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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 7  |  Issue : 2  |  Page : 37-40

Characteristics of open-globe injuries in a tertiary hospital of Southern India


Department of Ophthalmology, St. John's Medical College and Hospital, Bengaluru, Karnataka, India

Date of Submission13-Jun-2018
Date of Acceptance23-Jan-2019
Date of Web Publication21-Aug-2019

Correspondence Address:
Anupama Janardhanan
352, 6th Block, 18th F Main, Koramangala, Bengaluru - 560 095, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcor.jcor_54_18

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  Abstract 


Aim: This study aims to describe the epidemiology of open-globe injuries at a tertiary care hospital of South India over a period of 5 years. Materials and Methods: Review of records of 40 eyes with open-globe injuries from January 2012 to December 2016 was done for demographics, time, nature and cause of injury, visual acuity, and ocular findings. Results: The prevalence of open-globe injuries was 2%. Majority of patients underwent primary repair with 5% having undergone evisceration. Visual acuity at time of presentation was >0.74 log of minimal angle of resolution in 10% with 17.5% having no perception of light. The most common type of injury as per the Birmingham Eye Trauma Terminology System was penetration type, Zone-I. Occupational injury was the most common mode of injury. Increasing number of injuries with a mean of 8 injuries/year was noted. Vitreous loss and associated facial trauma can be taken as an added variable for predicting postoperative visual outcome. Conclusion: Our study shows a male preponderance with men between age group of 20 and 40 years being at risk of open-globe injury. Immediate recognition of eye injury by the general practitioner and quick referral of the patient to an appropriate tertiary hospital with eye care facilities, within 24 h is advisable. Occupational injury was the etiology for the majority of the patients and hence there is a need to introduce stringent worker safety protocols. Ocular trauma score is also a good indicator of the prognosis for vision.

Keywords: Open-globe injuries, risk factors in open-globe injuries, visual outcome in open-globe injuries, vitreous loss in open-globe injuries


How to cite this article:
Kothari A, Joseph M, Janardhanan A. Characteristics of open-globe injuries in a tertiary hospital of Southern India. J Clin Ophthalmol Res 2019;7:37-40

How to cite this URL:
Kothari A, Joseph M, Janardhanan A. Characteristics of open-globe injuries in a tertiary hospital of Southern India. J Clin Ophthalmol Res [serial online] 2019 [cited 2019 Nov 17];7:37-40. Available from: http://www.jcor.in/text.asp?2019/7/2/37/264894



Ocular trauma is one of the main causes of treatable visual morbidity and blindness. It is associated with a physical, socioeconomic and psychological stress, and frequent hospital visits. Birmingham Eye Trauma Terminology System (BETTS) defines open-globe injury as full thickness wound of sclera or cornea or both.[1] Occult open-globe injuries are prone to be missed at initial evaluation [Figure 1]a and [Figure 1]b. As per the World Health Organization, 55 million eye injuries limiting activities happen for >1 day each year. About 750,000 cases need hospitalization out of which 200,000 are open-globe injuries.[2],[3] Two thousand nine hundred and thirty-nine cases of open-globe injuries are reported to the National Eye Trauma System Registry.[4] Open-globe injuries bring about management dilemmas with many unresolved controversies. In few cases, multiple intraocular surgical procedures may be performed to salvage some beneficial vision.[5]

The data that is available on the pattern of eye injuries in developing countries are inadequate. Etiology for ocular trauma varies immensely in different parts of the world, even within the same country differing across various regions depending on occupations, traffic, and environmental factors among other factors. Since our hospital acts as an accessible tertiary care referral for three South Indian states, this study will provide a brief idea on demography of open-globe injuries referred here. This study should assist in developing preventative measures in avoidable etiologies.
Figure 1: (a and b) Examples of occult/hidden open-globe injuries

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Kuhn et al. gave a prognostic model, the ocular trauma score (OTS) which predicts visual outcome in ocular trauma. The OTS is calculated by providing numerical points to six variables: globe rupture, perforating injury, initial visual acuity, retinal detachment, endophthalmitis, and relative afferent pupillary defect (RAPD). The scores are grouped into five categories that give the probabilities of attaining a range of visual acuities postinjury.[7],[8] The postoperative visual outcome will be compared to visual prognosis deduced by OTS system.

In addition, we expect to identify additional significant clinical characteristics that may aid the surgeon in deciding on the prognostic value of primary repair of these open-globe injuries. Identifying these factors before surgical intervention or intraoperatively can help the surgeon in evidence-based counseling of the trauma victim and family.[6],[7]

The purpose of this study was to understand about the pattern of open-globe injuries in South India and to clarify about prognosticating factors of visual acuity in addition to that established by OTS system.


