Globe Trauma Research Articles

Traumatic open globe injury—epidemiology, risk factors and visual outcome at the University Hospital Aachen

Summary Background Ocular trauma is still a major cause leading to enucleation. This study aims to analyze the visual outcome, epidemiology and risk factors of open globe injury (OGI) at the University Hospital Aachen, Germany. Material and methods A retrospective analysis of patient records involving traumatic OGI treated surgically between 2005 and 2015 was conducted. Age, gender, cause of accident, ocular trauma score, best corrected visual acuity (BCVA) at presentation and after treatment as well as location of injury were evaluated. Results Of 2272 eyes with trauma, 102 patients with OGI were identified, of which 65% were male and 35% were female. Women were significantly older than men (p < 0.001). The most common cause of injury was domestic syncopal episodes (47%). Work-related injuries occurred exclusively in men in 8.8%. A total of 16% had no light perception (NLP) at presentation, 69% of which improved post intervention to hand movement or better. Endophthalmitis was observed in 4% of all cases. Enucleation was needed mostly due to rupture. Location of OGI, pseudophakia and initial BCVA are risk factors for poor final BCVA. Patients’ BCVA did not improve further after three surgeries. Conclusion Traumatic OGI still poses a challenge in terms of treatment planning and prognostic outcome. A rise in elderly patients with multimorbidity represents a secondary obstacle to treatment. Patients with initial NLP can be treated with moderate success. Nevertheless, risk factors and ocular trauma score are unable to provide definitive therapy decisions. OGI should be assessed case by case, taking risk factors for OGI into account. Treating physicians should consider the ethical and economic reasons with regard to whether a high number of surgeries with possible comorbidities is justified.

Result Of Pars Plana Vitrectomy In Post Traumatic Endophthalmitis

Aim:To evaluate visual outcomes and identify prognostic factors after pars plana vitrectomy (PPV) surgery for traumatic endophthalmitis.Methods:Medical records of 20 patients diagnosed with traumatic endophthalmitis that had undergone pars plana vitrectomy were retrospectively reviewed.Result:20 patients all underwent PPV surgery.50% of them obtained BCVA better than fingers counting (FC). Good final visual prognosis was significantly associated between trauma and PPV treatment.Conclusions:Good visual outcomes can be achieved for most patients who undergo vitreoretinal surgery after open globe trauma.

Health-seeking behavior and the initial economic impact of patients with open globe injuries seeking treatment in a tertiary care center in India.

Purpose:The aim of this study was to assess the health-seeking behavior and the costs of primary treatment in the immediate aftermath of open globe trauma among patients seeking care at a tertiary eye care center in South India.Methods:This prospective observational study was carried out from June to December 2019. Details of the patient’s demographic profile, health-seeking behavior immediately following the trauma and total cost incurred till the completion of primary treatment were collected.Results:Eighty-five patients were recruited. Majority of patients were men (53, 82.8%), came from rural areas (65, 76.4%) and were the main breadwinners (44, 68%) of their family. After the initial trauma, a vast majority of the patients (68, 80%) visited the nearest eye care provider to obtain treatment and a majority of them (47, 69.1%) reached there within 3 h. The remaining patients (17, 20%) came directly to our center, the base hospital (BH). The mean distance travelled to the BH was 113.6 km. The mean total cost incurred was INR 20107.6 ± 10441.3. Approximately 84.8% of the patients reported a monthly income less than this amount.Conclusion:The economic impact of receiving primary definitive care following open globe injuries is higher than the average monthly income of more than 2/3rd of the patients. To replicate the success stories like the cataract outreach programs, there is a need to implement an integrated program encompassing workplace safety, legal protection to primary eye care providers and providing economic support for definitive treatment for the vulnerable population.

