Eye injuries in patients with major trauma

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.

Globe trauma associated with falls at Australian tertiary centres

OBJECTIVE

Falls frequently cause globe and adnexal trauma, particularly in the elderly. The morbidity decreases confidence, independence and quality of life. We aimed to improve the understanding of fall-related globe and adnexal trauma and the involvement of ophthalmology at two tertiary trauma centres.

METHODS

A retrospective medical record review was conducted at Royal North Shore Hospital and Royal Prince Alfred Hospital of patients admitted with fall-related globe and/or adnexal trauma between January 2015 and December 2019. International Classification of Disease Tenth Revision codes were used to identify patients for inclusion. Medical records were reviewed to extract data on demographics, trauma, ocular examination and referrals to ophthalmology.

RESULTS

From January 2015 to December 2019, 346 patients, 186 were female (54%) and median age 76 years (interquartile range 24 years), were admitted to Royal North Shore Hospital and Royal Prince Alfred Hospital with fall-related globe and/or adnexal trauma. One hundred and twenty-five (36%) suffered globe trauma with 48 (14%) classified as severe. Patients over 65 years old had at least three risk factors contributing to falls. Alcohol and illicit substances were involved in 20% of falls and occurred predominantly in younger populations. There were significantly more patients with globe trauma if orbital/mid-facial fractures were present (55% vs 36%, P < 0.001).

CONCLUSION

Fall-related globe and adnexal trauma were more common in the elderly. Alcohol and illicit substances have a role in falls in younger populations. Thorough ocular assessment is required especially in mid-facial/orbital trauma to exclude globe trauma. Further, research is required to determine the effect of fall prevention strategies in preventing globe trauma.

Globe and adnexal trauma at Australian trauma centres

INTRODUCTION

In multisystem trauma, the assessment and management of globe and adnexal trauma is often complex. Ophthalmology input may assist managing such patients. To understand the role of ophthalmology in tertiary trauma centres we report on the management of globe and adnexal trauma at two tertiary trauma centres in Sydney, Australia.

METHOD

A retrospective case series was completed at Royal North Shore Hospital (RNSH) and Royal Prince Alfred Hospital (RPAH) on patients admitted between January 2015 and December 2019. International Classification of Disease, Tenth Revision codes, diagnostic and procedural coding data were used to identify patients admitted with globe and/or adnexal trauma. Data extracted from medical records included demographics, mechanism of injury, ocular examination and specialist ophthalmic referral.

RESULTS

Over 5-years, 773 patients, average age of 53.2years and 62% male, were admitted to RNSH and RPAH with globe and/or adnexal trauma. Most patients (83%) first presented to RNSH or RPAH. The most common mechanism of injury was falls (45%) followed by burns (13%). Two-hundred and thirty-five patients had multisystem trauma, of these patients, 121 (51%) suffered globe trauma with 49 (21%) classified as severe. Three patients were not diagnosed initially due to delayed ophthalmology referral.

CONCLUSION

Falls followed by burns were common causes of globe and adnexal trauma in Sydney, Australia. The presence of orbital/mid-facial injury may indicate a patient has globe trauma. In multisystem trauma, globe trauma may be diagnosed late or not identified. Ophthalmology review has an important role in diagnosing and managing globe trauma in multisystem trauma.

Pediatric Open Globe Injuries Caused by Firecrackers in a Tertiary Eye Care Hospital in Iran

OBJECTIVE

The aim of the study is to determine characteristic features of open globe injuries caused by firecrackers among pediatric population.

METHODS

In this retrospective cross-sectional chart review, medical records of children with ocular trauma who were hospitalized in Isfahan, Iran, during 2013-2017 were reviewed. We analyzed the collected data before and after propensity score (PS) matching.

