries can be as low as56–68% [29]. In a study by Gor et al. [30], helical CT comparedwith MRI or ultrasound offers the most sensitive imagingmodality for the detection of intraocular glass material [30].Zhang et al. [31] reported that CT can fail to detect metal frag-ments

nerve swelling, while CT detects whether there is optic canalfracture and neither is sensitive enough to pick up early post-traumatic changes that often occur at the microvascular andaxonal bundle levels. As such, false-negative rate remainshigh [32].

Orthoptic assessment/Hess chart

Baseline orthoptic assessment and Hess chart should be per-formed in cases of suspected orbital trauma only and prior toany surgical intervention. This can be repeated post-surgery tochart the progress of patient symptoms and diplopia andfuture management.

ManagementThe primary objective of primary globe repair is to restore theanatomical integrity and maximize the visual potential. Eventhough the primary objective is to restore anatomical integrity,the surgeon should bear in mind that eye is a refractive organwith visual function and all due care should be taken to pre-serve optical properties of eye and efforts should be taken forvisual rehabilitation of traumatized globe.

The four-pronged approach for management of open globeinjuries should be pursued as broad principles in preventingrisk and optimizing the outcome:

• minimize possibility of further trauma;• minimize risk of infection;• minimize psychological trauma to the trauma victim and hisfamily and

• minimize legal problems.

Preoperative work-upPreoperative antibiotics

While patients await investigation and surgical management,their tetanus status should be established in accordance withpolicy framework of the CDC and broad-spectrum intravenousantibiotics for at least 48 h is advocated depending on localhealth and infection control policy [33,34].

Timing of surgery

Primary globe repair should ideally be completed as soon aspossible, preferably within first 24 h unless contraindicated dueto other medical condition.

Consent

Long-term ophthalmic care can be demanding on patients,especially for those who assume an open globe repair is defini-tive treatment. After the initial evaluation, the ophthalmologistmust adequately inform the patient and family about the statusof the eye, the surgical plan and its complications. This shouldinclude preoperative discussion that the initial repair will likelybe only the first step to a successful recovery. The guardedprognosis of an OGI should be shared with the patient preop-eratively to ensure realistic expectations of recovery. Risk ofinfection and multiple surgeries should be clearly explained to

the patient while taking consent for surgery. Likewise, potentialrisk of sympathetic ophthalmia (SO) should be explained tothe patients with ocular trauma during the consent process.

Postoperative care & follow-up

Postoperatively, a multidisciplinary approach to managementand follow-up is essential for proper surgical rehabilitation ofOGI patients [35]. A meticulous follow-up and documentationis essential in management of eyes with trauma. Recording ofIOP, retina status and lens status and corneal sutures monitor-ing are all important components in postoperative care oftraumatized globe.

Anesthesia

Most lid repair in adults without canalicular tear or significantlid margin involvement can be performed under local/regionalanesthesia. The choice of anesthetic drug in management ofocular trauma and especially in presence of OGI remains con-troversial, but by and large general anesthesia is advised in ocu-lar trauma unless contraindicated. In our unpublished data, wehave performed repair of corneal laceration under topical anes-thesia, with good postoperative outcome (FIGURE 3). However, thecase selection for corneal laceration should be the key and itshould be done by an experienced surgeon only. Chidiac andRaiskin reviewed the risks involved with the use of succinylcho-line and its alternatives, including regional anesthesia for openglobe injuries and proposed an algorithm for airway manage-ment of patients with penetrating eye injuries, highlighting cir-cumstances where succinylcholine may be the safest musclerelaxant (FIGURE 4) [36].

Surgical approachLid & adnexa

Herzum et al. reported that lesions of lacrimal drainage systemare known to occur in 16% of all eyelid injuries [37]. Key ele-ment in the management of canalicular tear is careful preopera-tive assessment and meticulous surgery to reduce the incidenceof epiphora and poor cosmesis. Surgical techniques vary widelyincluding lid repair with laissez faire, canalicular exteriorization,mono- or bicanalicular stenting [38], with or without mucosalanastomosis, conjunctival/canaliculo-dacryorhinostomy, butthere is a general agreement on the need for immediate stentingof bicanalicular injuries. Stenting with monocanalicular or bica-nalicular silicone tubes helps to maintain the integrity of thelacerated system. Additional eyelid laceration repair then shouldproceed around the silicone tube. There is no consensus regard-ing the exact duration for which the canaliculi should remainstented to achieve long-term patency, but it generally is left inplace for 3–6 months.