Intravitreal injection worsens outcomes in a mouse model of indirect traumatic optic neuropathy from closed globe injury

It is well established that an intravitreal needle poke or injection of buffer is protective to the retina in models of photoreceptor degeneration due to release of endogenous neurotrophic factors. Here we assess the effect of intravitreal injection of buffer in a model of closed globe trauma that causes air-blast induced indirect traumatic optic neuropathy (bITON). We injected animals 1-day after the last bITON or sham procedure and performed assessments 1-month later. Surprisingly, we detected a lower electroretinogram (ERG), greater optic nerve damage, and increased levels of pro-inflammatory cytokines in animals given an intravitreal injection. The effect was sometimes independent of bITON and sometimes exacerbated by the injury. Retina histology appeared normal, however the total number of axons in the optic nerve was lower even in uninjured animals that were injected. The number of degenerative axons was further increased in injured animals that were injected. In contrast, we detected a decrease in the ERG a wave and b wave amplitudes, but no effect on the visual evoked potential. Levels of the pro-inflammatory cytokines, IL-1α and IL-1β were elevated in the mice that received an intravitreal injection. This increase was even greater in animals that also had a bITON. This suggests that intravitreal injections may be injurious to the optic nerve particularly during the acute stage of optic nerve injury. In addition, the data suggests a role for IL-1α and IL-1β in this response.

Visual Rehabilitation With Contact Lenses Following Open Globe Trauma.

To describe visual outcomes with various contact lens modalities in patients with a history of ocular trauma who underwent surgical open globe repair. Records of all patients with a history of open globe injury and repair at a tertiary care hospital between January 1, 2010, and December 31, 2016, were reviewed. Demographics, type of injury, and visual acuity were assessed before and after contact lens evaluation. Of 214 patients who underwent open globe repair, 29 (13.6%) were evaluated with a contact lens. Visual acuity improved in 97% (28 of 29) of patients from 1.47±0.75 to 0.67±0.71 logarithm of the minimal angle of resolution (logMAR) with manifest refraction to 0.28±0.45 logMAR with contact lenses (n=29; P<0.0001). Corneal opacity was the most common clinical indication (20 of 29) for fitting followed by aphakia (13 of 29). A range of contact lens modalities, including corneal rigid gas-permeable (12 of 28), soft (9 of 28), hybrid (3 of 28), scleral gas-permeable (2 of 28), and piggyback (2 of 28) lenses were prescribed. In this study, patients with a history of trauma and open globe repair with good neurosensory visual potential had improvements in visual acuity with contact lens greater than manifest refraction. Soft and gas-permeable lenses were used to improve visual acuity in patients with a history of open globe repair and corneal scarring, aphakia, iris abnormalities, or other ocular sequelae. Although corneal rigid gas-permeable lenses were prescribed most often, additional consideration should be given to other contact lens modalities, including soft, piggyback, hybrid, and scleral gas-permeable lenses.

Open-globe-injury: A single center Spanish retrospective 5-year cohort study.

To review and analyze the epidemiological profile, clinical characteristics and visual outcomes in patients attended for traumatic open globe injury (OGI) at our hospital over a 5-year period. Retrospective chart review study. Retrospective analysis of all patients attended at Fundación Jiménez Díaz University Hospital for OGI between 2011 and 2015. Data from 104 patients including demographics, ocular examination, medical and surgical treatment, visual outcomes, and complications were analyzed. Most patients were male (79.8%) and the median age at the time of injury was 41 years (interquartile range 31.5-58 years). Work-related accidents represent more than half of the cases and their main mechanism was penetrating trauma or foreign body. This type of accident had good prognosis (median final visual acuity in decimal scale 0.8; interquartile range 0.4-1). Falls were the second most common cause of OGI, predominantly affecting senior women (50%), with a high incidence of ocular rupture (50%) and associating a poor visual prognosis (median final visual acuity 0.01; interquartile range 0-0.5). There was a strong correlation (0.75; p < 0.001) between ocular trauma score (OTS) and final best corrected visual acuity. Two different patterns of OGI were identified in our sample. Work-related trauma in young males was the most common form of OGI and was associated with good prognosis. However, falls in senior women were associated with poor prognosis.

Less-Lethal Weapons Resulting in Ophthalmic Injuries: A Review and Recent Example of Eye Trauma.