RESULTS

Of 396 pediatric patients with open globe injury, 22 injuries (5.9%) were caused by firecrackers. Hyphema, iris prolapse, and lens rupture were noted in 15 (68.18%), 10 (45.45%), and 2 (9.09) eyes, respectively. None of patients had endophthalmitis. The mean age of patients in firecracker group was higher and significant (11.86 ± 4.05 in firecracker vs 7.80 ± 4.68 in nonfirecracker, P < 0.001). Furthermore, most boys were in firecracker group (95.5%, P = 0.005). Patients in firecracker group resided more in urban areas (86.4%, P = 0.054) and had more intraocular foreign body (IOFB) in the eyes (40.9%, P < 0.001). After PS matching, patients in firecracker group had higher IOFB ( P = 0.008). In logistic regression models, patients with corneal lacerations had lower odds for long-time admission (≥4 days) than patients with both corneal and scleral lacerations in crude model (odds ratio, 0.35; 95% confidence interval, 0.17-0.69) and adjusted model (odds ratio, 0.37; 95% CI, 0.18 to 0.74). After PS matching, there was no significant association between risk factors and outcomes.

CONCLUSIONS

The present study showed several differences between the pediatric open globe injuries caused by firecrackers and other mechanisms of injuries, including the age, sex, living place, presence of IOFB, and length of hospital stay.

Integration of ophthalmology in ocular trauma to improve patient care: A narrative review

Introduction

Ocular trauma can cause significant morbidity and is a leading cause of unilateral blindness. In multi-trauma, life- and sight-threatening injuries can co-occur causing increased complexity in the assessment and management of ocular injuries as the competing priorities in the severely injured must be balanced. We conducted a narrative review to determine how ophthalmology may be further integrated into a trauma service and/or the organisation of an ocular trauma service.

Methods

The literature was reviewed via EMBASE, MEDLINE, CINAHL and Google Scholar utilising comprehensive search strategies and keyword searches. Our review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

Results

The search yielded 437 articles, 30 studies met selection criteria and were included in the review. The included literature comprised guidelines, observational studies and reviews of registry data from Australia, England, the United States, Singapore, Iran and Israel.

Conclusion

The Australian Trauma Model has clear guidelines for referral of trauma patients to ensure appropriate care of the severely injured. However, there are no clear guidelines for the integration of ophthalmology into trauma. Therefore, early referral to ophthalmology and streamlining of referral pathways of specialist care would improve the care of patients with ocular trauma.

A Review of Frontal Orbital and Frontal Sinus Fractures and Associated Ocular Injuries - Level I Trauma Center - University Hospital Experience

BACKGROUND

Traumatic frontal fractures result from high force injuries and can result in significant morbidity and mortality. The purpose of the current study is to evaluate our Montreal General Hospital (MGH) experience with frontal bone fractures.

METHODS

A comprehensive review of our trauma database was performed. All adult patients (>18 years) presenting with a diagnosis of frontal sinus fracture were identified. A thorough retrospective electronic medical records search was performed and relevant data extracted. Specifically, all cases of ocular injury or sequelae were identified and an in-depth review was performed.

RESULTS

Between 2008 and 2014, 10,189 trauma patients presented to the MUHC Level 1 trauma center. A total of 1277 patients presented with a facial fracture and 140 had a frontal sinus fracture. The mean age was 43.5 years, 90% were male and the mean hospitalization time was 16.2 days. A significant proportion of patients suffered concomitant craniomaxillofacial fractures including orbital (79%), maxillary (66%), nasal (64%), zygomaticomaxillary complex (34%), nasoorbitoethmoid (31%), Lefort types I-III (18%), and mandibular (8%). Associated cervical spine injuries were documented in 16% of patients. Ocular injuries were present in 30% of subjects. 26% of patients had some form of permanent sequelae from their trauma, mainly neurological.

CONCLUSIONS

Due to the intimate association of the frontal bones with the brain and the orbits, frontal sinus fractures demand a sophisticated multidisciplinary craniofacial surgical approach. Given the high rate of ocular injury of 30% as well as severe systemic injuries, the authors propose a modified treatment algorithm for these complex cases.

Ultrasound Examination of the Pupil - A New Tool for the Neuro-Ophthalmological Assessment

BACKGROUND

 Pupil examination represents a diagnostic and prognostic test in the management of several neurological diseases. Infrared video pupillometry (IVP) is the gold standard, since it is not routinely available, a noninvasive bedside ultrasound assessment has been proposed as an alternative. The aim of this study was to assess the feasibility and reproducibility of ultrasound pupillometry (UP) in comparison with IVP.

