Ocular trauma among major trauma victims in a regional trauma center

Ocular injuries among patients with major trauma in England and Wales from 2004 to 2021

BACKGROUND

Ocular trauma is a significant cause of blindness and is often missed in polytrauma. No contemporary studies report eye injuries in the setting of severe trauma in the UK. We investigated ocular injury epidemiology and trends among patients suffering major trauma in England and Wales from 2004 to 2021.

METHODS

We conducted a retrospective study utilising the Trauma Audit and Research Network (TARN) registry. Major trauma cases with concomitant eye injuries were included. Major trauma was defined as Injury Severity Score >15. Ocular injuries included globe, cranial nerve II, III, IV, and VI, and tear duct injuries. Orbital fractures and adnexal and lid injuries were not included. Demographics, injury profiles, and outcomes were extracted. We report descriptive statistics and 3-yearly trends.

RESULTS

Of 287 267 major trauma cases, 2368 (0.82%) had ocular injuries: prevalence decreased from 1.87% to 0.66% over the 2004-2021 period (P < 0.0001). Males comprised 72.2% of ocular injury cases, median age was 34.5 years. The proportion of ocular injuries from road traffic collisions fell from 43.1% to 25.3% while fall-related injuries increased and predominated (37.6% in 2019/21). Concomitant head injury occurred in 86.6%. The most common site of ocular injury was the conjunctiva (29.3%). Compared to previous TARN data (1989-2004), retinal injuries were threefold more prevalent (5.9% vs 18.5%), while corneal injuries were less (31.0% vs 6.6%).

CONCLUSIONS

Whilst identifying eye injuries in major trauma is challenging, it appears ocular injury epidemiology in this setting has shifted, though overall prevalence is low. These findings may inform prevention strategies, guideline development and resource allocation.

Epidemiology and Clinical Patterns of Ocular Trauma at a Level 1 Trauma Center in Korea

BACKGROUND

To evaluate the patterns of distribution and clinical manifestations of ocular injuries referred to the level 1 trauma center of Pusan National University Hospital (PNUH) in Korea.

METHODS

We analyzed 254 of 4,287 patients who were referred to the Department of Ophthalmology at the level 1 trauma center of the PNUH, from January 2016 through December 2018. Data on the incidence of ocular injuries, sex, age, monthly and seasonal distribution, day and time of injury, side of injury, cause, residence of patients, referral time to an ophthalmologist and subsequent examination time, final visual acuity (VA), and complications were obtained from medical records and retrospectively reviewed. The patients were grouped according to their main diagnosis using the Birmingham Eye Trauma Terminology System (BETTS) and Ocular Trauma Score (OTS).

RESULTS

The incidence of ocular injuries with major trauma was higher in men (n = 207, 81.5%), the median age at time of injury was 54 years, and Pusan recorded the most cases. The incidences of ocular injury were 1.47/100,000, 1.57/100,000, 1.48/100,000 in 2016, 2017 and 2018, respectively. The most common cause was by a motorbike accident, followed by a pedestrian traffic accident and falls. According to the BETTS classification, open-globe injuries represented 4% of cases, closed-globe injuries represented 12.6%, and other injuries represented 83.1%. Open-globe injuries were significantly associated with low final VA (P = 0.01). In the OTS, 79.4% of patients received 4 or 5 points and 13.7% of patients received 1 or 2 points. The patients who received 1 or 2 points in the OTS score showed final VA below hand movement (P < 0.001), except for two patients. Lid laceration and low initial VA were highly correlated with poor final VA (P < 0.001).

CONCLUSION

This is the first study on the epidemiology and clinical manifestations in trauma patients with ocular injuries at a level 1 trauma center. The incidences of ocular injuries with major trauma were about 1.47-1.57/100,000. BETTS, OTS, lid laceration and initial VA were associated with final VA. We expect our study to provide a basis of data for the evaluation, prevention, and management of ocular injuries in patients with systemic trauma.