IntroductionPrior reports have highlighted the dangers of crowd control weapons such as rubber bullets, paintball guns, and pepper spray. Many of these reports were written decades ago and outside of the USA. We summarize a review of the literature and discuss a contemporary case of a ruptured globe and facial trauma secondary to a projectile weapon. This case serves to highlight the severity of eye trauma caused by less-lethal weapons; severe morbidity or even mortality can occur.Clinical DescriptionA civilian presented after a projectile weapon reportedly fired by Denver law enforcement struck his face during one of the recent protests in May 2020 in Denver. Upon ophthalmic examination, we observed no light perception (NLP) vision, periorbital ecchymosis, and devastating globe trauma.Primary Diagnosis, Interventions, and OutcomesFurther examination revealed a severely ruptured globe with extensive hemorrhage and extrusion of intraocular contents. Attempts to repair the ruptured globe failed because of the lack of remaining scleral tissue and expulsion of intraocular contents. Postoperatively, the visual acuity remained NLP and the eye was unable to hold pressure. Subsequently, the patient elected for enucleation.ConclusionDespite the purported safety advancements of less-lethal weapons, we continue to see high levels of morbidity and mortality. Permanent vision loss, loss of the eye, and death caused by these weapons have been reported. We hope that this information will serve as an example to help promote judicious use of these weapons by the proper authorities. Additionally, protesters and bystanders should be aware of these dangers and utilize high-quality eye protection.

International globe and adnexal trauma epidemiology study (IGATES): a report from Central India on visual outcome in open globe injuries and correlation with ocular trauma score.

To evaluate the factors influencing final visual outcome after surgical repair of open globe injuries (OGIs) and to correlate the Ocular Trauma Score (OTS) system. Prospective cross-sectional study of patients with OGIs from International Globe and Adnexal Trauma Epidemiology Study (IGATES) database at a tertiary referral eye centre in Central India over 2 years. Pre-operative factors affecting final visual outcome and correlation with OTS were evaluated. 208 patients had ocular trauma, of which data from 42 eyes with OGIs were reviewed. The majority of the patients were men (32, 76.2%) below the age of 40 (31, 73.8%). Patients were followed up for at least 6 months. Initial visual acuity (VA) was ≥ 20/40; 2 (4.8%), 20/200 to 20/50; 2 (4.8%), 1/200 to 19/200; 7 (16.7%), LP to HM; 26 (61.9%) and NLP (5, 11.9%). Final VA was ≥ 20/40; 1 (2.4%), 20/50 to 20/200; 8 (19.1%), 1/200 to 19/200; 9 (21.4%), LP to HM; 17 (40.5%) and NLP; 7 (16.7%). Univariate analysis of pre-operative variables showed initial VA (p = 0.0004), presence of hyphaema (p = 0.0323), laceration involving cornea visual axis (p = 0.0192) and retinal detachment (p = 0.0299) were significant prognostic factors in final visual outcome. OTS in our study does not fully correlate with international OTS system. Initial VA, hyphaema, visual-axis involving cornea laceration and retinal detachment are significant prognostic factors in OGIs. OTS remains a largely effective tool in counselling trauma patients.

Optical Coherence Tomography Findings Following Orbital Fractures.

A closed globe trauma is often associated with orbital wall fractures. In addition to diplopia, further eye disturbances can be observed. The aim of this preliminary prospective study was to investigate the optical coherence tomography (OCT) findings in patients that presented with orbital fractures in association with diplopia but without decreased visual acuity or further ocular symptoms. Only patients who were admitted and surgically treated for orbital wall fractures and that presented diplopia were included in this study. Patients with post traumatic ocular symptoms were excluded. All the patients that were diagnosed with an orbital fracture underwent an ophthalmological assessment, including best-corrected visual acuity (BCVA), examination of fundus oculi, Hess Scheme, OCT, and OCT angiography. Five patients met the inclusion criteria and were enrolled. Hess Scheme examinations confirmed the presence of diplopia in all the included patients. The examination of fundus oculi did not reveal any pathology in 4 patients, whereas in a patient a commotio retinae (Berlin's Edema) was diagnosed in the infero-papillary field. Following OCT assessment, a pachycoroid was observed in 4 patients. A thorough ophthalmological assessment in patients that have suffered from orbital fractures is fundamental. In particular, OCT examinations seem to provide more insight into the detection and monitoring of choroidal changes after ocular trauma without visible macular changes.