MATERIALS AND METHODS

 81 subjects (43 men and 38 women, mean age: 52 ± 20 years and 49 ± 19 years, respectively) with no history of neurophthalmologic disease were enrolled. UP was performed with a 12-MHz linear probe according to current guidelines for orbital insonation. Light and painful stimuli were applied to test pupillary light reflex (PLR) and ciliospinal reflex (CR). In 30 of these subjects IVP examination was performed additionally to obtain intra-observer and inter-observer agreement.

RESULTS

 Increasing age was associated with a decreased pupillary diameter (PD) at rest, after PLR and CR (R -0.728, p < 0.01, R -0.643, p < 0.01, R 0.674, p < 0.001 respectively), while no association was noticed with time to constriction/dilation. UP measurements were reproducible (rate of inter- and intra-observer agreement: R 0.979, p < 0.01, R 0.946, p < 0.01 respectively) and concordant with IVP (PLR R 0.831, p < 0.01; CR R 0.879, p < 0.01).

CONCLUSION

 According to our study, ultrasound pupillometry is a feasible and reliable technique for bedside pupillary function assessment, and is a good alternative to infrared video pupillometry. Moreover, it represents the only way for functional pupillary assessment in patients with periorbital hematoma.

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 comparison of pediatric ocular injuries based on intention in patients admitted with trauma

Purpose

Pediatric ocular trauma is a major source of morbidity and blindness and the number of epidemiological studies is incommensurate with its significance. We sought to determine differences in epidemiologic patterns of pediatric ocular injuries based on intention.

Methods

A retrospective review of the National Trauma Data Bank (2008–2014) was performed and patients < 21 years old, admitted with trauma and ocular injury, were identified using ICD-9CM codes. Demographic data, types of injury and external circumstances including intention were tabulated and analyzed with students’ t and chi-squared tests and logistic regression. Statistical significance was set at p < 0.05.

Results

Fifty-eight thousand seven hundred sixty-five pediatric patients were admitted for trauma and ocular injuries. The mean(SD) age was 11.9(6.9) years. Most patients were male (68.7%) and White (59.1%). Unintentional injuries (76.3%) were mostly associated with falls (OR = 13.4, p < 0.001), assault (16.3%) with firearms (OR = 9.15, p < 0.001) and self-inflicted trauma (0.7%) also with firearms (OR = 44.66, p < 0.001). There was increasing mean(SD) age from unintentional, 12.9(6.6) years and assault 12.3(8.1) years to self-inflicted trauma, 17(3.4) years. The 0-3 year age group had highest odds of open adnexa wounds (OR = 30.45, p < 0.001) from unintentional trauma, and traumatic brain injury (TBI) (OR = 5.77, p < 0.001) and mortality (OR = 8.52, p < 0.001) from assault. The oldest 19-21 year group, had highest odds visual pathway injuries (OR = 8.34, p < 0.001) and TBI (OR = 1.54, p = 0.048) from self-inflicted trauma and mortality (OR = 2.08, p < 0.001) from unintentional trauma.

Conclusion

Sight-threatening injuries were mostly associated with unintentional trauma in the youngest group and self-inflicted trauma in the oldest group. Patterns emerged of associations between demographic groups, mechanisms, types of injury and associated TBI with intention of trauma.

Electronic supplementary material

The online version of this article (10.1186/s12886-018-1024-7) contains supplementary material, which is available to authorized users.

Ophthalmological Evaluation by a Maxillofacial Surgeon and an Ophthalmologist in Assessing the Damage to the Orbital Contents in Midfacial Fractures: A Prospective Study

BACKGROUND AND PURPOSE

Midfacial fractures may often be associated with injuries to the orbit which may lead to notable dysfunction of the visual apparatus, if not detected early after injury. The purpose of this study is to evaluate the associated ophthalmic injuries in mid-face trauma and to emphasize the need for understanding the ophthalmic signs and symptoms by an attending maxillofacial surgeon.

PATIENTS AND METHODS

A total number of 60 clinically and radiographically proven subjects with midfacial fractures were considered in the study that underwent complete ophthalmological evaluation at initial presentation. Referral to ophthalmologist was considered to determine the exact nature of injury and its implications. Results by a maxillofacial surgeon and ophthalmologist were evaluated.