A systematic approach to CT evaluation of orbital trauma

Computed tomography (CT) is widely used in the initial evaluation of patients with craniofacial trauma. Due to anatomical proximity, craniofacial trauma often involves concomitant injury to the eye and orbit. These injuries may have devastating consequences to vision, ocular motility, and cosmesis. CT imaging provides a rapid and detailed evaluation of bony structures and soft tissues of the orbit, is sensitive in detection of orbital foreign bodies, and often guides clinical and surgical management decisions in orbital trauma. For this reason, radiologists should be prepared to rapidly recognize common orbital fracture patterns, accurately describe soft tissue injuries of the orbit, detect and localize retained foreign bodies within the globe and orbit, and recognize abnormalities of the contents and integrity of the globe. In this review, we present a systematic approach to assist radiologists in the rapid evaluation of orbital trauma using the "BALPINE" mnemonic-bones, anterior chamber, lens, posterior globe structures, intraconal orbit, neurovascular structures, and extraocular muscles/extraconal orbit. Using this approach, we describe common traumatic findings within each of these spaces, and present common postsurgical appearances that can mimic findings of acute trauma.

Concomitant cranial and ocular combat injuries during Operation Iraqi Freedom

BACKGROUND

Concomitant cranial and ocular injuries were frequently seen in combat casualties during Operation Iraqi Freedom. The incidence of these injuries is reported along with an interventional case series.

METHODS

A retrospective review was conducted of all surgical patients treated by U.S. Army neurosurgeons and ophthalmologists in Iraq from December 2005 to April 2006.

RESULTS

Out of 104 patients with cranial trauma and 158 patients with ocular trauma, 34 had both cranial and ocular injuries (32.7 and 21.5% of patients with cranial and ocular injuries, respectively). Neurosurgical procedures included exploratory craniotomy, decompressive craniectomy, and frontal sinus surgery. Ophthalmologic surgical procedures included globe exploration, open globe repair, primary enucleation, orbital fracture repair, lateral canthotomy and cantholysis, and repair of lid and periocular lacerations. Patients with cranial trauma had a higher incidence of orbital fracture, orbital compartment syndrome, and multiple ocular injuries compared with patients without cranial trauma (odds ratio 6.4, 3.9, and 3.3, respectively).

CONCLUSION

A strong association exists between cranial and ocular trauma in combat casualties treated during Operation Iraqi Freedom. Combat health support personnel should maintain a high level of suspicion for one of these injuries when the other is present. Co-locating neurosurgeons and ophthalmologists in support of combat operations facilitates the optimal treatment of patients with these combined injuries.

Does Blunt Ocular Trauma Induce Corneal Astigmatism?

PURPOSE

To determine the effect of blunt ocular trauma on refractive astigmatism.

METHODS

Eighty-six eyes of 86 patients with known previous refractive status exposed to blunt ocular trauma were included in the study. Trauma-induced astigmatism (TIA) was calculated using vector analysis. In eyes with TIA, central corneal thickness was assessed by ultrasound pachymetry, and corneal topographies were obtained. Anterior-chamber angles were examined by Goldmann 3-mirror lens to find microhemorrhages, scarring, or recession. Patients were followed up between 8 and 12 months (average, 9.2 months).

RESULTS

In 18 eyes (21%), TIA was detected. Six (7%) of these eyes had lenticular astigmatism caused by traumatic lens subluxation. In the remaining 12 eyes (14%), corneal topography showed regular astigmatic patterns, which were symmetrical in 3 eyes and asymmetric in the remaining 9. The etiologic factor was a game marble in 6 eyes and a stone in the remaining 6. The mean central corneal thickness was 535.75 microm (range, 498-570 microm) in these 12 eyes. In 9 of these 12 eyes, recession or scarring in the anterior-chamber angle was detected at 1 edge of the steepest axis.

CONCLUSIONS

Blunt trauma can induce astigmatism. Hard and small objects are more likely to induce astigmatism.

Ocular injuries in patients with major trauma

AIM

To study the epidemiology of ocular injuries in patients with major trauma in the UK, determining the incidence and causes of ocular injuries, and their association with facial fractures.

METHODS

A retrospective analysis of the Trauma Audit Research Network database from 1989 to 2004, looking at data from 39,073 patients with major trauma.

RESULTS

Of the 39,073 patients with major trauma, 905 (2.3%) patients had associated ocular injuries and 4082 (10.4%) patients had a facial fracture (zygoma, orbit or maxilla). The risk of an eye injury for a patient with a facial fracture is 6.7 times as that for a patient with no facial fracture (95%, confidence interval 5.9 to 7.6). Of the patients with major trauma and an eye injury, 75.1% were men, and the median age was 31 years. 57.3% of ocular injuries were due to road traffic accidents (RTAs).

CONCLUSION

The incidence of ocular injuries in patients with major trauma is low, but considerable association was found between eye injuries and facial fractures. Young adults have the highest incidence of ocular injury. RTAs are the leading cause of ocular injuries in patients with major trauma. It is vital that all patients with major trauma are examined specifically for an ocular injury.