  Materials and Methods Top


This study was conducted in a tertiary care center of South India mainly catering populations from borders of three South Indian states. Our study included 40 eyes with diagnosed open-globe injuries presenting to our hospital over 4 years between January 2012 and December 2016. Epidemiological parameters such as age and gender distribution, and specific variables such as mechanism zone and type of injury, time since injury, and time till operation from the time of presentation were noted. Examination notes were reviewed for initial visual acuity, presence of hyphema, RAPD, cataract, intraocular foreign body, vitreous loss, retinal detachment, and OTS was calculated for each case to compare with the postoperative recorded visual acuity to study its applicability in predicting the same.

Data of each patient were reviewed, segregated, and analyzed using appropriate statistical tests, and results were compared with previous existent comparable studies of same cadre. The classification of open-globe injury has been according to the BETTS.[1],[7],[9]

Descriptive analysis was carried out using mean and standard deviation. Inferential analysis was carried out using analysis of variance. P < 0.05 was considered statistically significant.


  Results Top


Out of the 40 eyes, 25 patients (62.5%) were below age of 30 years [Appendix Table 1]. Male-to-female ratio was 1:8. The most common etiology of injury that was found in our study was occupational injuries (45%) [Appendix Table 2]. These occupational injuries majorly belonged to steel industry (64%) followed by patients who were carpenter (13%) by occupation. Among other leading causes were globe injuries secondary to road traffic accidents and accidental domestic injuries [Figure 2] and [Figure 3].
Figure 2: Demography

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Figure 3: Etiology of open-globe injuries

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Among the type of open-globe injuries, penetrating type (82%) with Zone-I (45%) was found to be the most common type followed by Zone-III injuries as per the BETTS classification [Figure 4].
Figure 4: Classification of open-globe injuries on the basis of zone

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Visual acuity at time of presentation was >0.74 log of minimal angle of resolution (LogMAR) in 10% with 17.5% having no perception of light (PL).

RAPD was noted in four eyes (4%). Six eyes (15%) presented with lens opacities and two eyes had lens rupture. Retinal detachment was found in four eyes (10%).

In all, 95% eyes were salvageable and underwent primary repair out of which 84% of eyes had PL or more, implying the significance of surgical repair irrespective of being no PL or having disfigurement. Extensive blood loss can be prevented by a primary repair [Figure 5]. About 42.5% eyes had an initial visual acuity in range of LogMAR 3.0–5.0 (Hand movements to only PL) [Figure 6]. On postoperative day 3, visual acuity of 37.5% eyes had visual acuity >LogMAR 1.3 (counting fingers >3 m) [Figure 7].
Figure 5: Type of surgical repair and resultant visual outcome

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Figure 6: Visual acuity at the time of presentation in log of minimal angle of resolution

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Figure 7: Postoperative visual acuity in log of minimal angle of resolution

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At the time of presentation, around 30% eyes presented within 3 h of the injury, whereas 25% presented after 24 h of the injury. We observed time since injury was not a statistically significant factor affecting postoperative visual outcome in our study, but it qualitatively implies about the delay in presentation to the hospital. OTS was found to be highly statistically relevant for predicting the 1-week postoperative visual outcome (P = 0.014) [Figure 8]. Vitreous loss was observed in 35% eyes [Figure 9]. Associated facial trauma was found to affect the postoperative visual acuity (P = 0.04) [Figure 10].
Figure 8: Ocular trauma score

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Figure 9: Frequency distribution of clinical variables

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Figure 10: An open-globe injury associated with severe facial trauma

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  Discussion Top


Open-globe injuries are devastating and highly challenging. Timely diagnosis and intervention must be attempted to preserve possible useful vision. Although the common causative etiology found in our study was occupational cause in accordance with Vasu et al., Larque-Daza et al., and Rao et al. Our study revealed that men were more prone and Zone-1 injuries were invariably the most common type noted.[10],[11],[12]

The most important factor affecting postoperative visual outcome in penetrating open-globe injury is the initial visual acuity. Sternberg et al. found that if the visual acuity at time of presentation is >20/800, it leads to a better outcome. Applying univariate analysis, presenting visual acuity was found to be statistically significant to the postoperative visual outcome (P < 0.05).[13],[14]

Sternberg et al. found that corneal lacerations have a better outcome compared to other injuries. Similarly, we found that the zone of injury had a statistically significant effect on the postoperative visual outcome as observed in Qayum et al.'s study (P < 0.05).[13],[15] Vitreous hemorrhage and intraocular foreign body were not found to be statistically significant factors affecting the visual outcome (P > 0.05).