Chang and Rubin [39] in their review highlighted key man-agement issues in lid laceration repair. Delay in surgical lidrepair by 12–36 h did not alter the outcome of closure, andallowed periorbital swelling to subside in order to allow bettervisualization of tissue re-approximation. The authors recom-mend 5-0 or 6-0 polyglactin sutures for deep tissue, 6-0 or



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7-0 nylon or silk sutures for eyelid mar-gin approximation, followed by 6-0 silkor nylon sutures for superficial skin clo-sure. In children, self-absorbing plain gutsutures may be substituted for the marginand the superficial skin at it may bedifficult to remove sutures without expos-ing them to risk of additional generalanesthesia.

Cornea & sclera

Under general anesthesia, during the ini-tial exploratory surgery, foreign debrisshould be removed as much safely as pos-sible. Limbus should be secured first fol-lowed by cornea and sclera at the end. Standard surgical stepsinvolved 360 degrees conjunctival peritomy with blunt dissec-tion, limbal followed by corneal laceration repair with inter-rupted 10-0 nylon suture followed by sclera with interrupted7-0 vicryl sutures. Corneal sutures should be placed radiallyand watertight. They should neither be too tight to distort thecornea nor too loose leading to wound disintegration duringsecond stage surgery for traumatic cataract or vitreoretina, ifindicated. Corneal sutures should straddle the wound and theyshould not be passed through the visual axis, if possible. Cor-neal sutures should be superficial, slightly loose and shorter incenter of the cornea than in peripheral cornea. In peripheralcornea, the sutures should be deep, tight and longer as com-pared with central sutures (FIGURE 5). Similarly, delicate or mini-mal handling of corneal tissue should be done to preventdistortion of the wound edges. We advocate no touch tech-nique (FIGURE 6) by experienced surgeons to further optimize theoutcome in patients with corneal laceration. Stellate corneal lac-eration should be repaired using purse string sutures. Futurerisk of cheese wiring can be avoided by using longer tightsutures in corneal wound with edematous edges.

Scleral wound extending beyond rectus insertion, the rectusmay need to be disinserted in selectedcases after placing preplaced 6-0 vicrylsuture and is repaired as far posteriorly aspossible. The scleral wound where thelaceration is not underneath the rectusmuscle, we may not need to disinsert therectus. Care should be taken to preventuveal/choroidal/retinal incarcerationwithin wound. Any prolapsing vitreousshould be cleared by cutting with help ofvitrector to avoid stress and traction onthe vitreous and on the retina. We wouldlike to advocate the term ‘atraumaticrepair’ in management of scleral wound,where surgeon should take due cautionto explore and close the scleral woundusing hands on technique. Surgeon needto exercise due care to not cause further

trauma to the globe during repair of corneoscleral laceration.Basic principles of corneal laceration repair should be followedto prevent distorting the final anatomical configuration of thecornea (FIGURE 6A). During scleral wound exploration and repair,there can be undue traction on the wound leading to expulsionof vitreous or intraocular contents (FIGURE 6B), hence gentlemaneuvering of tissue is advised during scleral wound repairextending posteriorly. No attempt should be done tocompletely explore the wound before attempting part closureof the scleral wound as that would lead to expulsion of the vit-reous and intraocular contents. Wound should be securedwatertight followed by re-insertion of muscle and generous sub-tenon’s antibiotic wash and suconjunctival antibiotics. Eyeshould be checked on day 1 following surgery and visualacuity, anterior and posterior segment examination and serialB-scans for posterior segment status should be carried out.

Lens & cataract surgery

Cataract can develop promptly after trauma to the globe eitherdue to breach in capsule or perforating injury or in cases withCGI it can take up to many years for rosette cataract to form.The lens status and stability can get further compromised due

Post operativePre operative

Figure 3. Pre- and postoperative corneal laceration repair performed undertopical anesthesia.

Yes

Is this an easy airway?

Non-depolarizing muscle relaxant Is the eye viable?

No

Yes

Succinylcholine androutine laryngoscopy

Fiberoptic laryngoscopy

No

Figure 4. Anesthetic algorithm in management of open globe injury.Adapted from [36].