Résultats fonctionnels et facteurs pronostiques des traumatismes oculaires à globe ouvert avec acuité visuelle initiale à perception lumineuse négative

To analyse the clinical ocular characteristics and determine prognostic factors for functional recovery in eyes presenting with no light perception (NLP) after open globe ocular trauma. In this retrospective study were included all the patients with no light perception after open globe trauma who presented to Amiens University Hospital between October 2014and June 2018. Fifteen eyes of 15patients were included in this study. The main mechanism of the trauma was globe rupture (80%, n=12). The most common location was zone III (66%, n=10). The wound size was greater than 10mm in 9patients (60%). The ocular lesions included expulsion of the crystalline lens or posterior chamber intraocular lens, hyphema, retinal detachment, vitreous hemorrhage and ciliochoroidal lesions. Damage to the ciliary body was a negative prognostic factor for functional recovery (P=0.04). Nine patients remained with no light perception, whereas 6patients experienced an improvement in visual acuity (2.3logMAR in 3patients, 0.7logMAR in 1patient, 0.4logMAR in 1patient and 0.2logMAR in 1patient). These 6patients had undergone posterior vitrectomy due to vitreoretinal involvement (P<0.001). In the case of open globe trauma with no light perception on presentation, a functional recovery is possible if there is no irreversible anatomical damage.

A new intraocular lens with artificial iris for treating a case of iris extrusion secondary to traumatic opening of a radial keratotomy

Traumatic globe rupture can lead to aniridia with subsequent glare, light sensitivity and psychological discomfort. The authors report the results of a sulcus implantation of a new intraocular lens with artificial iris (Reper) in an eye affected by traumatic opening of a radial keratotomy incision with total iris extrusion and subluxated cataract. A case of 56-year-old female affected by aniridia and subluxated cataract in left eye secondary to a traumatic opening of one of 12 radial keratotomy underwent a Reper implantation with three-point transcleral fixation. The following parameters were collected at 1, 3 and 6 postoperative months: best-corrected visual acuity (BCVA), intraocular pressure (IOP), central corneal thickness (CCT), simulated keratometry (Sim K), endothelial cell count (ECC) and anterior chamber depth (ACD). Pupil spread function study was performed to evaluate the high-order aberrations and the quality of vision. BCVA improved from light perception to 20/20 (Snellen fraction) at 6 postoperative months. No IOP postoperative peaks were detected. CCT was 520 μm at 6 postoperative months. Corneal topography showed regularization with symmetrical flattening of the central part and a residual peripheral curvature. No significant reduction of ECC was detected. ACD was stable, superior to 3 mm at each time point of follow-up. Pupil spread function study highlighted that the quality of vision was the same in both eyes at the end of follow-up. Reper is a promising functional and cosmetic solution for the treatment of aphakia and aniridia.

Six-year epidemiological analysis of post traumatic endophthalmitis in a Brazilian hospital

BackgroundTo evaluate the epidemiology of endophthalmitis cases related to ocular trauma, including visual acuity during and 1 year after trauma, source of trauma and method of treatment.MethodsA retrospective study analyzed the epidemiological data of patients with a clinical presentation of endophthalmitis after ocular penetrating trauma between January 2012 and January 2017 at Escola Paulista de Medicina/UNIFESP, a hospital in São Paulo, SP, Brazil.ResultsA total of 453 patients with antecedent open globe trauma were evaluated, among these, 30 patients with suspected endophthalmitis. All patients were male. The time interval between trauma and ophthalmological evaluation and collection of vitreous and aqueous material was 1 day in 36.66%, 2–7 days in 43.44%, 7–14 days in 10% and more than 15 days in 10% of patients; 66.66% had positive cultures. 11 patients had intraocular foreign body. One year after trauma, visual acuity was classified as no light perception (NLP) in 33.33%, light perception in 6.66%, hand motion in 13.33%, counting fingers in 13.33%, and better than 20/400 in 20% of patients. Considering presence of intraocular foreign body, initial visual acuity and symptoms onset time, only initial visual acuity showed as better prognostic factor in final visual acuity.ConclusionEndophthalmitis is a severe ocular inflammatory condition that may lead to irreversible vision loss. Initially only one patient had visual acuity of NLP, but after 1 year, 33% showed visual acuity of NLP, and only 20% had visual acuity better than 20/400, what is consistent with a severe infection with a guarded prognosis. The high incidence of endophthalmitis after ocular penetrant trauma justifies distinct treatment and greater attention.