RESULTS

In our study, a male predominance with a mean age of 32 years was observed, with the most common etiology being Road Traffic Accidents. Forty-two of the 60 patients exhibited sub-conjunctival hemorrhage accounting for 70 % of ocular injuries recorded. While 28 of the 60 patients displayed peri-orbital edema (53.3 %), 8 patients experienced diplopia (13.32 %) and 8 patients showed relative afferent pupillary defect (13.32 %).

CONCLUSION

From our study, it becomes imperative that the maxillofacial surgeon should have a thorough knowledge of the various ophthalmic injuries that could occur in association with midfacial trauma in order to prevent visual complications to the patient. Understanding of the subtle injuries to the ocular apparatus which may be undiagnosed by a maxillofacial surgeon but have significant grave outcomes is essential.

Maxillofacial trauma scoring systems

The changing complexity of maxillofacial fractures in recent years has created a situation where classical systems of classification of maxillofacial injuries fall short of defining trauma particularly that observed with high-velocity collisions where more than one region of the maxillofacial skeleton is affected. Trauma scoring systems designed specifically for the maxillofacial region are aimed to provide a more accurate assessment of the injury, its prognosis, the possible treatment outcomes, economics, length of hospital stay, and triage. The evolution and logic of such systems along with their merits and demerits are discussed. The author also proposes a new system to aid users in quickly and methodically choosing the system best suited to their needs without having to study a plethora of literature available in order to isolate their choice.

Clinical findings provide criteria to evaluate priorities of ophthalmologic intervention in conscious multiple trauma patients

INTRODUCTION

Multiple trauma patients frequently suffer eye injuries, especially those patients with head traumas. We evaluated the accuracy of physical findings to determine the priorities of emergency ophthalmologic intervention in these patients.

PATIENTS AND METHODS

This study included all multiple trauma patients with ophthalmic trauma who had a GCS of 15 when they arrived at the emergency department during the period of March, 2008-March, 2009. First, we evaluated the patients according to the criteria of the study. Then, an ophthalmologist evaluated them.

RESULT

From March 2008-March 2009, 306 multiple trauma patients with ocular trauma came to our ED. The sensitivity and accuracy of emergency physicians in diagnosing the priority of ophthalmologic treatment were comparable to an ophthalmologist (measure of agreement in kappa=0.967).

DISCUSSION

The ability of an emergency physician or general surgeon to determine the actual need of early ophthalmologist intervention can improve decision making and saving both time and money. Our study suggests that it is possible to determine according to clinical findings the need of the patient to have ophthalmologic intervention without referring the patient to ophthalmologist examination.

CONCLUSION

Defining specific criteria of ophthalmologic examinations can clarify the necessity of emergency ophthalmologic examination and intervention.

Ocular Injuries Associated with Midface Fractures: A 5 Year Survey

AIM

The aim of this study is retrospective analysis of ocular injuries after maxillofacial trauma reporting to the Department of Oral and Maxillofacial Surgery at V.S. Dental College and Kempegowda Institute of Medical Sciences and Hospital, Bangalore.

STUDY DESIGN

A retrospective analysis of ocular injuries following facial trauma from 2008 to 2013.

RESULTS

Road traffic incident was the most common etiology (55.46 %). Zygomaticomaxillary complex fracture was the most common fracture associated with ocular injuries (67.22 %). Out of 119 patients, 5 had severe visual impairment and (0.84 %) had blindness.

CONCLUSION

Maxillofacial trauma particularly that associated with Lefort II, Lefort III and Zygomatico maxillary complex fracture may lead to opthalmic injuries and even blindness. A thorough opthalmic examination should be carried out for every patient with maxillofacial trauma and suspected cases should be placed under closed observation so that immediate and active treatment can be taken if necessary.

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.