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to associated zonular dehiscence, posterior capsular rupture andnumber of surgeries to posterior segment to restore anatomicalintegrity and use of intraocular tamponade agent. Anterior cap-sular disruption increases the risk of severe postoperativeinflammation, endophthalmitis and in cases with OGI andanterior capsular disruption with lens matter in anterior cham-ber, combined wound repair with lens aspiration with or with-out intraocular lens (IOL) implantation may be indicated.Primary cataract extraction should be considered if it hindersvisualization of the posterior segment or risk of rapid elevationof the IOP [40]. Simultaneous repair of the penetrating woundand IOL implantation after cataract extraction has been welladvocated [41,42], but in all cases silicone lenses should beavoided and caution is advised as inaccuracy in IOL calculationis well documented when using biometry from the othereye [43]. It is imperative that cataract surgeon should understandthe complexities involved in management of traumatic cataract

and IOL implantation and should apprehend the patient pre-operatively. In a study by Shah et al. [44] at 6 weeks postopera-tively, 31% eyes had a visual acuity > 20/40 and 61.0% > 20/200 after surgery and IOL implant following traumatic cataractrepair and amblyopia management wherever necessary. Theresults with secondary lens implantation seem at least as goodbut not necessarily any better than primary lens implanta-tion [45] and gives time for the inflamed eye to settle and sur-geon to plan better. Primary cataract extraction along withOGI should hence be done in eyes with ruptured lens matterin the anterior chamber. Two-stage surgery is advocated in eyeswith less severe trauma to the lens where anterior capsularintegrity is preserved or minimally disrupted without significantlens matter in the anterior chamber. For combined cataractextraction along with primary corneal wound repair, separatesurgical section (limbal incision) should be planned and at nopoint cataract should be removed through site of laceration.

Orbital fracture

The types of fractures, mechanism of injury and timing of pos-sible treatment differ among children and adults. Orbital bonesare more elastic in children compared with adults. This resultsin more trapdoor-type injuries and frequent entrapment ofextraocular muscle, orbital connective tissue and fat in compari-son to adults [46,47]. Timing and indications for orbital fracturerepair are controversial. Detailed discussion about orbitaltrauma is beyond the scope of this article.

Vitrectomy

Vitreoretinal surgical techniques allow many poor prognosiseyes to be salvaged [48,49]. Broadly, indications can begrouped under retinal detachment with or without prolifer-ative retinopathy, intraocular foreign body, lens-related prob-lems and others. Scleral buckling also can be considered intraumatic retinal detachment without vitreous hemorrhage orproliferative vitreoretinopathy (PVR). In some of the com-plex cases, combined buckle and vitrectomy may have to beperformed.

Retinal detachment

Traumatic detachments may occur as aresult of retinal dialysis, flap tears, giantretinal tears, retinal necrosis and stretchtears. Eyes with trauma and retinal tearare at high risk of PVR and likely toundergo vitrectomy. It can be present atthe time of injury or develop post-globerepair and the incidence varies from2.5 to 39% [50]. More posterior injuriesare associated with at least a fourfoldincreased likelihood of retinal detach-ment [51]. Longer wound length(>10 mm), vitreous prolapse, vitreoushemorrhage, rupture injury (vs laceration)and retained IOFB are other factors that

Central cornealsutures to be shorter

and loose ascompare to

peripheral sutures

Peripheral cornealsutures to be longer and

tight as compare tocentral sutures

Figure 5. Diagrammatic representation of corneallaceration repair with varying suture lengths in center andmid-periphery.

A B

Figure 6. Atraumatic repair of the globe. (A) Corneal laceration repair resulting indistorted anatomical shape of the cornea. (B) Intraoperative snap shot of scleral lacera-tion repair showing use of traction suture resulting in severe traction on the scleralwound with partial expulsion of the vitreous. Both figures illustrates further trauma tothe globe and hence surgeon should exercise atraumatic repair of the traumatized eyes.



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increase the likelihood of retinal detachment after OGI [50].Other indication for vitrectomy in presence of retinal detach-ment can include prior failed vitreoretinal surgery, cataract orlens subluxation, vitreous hemorrhage or haze, multiple retinalbreaks, posterior retinal breaks, giant retinal tear, retinal or vit-reous incarceration and intragel abscess.

With the development of better instrumentation, smallergauge vitrectomy, improved fluidics control and wide-angledviewing system pars plana vitrectomy (PPV) is now the pre-ferred method of retinal detachment repair after open-globeinjury with or without scleral buckle. The anatomic and func-tional success rate vary between 75 and 85% [52,53]. There wasno consensus as regarding timing of PPV with some surgeonsopting to go for early vitrectomy (

orbit or axonal swelling post-traumatic inflammation. Othermechanism can be direct impingement of bony fragmentwithin optic canal. Large multicenter have failed to show anybeneficial effect of mega dose steroids or orbital decompressionin improving recovery compared with observation and there arehigh rates of spontaneous recovery [71,72].