Ocular injuries in children after major trauma

OBJECTIVE

To determine the variety of ocular injuries sustained by children during major trauma.

SUBJECTS AND METHODS

The pediatric trauma registry of The Children's Hospital in Denver, Colorado, was surveyed for children with ocular injuries and an Injury Severity Score higher than 15. The injuries were tabulated and correlated with mechanisms of injury to determine identifiable injury patterns.

RESULTS

In a pediatric trauma center, ocular injuries were nearly twice as frequent among children with major trauma (Injury Severity Score > 15). Two-thirds of the children with an Injury Severity Score higher than 15 had been involved in a mishap with a motorized or a nonmotorized vehicle. Ocular injuries in children with an Injury Severity Score higher than 15 were characterized by fracture of the surrounding bony structures and contusions. Children with an Injury Severity Score higher than 15 had 50% to 80% fewer open wounds of the ocular adnexa and eyeball than did children with an Injury Severity Score of 15 or lower. The one optic nerve injury and two-thirds of the other ocular cranial nerve injuries occurred in children with an Injury Severity Score higher than 15.

CONCLUSIONS

Serious ocular injury should be suspected in children involved in a motor vehicle accident who have an Injury Severity Score higher than 15 and fractures of the surrounding bony structures, contusions, or both. Absence of an open wound of the ocular adnexa or eyeball does not eliminate the possibility of serious ocular injury.

Spectrum of ocular injuries in children with major trauma

BACKGROUND

Few studies document the variety of ocular injuries encountered in children after major trauma. This study was performed to determine the type and frequency of ocular injuries in a large population of children with major trauma.

METHODS

All children with ocular and adnexal injuries (n = 7497) among 96,879 children registered in the National Pediatric Trauma Registry (NPTR) were analyzed. Children were stratified for Injury Severity Score (ISS is a method for categorizing patients with multiple injuries in which an ISS > 15 is considered major trauma), age, sex, injury, protective restraint, vision threatening injury, and basilar skull fracture.

RESULTS

Nearly 8% of the children in the NPTR sustained an ocular injury. These children had one or more injuries to one or both eyes and/or the ocular adnexa for an average of 1.3 ocular injuries per child. Three-fourths (75%) of the children with an ocular injury had an ISS < or = 15 and one-fourth (25%) had an ISS > 15. Among children with an ISS > 15 the most common injuries were orbital wall fracture (59%) and contusion of the eye and ocular adnexa (18%). Among these same children with an ISS > 15, the percent of orbital wall fractures, injuries to the optic nerve, and injuries to the other ocular cranial nerves doubled while the percent of basilar skull fractures tripled when compared with children with an ISS < or = 15. Penetrating injuries of the globe were significantly lower in children with an ISS > 15 than in children with an ISS < or = 15. Over 70% of the children with an eye injury and an ISS > 15 sustained injury in an accident involving a motorized or non motorized vehicle, and over 75% of those who could have been restrained, were not restrained.

CONCLUSIONS

Children with an ocular injury sustained during major trauma (ISS > 15) are more likely to have a basilar skull fracture, orbital wall fracture, and a contusion of the eye and/or the ocular adnexa as compared with children with ISS < or = 15. Children with any of these injuries sustained during major trauma should be afforded prompt ophthalmologic evaluation to uncover injury to components of the visual system.

Pattern of mandibular fractures in an urban major trauma center

PURPOSE

Many studies focusing on the pattern of presentation of mandibular fractures are inconclusive. This is largely due to a multifactorial involvement of associated factors and the role of anatomic factors.

PATIENTS AND METHODS

We reviewed a 10-year retrospective analysis of the pattern of presentation of mandibular fractures at an urban level I trauma center in Washington, DC, and the significance of the variables in association with the fractures. These include mechanism of action, age group, illicit drug use, seasonal variation, and the incidence of multiple fracture sites. We also looked at the evolving pattern of mandibular fractures in comparison to an earlier study conducted in the 1960s at the same hospital. Data collection was done through the use of medical records and all documented radiographs. Variables that were analyzed in association with the fractures include age, gender, mechanism of action, seasonal variation, and anatomic location. Data analysis was done using subjective analysis, frequency distribution, and multiple regression tests, where appropriate.