Imaging of orbital trauma

Assessing traumatic orbital injuries is an important challenge for radiologists; this assessment is even more difficult when the orbital injury is associated with injuries involving multiple organs. Common posttraumatic orbital injuries include anterior chamber injuries, injuries to the lens, open-globe injuries, ocular detachments, intraorbital foreign bodies, carotid cavernous fistula, and optic nerve injuries. Radiographic examination of the orbits is rarely performed. Ultrasonography (US) can be very useful for evaluating the globe and its contents; however, US is contraindicated if a ruptured globe is suspected. Magnetic resonance imaging may be difficult to perform emergently; it is contraindicated if there is a possibility that a metallic intraorbital foreign body is present. Computed tomography (CT) is considered to be the top choice for evaluating orbital trauma. The best protocol is to obtain thin-section axial CT scans, then to perform multiplanar reformation. When evaluating a patient with an orbital injury, the radiologist should do the following: (a) evaluate the bony orbit for fractures, note any herniations of orbital contents, and pay particular attention to the orbital apex; (b) evaluate the anterior chamber; (c) evaluate the position of the lens (the lens may be displaced, and it may be either completely or partially dislocated); (d) evaluate the posterior segment of the globe, look for bleeds or abnormal fluid collections, and evaluate for radiopaque or radiolucent foreign bodies; and (e) evaluate the ophthalmic veins and the optic nerve complex, especially the orbital apex.

Reconstruction of acquired orbital deformity characterized by volume change

Acquired orbital deformity is a common disease in the practice of craniofacial surgery. Defective orbital volume and abnormality of eyeball position are the most important characteristics of pathologic changes. This study includes 87 cases of acquired orbital deformity, which received surgery for volume aberration from 2002 to present. Among them, 73 cases received orbital volume expansion surgery and 14 cases received reduction surgery. Coronal scalp, lower eyelid, or intraoral gingival-buccal incisions were carried out for the approach. In some patients, the original scar around the orbit was chosen for the incision. Operation aims were reduction of orbit and reconstruction of the orbital wall integrity. Operative methods were osteotomy for reduction and implantation of autologous bone or artificial materials. Orbital volume and eyeball position were restored to normal in all patients after the operation, and no serious complications occurred. Treatment of acquired orbital deformity should make restoration of orbital volume as the most important target of therapy. Autologous bone should be the material of first choice, and the selection and amount of implanted material should be decided by the specialty and experience of the physician.

Orbital Fractures Complicated by Late Enophthalmos: Higher Prevalence in Patients With Multiple Trauma

PURPOSE

To present our experience with orbital fracture treatment outcomes in patients with multiple trauma and those suffering localized orbital trauma.

METHODS

Retrospective data review of all patients examined for ocular motility problems and/or enophthalmos following orbital trauma in a 4-year period.

RESULTS

Forty-three patients were included in the study: 31 (72%) had localized orbital trauma (LOT) and 12 (28%) had concomitant traumatic insults to other organs (MT). More orbital walls were affected in MT patients than in LOT patients, and the incidence of zygomatic fracture was higher in MT patients. Late enopthalmos was much more prevalent in the MT group compared with the LOT group. Differences of outcome of extra ocular motility disturbance between groups in our series did not reach statistical significance.

CONCLUSIONS

The findings of more walls affected and higher incidence of zygomatic fractures in MT patients probably represent a stronger impact of the original insult, causing both more damage to other organs and more severe damage to the orbit. The increased rate of late enophthalmos in MT patients may be associated with their primary presentation to the emergency room with potentially life-threatening injuries. Under such circumstances, thorough ophthalmologic examination is nearly impossible, both because the patient cannot cooperate sufficiently and because medical priorities dictate concentration on taking care of the injuries threatening life. The lack of a thorough ophthalmic examination prevents early comprehensive treatment.

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.

Maxillofacial Injury Severity Score: proposal of a new scoring system

In this study a new injury severity score system, the Maxillofacial Injury Severity Score (MFISS), was developed to evaluate the characteristics of injury from maxillofacial trauma. Nine hundred and two cases of maxillofacial trauma were included in this study to evaluate injury severity using the MFISS, which was designed on the basis of Abbreviated Injury Scale, 1990 revision (AIS-90), and defined as the product of the sum of the three highest maxillofacial AIS scores and the sum of the injury severity scores for three maxillofacial functional parameters, malocclusion (MO), limited mouth opening (LMO), and facial deformity (FD). The correlation analysis was undertaken with the dependent factor of cost and number of days of stay in hospital. The results demonstrated a significant difference (P < 0.01) between bone and soft-tissue injuries and among various regional fractures. There was correlation (P < 0.01) between the MFISS and the cost of treatment and days of stay in hospital. The newly established MFISS thus characterizes maxillofacial injury severity while reflecting the management costs and treatment complexity.