Traumatic maculopathy & extramacular retinal injuries

Commotio retinae accounts for 0.4% of civilian and 15% ofmilitary eye injuries, affecting the macula in 73% of militaryinjuries [73]. In a study by Blanch et al. [74], 26% of theirpatients were left with a visual acuity of 20/30. There is known treatment for thiscondition.

Evisceration/enucleation

Primary enucleation should be avoided because the occurrenceof SO is rare [75] and also it can leave severe mental and psy-chological trauma to the patient and his/her family. In a studyby Knyazer et al. [76], less than 4% required primary enucle-ation and only a total of 6% eyes required eventual eviscera-tion/enucleation. However, failure to primarily enucleate amassively traumatized globe with no visual potential can have adeleterious effect on the ability of allied specialties to repairassociated maxillofacial injuries for fear of damaging therepaired globe. Further, secondary enucleation requires addi-tional general anesthesia, presents a higher risk of implantexposure and extrusion and further compounds the already sig-nificant psychological effect of poor cosmesis [6]. Hence, duediligence should be exercised in anatomically restoring theglobe integrity even in eyes with no light perception and only

in exceptional cases (FIGURE 7), the surgeon should contemplateprimary removal of the globe. Presence of lid laceration,RAPD, the absence of a red reflex and blunt mechanism ofinjury pose high risks for enucleation [6].

Management of infection/inflammationInfection to globe

Post-traumatic endophthalmitis comprises 25–30% of allendophthalmitis cases and it occurs in 3–10% [33,76] of casesafter penetrating trauma to the eye. This rate changes to6–30% with the presence of an IOFB [77]. Early surgical repairand prophylactic systemic intravenous antibiotics for 48 h mayreduce this incidence to 24 h. Most common bacteria being coagulase-negative Staphylococcus, Bacillus cereus streptococci, Gram-negative bacilli such as Klebsiella and Pseudomonas andmoulds [33]. The diagnosis of post-traumatic endophthalmitis ismainly based on clinical examination and treatment includeprompt recognition, intervention such as vitreous tap or vitrec-tomy followed by intravitreal injection of antibiotics (e.g., van-comycin plus ceftazidime) and systemic therapy [33,34]. Orallevofloxacin 500 mg (5–10 days) or moxifloxacin 400 mg peraverage adult per day can be sufficient to reach adequate vitre-ous concentration against the majority of microorganisms [78].In high-risk cases, intravenous administration of 1 g vancomy-cin and 1 g ceftazidime per average adult per day is effective;0.3% concentrations of topical fluoroquinolones like ciprofloxa-cin, moxifloxacin or gatifloxacin can be added to support thetreatment [78]. Molecular biology techniques, especially PCRmay be helpful as it is more sensitive and increases the diagnos-tic yield from a small vitreous sample [79]. The prognosis ofstreptococcal and Gram-negative B. cereus endophthalmitis isworse than coagulase-negative staphylococcal endophthalmitis.Also there has been increased resistance of coagulase-negativebacteria to fourth-generation quinolones [80] and hence systemicantibiotics should be tailored according to clinical needs and inconsultation with local infection control team. There is highincidence of retinal detachment (17–58%) and risk of phthisisin eyes with post-traumatic endophthalmitis.

Sympathetic ophthalmia

SO is a rare, bilateral granulomatous panuveitis following acci-dental or surgical trauma to one eye. The time from ocularinjury to its onset varies greatly, ranging from a few days todecades, with 80% of the cases occurring within 3 months afterinjury to the exciting eye and 90% within 1 year [81]. Thepathophysiology is not clearly understood, but is believed to bea T-cell-mediated autoimmune response. The mainstay of treat-ment is systemic immunomodulatory therapy. Systemic cortico-steroids are the first-line therapy for SO, but other agents likecyclosporine, chlorambucil, cyclophosphamide or azathioprinemay also be utilized if the inflammatory reaction cannot beadequately controlled with corticosteroids alone.

Figure 7. Severely traumatized globe withsemi-autovisceration (rare indication for primaryenucleation/evisceration.