Most importantly, our study found that early presentation of open-globe injuries to the hospital influences postoperative visual outcome in accordance with Agrawal et al., Qayum et al., and the JUDO study.[8],[15],[16] Associated severe facial and other injuries can have a significant effect on postoperative visual acuity agreeable with Kanoff et al.,[7] whereas as per Rao et al., there is no significance between time since injury and visual outcome.[12]

Our study was retrospective in nature, but we intend to do a prospective study to understand the dynamics of open-globe injuries in detail in our hospital setting. Visual outcomes included in our study were immediate postoperative in nature and due to unavailability of long-term visual outcome, either visual acuities could not be compared. In addition, number of pediatric open-globe injuries was less in number to be assessed against adult injuries.


  Conclusion Top


Our study shows a male preponderance with men between age group of 20 and 40 years being at risk of open-globe injury. Immediate recognition of eye injury by the general practitioner and quick referral of the patient to an appropriate tertiary hospital with eye care facilities, within 24 h is advisable. Occupational injuries were the etiology for the majority of the patients hence there is a need to introduce stringent worker safety protocols. OTS is also a good indicator of the prognosis for vision.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Khurana AK. Profile and Management of Ocular Trauma. 1st ed. Delhi: CBS; 2016.  Back to cited text no. 1
    
2.
Titiyal GS, Prakash C, Gupta S, Joshi V. Pattern of ocular trauma in tertiary care hospital of Kumaon Region, Uttarakhand. J Indian Acad Forensic Med 2013;35:116-19.  Back to cited text no. 2
    
3.
Négrel AD, Thylefors B. The global impact of eye injuries. Ophthalmic Epidemiol 1998;5:143-69.  Back to cited text no. 3
    
4.
Dannenberg AL, Parver LM, Brechner RJ, Khoo L. Penetration eye injuries in the workplace. The national eye trauma system registry. Arch Ophthalmol 1992;110:843-8.  Back to cited text no. 4
    
5.
Rahman I, Maino A, Devadason D, Leatherbarrow B. Open globe injuries: Factors predictive of poor outcome. Eye (Lond) 2006;20:1336-41.  Back to cited text no. 5
    
6.
Kuhn F, Morris F, Witherspoon CD. The birmingham eye trauma terminology system (BETT). J Fr Ophthalmol 2004;27:206-10.  Back to cited text no. 6
    
7.
Kanoff J M, Turalba A V, Andreoli M T, Andreoli Mc. Characteristics and outcomes of work-related open globe injuries. American J Ophthalmology 2010;150:265-9. e2.  Back to cited text no. 7
    
8.
Agrawal R, Rao R, Naigaonkar R, Ou X, Desai S. Prognostic factors for vision outcome after surgical repair of open globe injuries. Indian J Ophthalmology 2011;59:4733-38.  Back to cited text no. 8
    
9.
Man CY, Steel D. Visual outcome after open globe injury: A comparison of two prognostic models—The ocular trauma score and the classification and regression tree. Eye 2010;24:84-9.  Back to cited text no. 9
    
10.
Larque-Daza AB, Peralta-Calvo J, Lopez-Andrade J. Epidemiology of open-globe trauma in the southeast of Spain. Eur J Ophthalmol 2010;20:578-83.  Back to cited text no. 10
    
11.
Vasu U, Vasnaik A, Battu RR, Kurian M, George S. Occupational open globe injuries. Indian J Ophthalmol 2001;49:43-7.  Back to cited text no. 11
[PUBMED]  [Full text]  
12.
Rao LG, Ninan A, Rao KA. Descriptive study on ocular survival, visual outcome and prognostic factors in open globe injuries. Indian J Ophthalmol 2010;58:321-3.  Back to cited text no. 12
[PUBMED]  [Full text]  
13.
Sternberg P Jr., de Juan E Jr., Michels RG, Auer C. Multivariate analysis of prognostic factors in penetrating ocular injuries. Am J Ophthalmol 1984;98:467-72.  Back to cited text no. 13
    
14.
Pieramici DJ, MacCumber MW, Humayun MU, Marsh MJ, de Juan E Jr. Open-globe injury. Update on types of injuries and visual results. Ophthalmology 1996;103:1798-803.  Back to cited text no. 14
    
15.
Qayum S, Anjum R, Garg P. Epidemiological pattern of ocular trauma in a tertiary hospital of northern India. Int J Biomed Res 2016;7:420-2.  Back to cited text no. 15
    
16.
Asaminew T, Gelaw Y, Alemseged F. A 2-year review of ocular trauma in JIMMA University specialized hospital. Ethiop J Health Sci 2009;19:67-76.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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