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.

Blindness after Blunt Facial Trauma: Are There Any Clinical Clues to Early Recognition?

BACKGROUND

Vision-threatening injury is a relatively rare but devastating complication of maxillofacial trauma. Identification is not always straightforward. The purpose of this study was to look at our experience of blindness after blunt facial injuries to see whether any useful patterns or risk factors were identified to assist in early recognition.

METHODS

This was a retrospective, qualitative study undertaken at the University Hospital of North Staffordshire. All case notes, plain radiographs, and computed tomographic scans were reviewed and the relevant data collated.

RESULTS

Over a 10-year period, 17 patients were identified in which loss of vision occurred secondary to blunt injury to the face.

CONCLUSION

It is important to maintain a high index of suspicion when dealing with maxillofacial trauma, particularly if the patient is not cooperative. We provide a list of salient features to look for in the examination and history to aid the clinician.

[Personnel and structural requirements for the shock trauma room management of multiple trauma. A systematic review of the literature]

The aim of the study was the description of personal and structural preconditions essential for adequate diagnostic requirements and treatment in severely injured patients. Herein we give detailed information regarding both the composition and qualification of the trauma team and the activation criteria as well as instructions for the design of the emergency room and technical requirements. Clinical trials were systematically collected (MEDLINE, Cochrane, and hand searches) and classified into evidence levels (1 to 5 according to the Oxford system). The trauma team should consist of (trauma) surgeons, anesthesiologists, radiologists, and one to two nursing staff members of each department. The attending physician should be present within 20 min. Trauma team activation criteria are among others: high energy/velocity trauma, penetrating injuries, GCS < or =14, and intubation. The emergency room should be integrated in the emergency department with all technical equipment being permanently available for optimal diagnostic and therapeutic management. A CT scanner should be positioned nearby.Adequate management of severely injured patients requires optimal personal and structural conditions. High costs and additional personnel are justified by improved quality of treatment.

Prevalence of significant intraocular sequelae in blunt orbital trauma

The purpose of this study was to describe the prevalence of significant intraocular sequelae (SIOS) and its correlation with the severity of blunt orbital trauma. Four hundred ten consecutive patients presenting to the ED who had sustained blunt orbital trauma were studied. The severity of orbital trauma was graded and SIOS was determined by the presence of an intraocular injury as listed in Table 2. The presence of SIOS was noted in 14 (41.2%) mild, 22 (59.5%) moderate, and 20 (29.4%) severe orbital trauma. In the severe group, the presence of SIOS was detected in 8 (23.5%) blowout fractures and in 12 (35.3%) non-blowout fractures. In view of the high rates of ocular complications among mild and moderate orbital injuries, such patients should have prompt ophthalmic follow up. The relatively low prevalence of SIOS in patients with severe orbital trauma could suggest a protective mechanism in this type of injury.

The effects of airbags on orbital fracture patterns in frontal automobile crashes

PURPOSE

To investigate orbital fractures that occurred in frontal automobile crashes and to determine the effects of frontal airbags on injury incidence and severity.

METHODS

The National Automotive Sampling System database files from 1993 to 2000 were examined. Frontal crashes were selected that included drivers and front-seat passengers only and excluded ejected occupants and rollover crashes. Orbital fractures could be closed, open, displaced, or any combination of these and were identified by using the Abbreviated Injury Scale codes.

RESULTS

The analysis included 12,429,580 front-seat occupants from 25,464 cases. Of all occupants who were exposed to an airbag deployment, 0.09% sustained an orbital fracture. In contrast, occupants who were not exposed to an airbag deployment were more than twice as likely to sustain an orbital fracture (0.22%). In addition to reduction in incidence, airbags were also shown to decrease the severity of orbital fractures that occupants sustained. Occupants exposed to airbag deployment mostly sustained closed, less severe fractures (61.9%), whereas occupants not exposed to airbag deployment sustained the majority as more severe, open, displaced, or comminuted fractures (61.3%).