Indications, Findings, and Outcomes of Pars Plana Vitrectomy after Open Globe Injury

To determine the indications, findings, and outcomes of patients with open globe injury (OGI) requiring pars plana vitrectomy (PPV). Retrospective, single-vitreoretinal surgeon case series. Sixty-one consecutive eyes with OGI that required PPV. Retrospective chart review of consecutive patients who underwent PPV after OGI between March 1, 2011, and August 1, 2017, at Massachusetts Eye and Ear by 1 surgeon. Final visual acuity and rates of recurrent retinal detachment (RD) and proliferative vitreoretinopathy (PVR). Sixty-one eyes of 61 consecutive patients underwent PPV after sustaining OGI. Mean follow-up was 12.8±12.1 months (range, 0.5-65 months). At the time of presentation after OGI, 64% of eyes showed light perception or worse vision. The indications for PPV, which was performed on average of 15 days after injury, included RD without retinal incarceration (39%), RD with retinal incarceration in the scleral or corneal wound or both (13%), media opacity without RD (28%), vitreous traction without RD (11%), intraocular foreign body (5%), and endophthalmitis (3%). At the time of PPV, substantial comorbidities were noted, including corneal trauma (20%), hyphema (41%), iris trauma (62%), lens expulsion (54%), subretinal hemorrhage (51%), and choroidal hemorrhage (30%). Using multivariate analysis, factors associated with RD after initial PPV were preoperative subretinal hemorrhage (odds ratio [OR], 5.73; P= 0.03), PVR found at initial PPV (OR, 11.94; P= 0.021), and retinectomy (OR, 17.88; P= 0.003). No patients were inoperable, because all patients left the operating room with complete retinal reattachment. Of 35 eyes that showed RD, 19 (54%) redetached as a result of PVR. In 80% of eyes with RD at initial presentation (28/35 eyes), the retina remained completely attached at last follow-up, and 5 additional eyes remained partially attached (33/35 [94%]). Of 61 total eyes included in this study, 89% remained completely attached, and 42 (69%) achieved visual acuity of 20/200 or better at last follow-up. Despite substantial ocular comorbidities, PPV can result in retinal reattachment in even the most severe cases. Good visual outcomes can be achieved for most patients who undergo vitreoretinal surgery after open globe trauma.

Outpatient Surgical Management of Orbital Blowout Fractures.

There is ample investigation into the optimal timing and approach to orbital blowout fracture (OBF) repair; however, less attention has been directed toward postoperative care. This is a multicenter IRB-approved retrospective review of patients with OBF presenting to our study sites between November 2008 and August 2016. Those with isolated OBF, over 18 years of age, and who had not suffered additional facial injuries or globe trauma were included. A total of 126 surgical cases of isolated OBF repair were identified that met our inclusion and exclusion criteria; 42.1% were outpatient repairs while the remaining 57.9% were admitted for overnight monitoring. Time elapsed prior to repair differed between the two groups at a mean of 8.4 days versus 5.2 days for the outpatient and inpatient cohorts, respectively ( p = 0.001). A majority of inpatient cases underwent immediate repair, while a majority of outpatient cases were delayed. There were two cases of RBH in the outpatient cohort resulting in an overall incidence of 1.6%. In both instances, a significant change in clinical exam including decreased visual acuity, diplopia, and eye pain prompted repeat evaluation and immediate intervention for hematoma evacuation. Estimated hospital charges to the patient's insurance for key components of an inpatient versus outpatient isolated OBF repair amounted to a total cost of $9,598.22 for inpatient management and $7,265.02 for outpatient management without reflexive postoperative imaging. Reflexive postoperative CT scans were obtained in 76.7% of inpatient cases and only two led to a reoperation. No outpatient repairs included reflexive postoperative imaging. Outpatient OBF repair is an attractive alternative to inpatient management. The potential cost savings of outpatient management of OBF, which do not detract from quality or safety of patient care, should not be ignored. Our results will hopefully contribute to updated shared practice patterns for all subspecialties that participate in the surgical management of OBF.

Work Related Open Globe Injury

Traumatic open globe injuries are a leading cause of blindness/visual impairment in the world. A significant number of reported open globe injuries occur at the workplace and have been historically associated with non-compliance with workplace safety guidelines and not wearing eye related personal protective equipment (PPE). In this case report, we describe a 27-year-old man’s workplace related open globe injury despite wearing PPE. We explore the prognostic factors in determining final visual acuity and do a literature review of case reports with good outcomes despite poor initial prognostication in severe open globe injuries. The option of enucleation and its common indications are discussed. We also examine the factors determining patient satisfaction with ocular prosthesis along with an assessment of the role of PPEs in workplace related ocular trauma.