RESULTS

Data analysis shows that 86% of all fracture patients are male, and 37% of all patients were in the 25- to 34-year-old age group. Use of an illicit substance at the time of trauma was seen in 55% of all cases. Interpersonal violence accounted for 79% of all patients, with prevalence in the summer (31%) and winter (28%) months. The most common location of fracture is in the angle region (36%), followed by the body (21%) and parasympyhseal region (17%), with 52% presenting with more than one fracture site.

CONCLUSION

The evolving pattern of fractures in urban trauma centers is showing an increasing trend of association with illicit substances and interpersonal violence as a major causative factor.

Eye injuries in patients with major trauma

BACKGROUND

A study was performed to determine the type and frequency of ocular injuries in patients with major trauma.

METHODS

All patients with ocular and adnexal injuries (n = 178) among 1,119 patients admitted with major trauma (Injury Severity Score >15) to the Royal Prince Alfred Hospital from July 1990 to December 1997 were analyzed.

RESULTS

Sixteen percent of the major trauma cohort had ocular or orbital trauma. Fifty-five percent of patients with injuries involving the face had ocular or orbital injuries. A range of ocular injuries was seen. Analysis of the major trauma cohort showed that motor vehicle drivers, orbital and base of skull fractures, eyelid lacerations, and superficial eye injuries were strongly associated with vision-threatening injury.

CONCLUSION

Patients with major trauma and facial injuries have a high risk of vision-threatening injury. Patients with orbital fractures, base of skull fracture, eyelid lacerations, and superficial eye injuries should be assessed by an ophthalmologist as part of the early management of their trauma to determine whether an ocular injury is present.

The global impact of eye injuries

Using data compiled from the ophthalmic literature and WHO's Blindness Data Bank, the available information on eye injuries from an epidemiological and public health perspective has been extensively reviewed. This collection of data has allowed an analysis of risk factors, incidence, prevalence, and impact of eye injuries in terms of visual outcome. However, most of the estimates are based on information from More Developed Countries (MDCs). The severity of eye injuries can be assessed through proxy indicators such as: (i) potentially blinding bilateral injuries; (ii) open-globe injuries; (iii) endophthalmitis; (iv) enucleation or (v) defined visual impairment. Major risk factors for ocular injuries include age, gender, socioeconomic status and lifestyle. The site where the injury occurs is also related to a risk situation. Available information indicates a very significant impact of eye injuries in terms of medical care, needs for vocational rehabilitation and great socioeconomic costs. The global pattern of eye injuries and their consequences emerging from the present review, undertaken for planning purposes in the WHO Programme for the Prevention of Blindness, suggests that: some 55 million eye injuries restricting activities more than one day occur each year; 750,000 cases will require hospitalization each year, including some 200,000 open-globe injuries; there are approximately 1.6 million blind from injuries, an additional 2.3 million people with bilateral low vision from this cause, and almost 19 million with unilateral blindness or low vision. Further epidemiological studies are needed to permit more accurate planning of prevention and management measures; a standardized international template for reporting on eye injuries might be useful to this effect, along the lines of the reporting occurring through the US Eye Injury Registry.

Assessment of ocular trauma associated with head and neck injuries

We reviewed the real and potential ocular problems in all head and neck injuries at a tertiary care and regional trauma center from April of 1994 to March of 1995. Through a retrospective study, 127 charts were reviewed, specifically looking at the mechanism of injury, types of injury, whether there was any ocular trauma noted in the chart, and whether there was a consultation to the ophthalmology department. Forty-one of these patients were seen by an ophthalmologist as the initial consultant for ocular and orbital injuries recognized by the emergency staff. In the 86 remaining patients, signs of potential ocular injury were recorded in the chart in 62 (72%) of these patients, yet an ophthalmology consultation was requested for only 23 of them (37%). This survey reveals the lack of awareness in a regional trauma center of certain ocular and periocular signs that may be indicative of more serious ocular injuries. It is the purpose of this article to highlight these concerns to the various health professionals involved with head and neck trauma patients in the hope that the patients will, in the end, benefit from a more thorough and complete assessment of the potential ocular and periocular injuries.

Retinal hemorrhage secondary airbag-related ocular trauma

A case is presented in which a driver, who was wearing a three-point restraint system, was involved in a collision that triggered deployment of the vehicle's driver's-side airbag. The victim complained of blurred vision after the crash and on examination was found to have suffered a retinal hemorrhage in his right eye. Since no other cause could be determined, his injury was considered to be a result of contact with the deploying airbag.