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Visual predictors

It is still difficult to predict final visual outcome. On average,around 30% of OGIs remain in the visual acuity of finger countonly. There have been numerous variables identified to affectfinal outcome in patients with OGI [6,82]. Those that have beenfound to correlate significantly with vision outcome include age,type or mechanism of injury, initial visual acuity, presence ofRAPD, extent, size and location of wound, lens damage,hyphema, vitreous hemorrhage, retinal detachment and presenceof IOFB [6,82]. Other variable that may affect final visual out-come may include nature of object. Injury from a sharp object(laceration) has better final visual acuity than patients who suffercontusion. This finding is explained by limited tissue damagedue to different velocity and mechanism of injury with sharpedges of the wound that promote accurate and less disfiguringwound closure. In data from the US Eye Injury Registry, all theeyes with initial visual acuity of hand movements or better eitherimproved from presenting visual acuity or maintained samevision [23]. In a study by Rahman et al., initial good visual acuity(6/60 or better) was associated with an excellent visual outcome(6/12 or better) in 93% cases [6].

An eye injury that causes NLP typically carries an unfavor-able prognosis and is a common indication for enucleation.Very few studies have analyzed outcome of severely traumatizedeyes with NLP. The US Eye Injury Registry had reportedimprovement of vision in 16% of eyes with NLP at initialvision. In a study by Agrawal et al. [22] of the eyes that pre-sented with NLP, 66.7% eyes remained NLP after primaryglobe restoration surgery and 22.22% eyes had phthisicalchanges. Schmidt et al. [4] reported on 39 eyes with NLP inwhich 6 eyes recovered more than light perception vision.However, more encouraging results were reported by Heidariand Taheri [83], with 35% eyes achieving having final vision>20/200 and 90% eyes improving from NLP at presentation.Similar good results were reported by Salehi-Had et al. [84] intheir case series of eight eyes with NLP. In a study byFeng et al. [85], ciliary body damage, closed funnel retinaldetachment and choroidal damage were independent risk fac-tors for NLP post-trauma, but were not prognostic indicatorsfor NLP visual outcome. They concluded that traumatized eyeswith NLP may recover light perception or better vision ifappropriate interventional measures are used for treatment ofthe injured ciliary body, retina and choroid [85]. Visual acuitycan be profoundly impaired in presence of significant mediaopacity (e.g., corneal edema, hyphema, cataract, dense vitreoushemorrhage), retinal detachment, associated subretinal or sub-hyaloid hemorrhage, hemorrhagic choroidals and even psycho-logical factors (e.g., hysteria). Assessment of light perception inpresence of severe media opacity even with the brightest lightof an indirect ophthalmoscope can give impression of NLP [86].Similarly, RAPD may be falsely positive in the presence ofdense hyphema or subretinal vitreous hemorrhage and may dis-appear after reabsorption or removal of the hemorrhage [25].Before deciding on enucleation in patients with NLP, reversiblecauses of vision loss should be excluded including psychological

factors. Even in situations in which enucleation seems inevita-ble, all possible option should ideally be explored in consulta-tion with patient.

In pediatric patients with OGI: age 6 mm, vitreoushemorrhage and retinal detachment were shown to be indepen-dent predictive factors for a final best corrected visual acuity>20/40. A shallow anterior chamber, absence of the red reflex,hyphema and lens dislocation/extrusion were not found to beindependently associated with a poor final visual outcome [21].Amblyopia can also occur in older children, it is likely to repre-sent a major confounding factor in those

findings and hospital visits should be well documented, timedand dated. This information may stand as important piece ofevidence in court of Law and in legal cases where compensa-tions are granted against employers, other person, etc. Properdocumentation and decision taken with involvement of patientin general minimize risk of future litigations against treatingphysicians.