Open globe trauma in a military hospital: a review of the Ocular Trauma Score to help predict enucleation or evisceration.

The aim of this study was to use the Ocular Trauma Score (OTS) to review and analyze all the open globe injuries (OGIs) that presented to Brooke Army Medical Center (BAMC) from July 2011 to March 2017, and whether or not the OTS can be used to predict enucleation or evisceration. Retrospective chart review was performed through the medical record systems at BAMC for all OGIs from July 2011 to March 2017. This study was not performed on wartime patients. The primary outcome measures were the variables in the OTS and need for enucleation or evisceration. A total of 126 OGIs in 125 patients were identified from July 2011 to March of 2017. A lower calculated OTS was negatively associated with the outcome variables. A total of 25 cases resulted in enucleation or evisceration (19.8%). Of these, 17 underwent enucleation and 8 underwent evisceration. The average OTS for all eyes was 37.15, and the average OTS for eyes resulting in enucleation or evisceration was 22. Retinal detachment (RD), afferent pupillary defect (APD), globe rupture, globe perforation, and presenting visual acuity (VA) were all found to be statistically significant risk factors in patients who underwent enucleation or evisceration. The present study shows that the OTS and the OTS pre-operative variables can help predict the likelihood that an OGI will ultimately result in enucleation or evisceration. Our study shows that the OTS is a valuable tool to use when evaluating OGI and can help in evidence-based counseling.

Intraocular application of Mitomycin C to prevent proliferative vitreoretinopathy in perforating and severe intraocular foreign body injuries.

To assess the long-term anatomical and functional outcomes in addition to complications of a new surgical technique of localized intraocular application of mitomycin C (MMC) to prevent proliferative vitreoretinopathy (PVR) in eyes with open globe trauma. Prospective non-comparative interventional case series of 16 consecutive eyes with perforating and deep choroidal impact foreign body injuries presenting over a 2-year period. Patients underwent vitrectomy with intraocular application of MMC at the site of the chorioretinal injury and were followed-up for 1 year. The primary outcome measure was the rate of postoperative PVR. Secondary outcome measures were number of vitreoretinal surgeries (VRS) required, best corrected visual acuity (BCVA), final anatomical success rate and globe survival rate (GSR). Patients underwent VRS at a mean time of 8.5 ± 4.6 days after the injury. Postoperative PVR developed in 2 (13 %) eyes and required only one additional VRS each. One other eye underwent further peeling of an epimacular membrane. BCVA improved from mean LogMAR 3.08 ± 0.72 preoperatively to 0.66 ± 0.79 at 1 year. All 10 eyes without a macular injury had a final BCVA of LogMAR 0.40 or better. The final anatomical success rate was 94% and GSR rate was 100%. There were no complications related to the intraocular use of MMC. Vitrectomy and intraocular application of Mitomycin C may have a potential role in reducing the rate of post traumatic PVR and improving anatomical and functional outcomes in eyes with perforating and deep choroidal impact foreign body injuries.

Optimal refinement of residents' surgical skills by training on induced goat's eye corneoscleral perforation.

Surgical skill enhancement for the residents under training can be performed through various efforts. Here in this report, the authors describe a technique of corneoscleral perforation repair on goat's eye, as the tissue resemblance and the reality of experience while performing crucial steps are similar to human eyes. Beginning from tissue handling, optimal suture placement was taught with an intention to impart quality techniques of traumatic globe injury repair. Therefore, rather than training on expensive artificial eye model, training budding surgeons on goat's eye gives much more realistic tissue handling experiences in the presence of constant challenges almost similar to human eyes.

Clinical charactheristics, prognostic factors and outcome of 23-gauge pars plana vitrectomy in traumatic globe injuries with posterior segment complications

Clinical charactheristics, prognostic factors and outcome of 23-gauge pars plana vitrectomy in traumatic globe injuries with posterior segment complications

Traumatic Bilateral Globe and Optic Nerve Avulsion: Rare Case Report

Avulsion of optic nerve is a rare condition and vere serious injury We report a rare case report of bilateral optic nerve avulsion from severe trauma of orbit and face...