CONCLUSIONS

This article presents the most comprehensive study of orbital fractures in automobile crashes to date. It is shown that both the incidence and the overall severity of orbital fractures decreases considerably with exposure to airbag deployment. This is accomplished because the airbag minimizes occupant contact with the windshield and steering wheel, which are the two leading sources of orbital fractures for occupants not exposed to airbag deployment.

Orbital and adnexal trauma associated with open-globe injuries

PURPOSE

To describe the incidence and patterns of orbital and adnexal injuries in patients with open-globe injuries.

METHODS

Charts of 300 consecutive patients with open-globe injuries presenting to the Massachusetts Eye and Ear Infirmary were retrospectively reviewed. The data were analyzed with respect to the type of open globe (penetrating, perforating, or rupture) and location (zone) of globe injury. Each of these subgroups was then evaluated for the absence (group 1) or presence (group 2) of coexisting orbital and/or adnexal injury. Visual acuity at presentation was compared between the two groups.

RESULTS

Orbital and adnexal injuries were present in 25.7% of patients with open globes. The most common concurrent injuries were lacerations of the eyelid, orbital fracture, and retrobulbar hemorrhage. The mechanisms of globe injury differed significantly between groups 1 and 2. Penetrating injuries accounted for 82.1% of group 1 but only 49.3% of group 2 patients, whereas rupture occurred more frequently in group 2 (48.1%) than in group 1 (17.0%) patients. Orbital and adnexal injuries were associated with poorer visual acuity at presentation, probably because of the high incidence of posterior globe injuries in these patients.

CONCLUSIONS

Orbital and adnexal injuries were observed in 25.7% of patients who sustained trauma that resulted in open globes. Concurrent injury to these extraocular structures is associated with worse visual acuity at presentation and an increased likelihood of posterior globe injuries.

Ophthalmologists in teaching hospitals: do we make a difference to patient outcome?

PURPOSE

To determine the type and frequency of consultations with the eye department of a major tertiary care teaching hospital.

METHODS

A retrospective review was undertaken of the medical records of npatient consultations within the Ophthalmology Department of Royal Prince Alfred Hospital over the period from July 1995 to 30 June 1997. The consults were dvided into sx types of consultation. A determination was made of the outcome and effect on patient management of each consultation.

RESULTS

There were 506 consultations over the 2-year period. For 389 patients a full ophthalmic assessment was requested and 175 of them (45%) had an ophthalmological diagnosis made or had change in management as a result of the consultation.

CONCLUSION

Ophthalmological consultation is a valuable npatient consultation service that makes a significant difference in the management of patients from other medical and surgical units within the hospital.

Facial gunshot wounds: a 4-year experience

PURPOSE

Facial gunshot wounds can result in devastating functional and aesthetic consequences for patients. In an attempt to evaluate the management and outcome in these patients, a 4-year retrospective review was undertaken of all patients presenting with facial gunshot wounds at a level I trauma center.

PATIENTS AND METHODS

A total of 121 patients were identified. Medical documentation could be obtained on 84 of those patients. The patients' maxillofacial injuries were treated by the 3 participating services: plastic surgery, oral and maxillofacial surgery, and otorhinolaryngology. The patients ranged in age from 6 to 64 years, with a mean age of 27 years.

RESULTS

The gunshot wounds were single in 64% of the cases and multiple in 36% of the cases. Overall mortality in the series was 11%. Sixty-seven percent (56/84) of the patients suffered an injury to the underlying craniofacial skeleton. Seventy-five percent of these patients required surgical intervention. Twenty-one percent of the patients (16/75) required tracheostomy emergently for management of the airway. Eighteen percent (15/84) of these patients had an intracranial injury, with 50% of these patients requiring surgery. Fourteen percent of the patients in the series (12/84) had great vessel injuries diagnosed at the time of angiography, with 50% of these patients requiring surgery for treatment.

CONCLUSION

Contrary to much of the published literature, most patients in this series required surgical intervention for treatment of their facial gunshot wounds. Reconstructive procedures were performed early in the patient's course and, when possible, addressed both the soft tissue and underlying bony injury in a minimum number of stages.