Expert commentaryOpen globe injuries present an ophthalmologist with manage-ment dilemmas with many unresolved controversies. The visualprognosis at presentation is often difficult to assess in the vastmajority of injuries leading to primary repair. Multiple intraoc-ular surgical procedures may be needed on such eyes in anattempt to salvage some useful vision. We have come a longway in the field of ophthalmology from intracapsular cataractsurgery to femtosecond refractive surgery and from subjectivemacular assessment to Fourier domain and adaptive opticsimaging of the macula. Likewise, we are in the era of ocularnanotechnology and its application in ocular pathologies. Theresults of globe injuries have improved with better understand-ing of complications and improvement in techniques of vitrec-tomy, however, still many eyes still end up in poor vision.Despite all the work and efforts of key players in the field ofocular trauma, it still searches for recognition and identity as asubspeciality. Not many ophthalmologists are familiar with theterminology of ocular trauma and still reckon OTS as researchtool and the eye injury registry is most ignored and neglectedpart in the clinics. With the basic understanding of eyes withOGI and following the concepts of ocular trauma repair, wecan prevent significant ocular morbidity due to this devastatingentity. Concept of atraumatic repair needs to be ingrained intostrategic planning in ocular trauma management to achieveoptimal outcome in globe trauma. Multidisciplinary approachis warranted in patients with complex ocular trauma. Empow-ering the patients with tools such as OTS can further enhancethe holistic management of trauma victim and family. Likewise,empowering the fellow ophthalmologists with specialty trainingin ocular trauma can be one of the steps forward in optimizingthe outcome in patients with ocular trauma and further stream-lining the care of traumatized eyes. Medicolegal litigation can

be minimized by good documentation, establishing rapportwith the patient and family and following the basic principlesin management of ocular trauma.

Five-year viewOne of the most neglected parts in ocular trauma managementis very weak epidemiological data. Every attempt should bemade by the local and national societies to mandate the report-ing of eyes with OGI, if not all eyes with ocular trauma undercommon local registry. Further attempts should be made tolink the local registry with the state and national registry, whichshould be eventually linked to the international registry of ocu-lar trauma. The epidemiologic data hence generated will guideus about the impact and burden of this problem and in termsof health economics research will pave the way for boosting uphealthcare policy and resources to prevent this gigantic but pre-ventable cause of blindness. It will also highlight any obviousregional and national causes and safety tools than can bedevised accordingly. Training of junior ophthalmologists inmanagement of orbital trauma along with training in cataractshould be part of the curriculum and the trainees should begiven exposure in theatres or use of wet labs. Unsupervisedrepair of the traumatized eyes by inexperienced surgeons shouldbe strongly discouraged and every attempt should be made totransfer the surgical skills to the novice surgeon by more experi-enced surgeon. Likewise, prospective multicenter studies needto be conducted to further investigate the prognostic factors inOGI and to revisit classification of ocular trauma and OTSand to redefine some of these parameters based on the analysisand outcome of prospective multicenter studies. A strongemphasis on preventative aspects should be the major goal inthe next 5 years and this may involve closely working with reg-ulatory authorities in healthcare planning.

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with

any organization or entity with a financial interest in or financial conflict

with the subject matter or materials discussed in the manuscript. This

includes employment, consultancies, honoraria, stock ownership or options,

expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• In any patient with ophthalmic trauma, any life-threatening injury should be first ruled out.

• Assess visual acuity status in patients with ocular trauma at time of presentation and in both eyes.

• Document all the findings legibly using clinical photographs or diagrammatic representation as these cases can be potentially

medicolegal.

• Use the international terminology and classification system in ocular trauma eyes to prevent any ambiguity in communication.

• There should be committed multidisciplinary team in management of the complex traumatized eyes.

• Globe injuries should be managed using the broad principles of ocular trauma management and surgical repair of these eyes should be

based on ‘atraumatic repair’ approach.

• Counseling needs to be the main backbone in management of trauma patients and hence the clinicians need to empower patients with

tools such as ocular trauma score and it should be used regularly with use of standardized terminology for ocular trauma.



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ClassificationModel to prognostic outcome in OGIModel to prognosticate outcome in pediatric OGIFirst contact management with ocular trauma patientHistorySystemic assessmentVisual acuityOphthalmic assessmentOcular signsPupillary reaction

Ancillary investigationsImagingB-scanComputed tomography/MRIOrthoptic assessment/Hess chart

ManagementPreoperative work-upPreoperative antibioticsTiming of surgeryConsentPostoperative care & follow-upAnesthesia

Surgical approachLid & adnexaCornea & scleraLens & cataract surgeryOrbital fractureVitrectomyRetinal detachmentIntraocular foreign bodyVitrectomy in eyes with no light perception

Other injuriesRetrobulbar hemorrhageTraumatic hyphemaTraumatic optic neuropathyTraumatic maculopathy & extramacular retinal injuriesEvisceration/enucleation

Management of infection/inflammationInfection to globeSympathetic ophthalmiaVisual predictorsVisual rehabilitation & quality of lifeMedico-legal

Expert commentaryFive-year viewFinancial & competing interests disclosure

ophthalmic trauma: risk and management update...ocular traumatologists and also to give...

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