Clinical Diagnosis and Management of Ocular Trauma Ashok Garg, Mahipal S Sachdev, Jerome Jean Bovet, B Shukla
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Section I
1Preliminary and Basic Considerations in Ocular Trauma
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Epidemiology and New Classification of Ocular TraumaCHAPTER 1

João J Nassaralla Jr,
Belquiz A Nassaralla
(Brazil)
 
Introduction
An injury to the eye or its surrounding tissues is the most common cause for attendance at an eye hospital emergency department. The extent of trauma may range from simple superficial injuries to devastating penetrating injuries of the eyelids, lacrimal system, and globe. The surgical management of such injuries is directed primarily at the restoration of normal ocular anatomy; the ultimate goal is to prevent secondary complications and maximize the patient's visual prognosis. Dramatic improvements in the surgical management of ocular trauma have evolved over the past two decades. However, persistent inadequacy in the standardized documentation of eye injury morbidity and treatment outcome limits the development and widespread introduction of techniques for preventing and improving the prognosis of serious eye trauma.
Professional associations like the International Society of Ocular Trauma (ISOT), and the United States Eye Injury Registry (USEIR), have been formed to promote research, elaborate epidemiologic investigations, highlighting preventable sources of injury, emerging patterns of trauma, treatment outcomes and disseminate its results. The USEIR is presently working with the ISOT to establish the World Eye Injury Registry (WEIR). International registries have been established or are in start-up phase in Brazil, British Armed Forces, Bolivia, Canada, China, Colombia, Croatia, Finland, India, Italy, Germany, Greece, Hungary, Israel, Kenya, Korea, Lithuania, Mexico, New Zealand, Portugal, Romania, Saudi Arabia, Singapore, Slovakia, Slovenia, South Africa, Spain, Switzerland, Turkey, Venezuela, West Indies(Trinidad), Yugoslavia, Zimbabwe with assistance from the United States Eye Injury Registry.1
Unfortunately, the lack of an unambiguous common language remains a major limiting factor in effectively sharing eye injury information. Without a standardized terminology of eye injury types, it is impossible to design projects like the USEIR or the WEIR; clinical trials in the field of ocular trauma cannot be planned; and the communication between ophthalmologists remains ambiguous.1,2 So, a standardized terminology for eye injury has been developed by the USEIR based on extensive experience and repeated reviews by international ophthalmic audiences. By always using the entire globe as the tissue of reference, classification is unambiguous, consistent, and simple. It provides definitions for the commonly used eye trauma terms within the framework of a comprehensive system.1
 
Epidemiology
Eye injuries are a major and under recognized cause of disabling ocular morbidity that especially affect the young. The public health importance of such ocular trauma is undeniable. Injuries generate a significant and often unnecessary toll in terms of medical care, human suffering, long-term disability, productivity loss, rehabilitation services, and socioeconomic cost.1-3
Globally, more than 500.000 blinding injuries occur every year. Approximately 1.6 million people are blind owing to ocular trauma, 2.3 million are bilaterally visually impaired, and 19 million have unilateral visual loss.3,4 Every year, approximately 2 million eye injuries occur in the United States, of which, more than 40 thousand results in permanent visual impairment.6,7 Prior studies in which the incidence of eye injury has been examined have produced varied results, in part because of study design differences.8-13 When considering eye injuries requiring hospital admission, rates have ranged from 8 to 57 per 100.000.8-13 Despite the heterogeneity of results, these studies provide important information regarding the burden of eye injury. However, they have all been limited to a single year or narrow time frame making it difficult to determine trends in injury rates over time. In the United States, a population-based study reported a prevalence rate of 19.8% and an average annual incidence rate of 3.1 per 1000 population.144
In a more recent study from 1992 through 2002, the incidence of eye injury declined overall and the estimated rate of eye injury ranged from 8.2 to 13.0 per 1000 population.5
Worldwide, ocular trauma is a leading cause of no congenital monocular blindness among children.16-20 Children are disproportionately affected by ocular injuries. In the United States, a population-based study reported an annual incidence of ocular trauma in children of 15.2 per 100.000.18 In general, males are more frequently reported to have eye injuries than females.17-24 Results varied across studies regarding the age-specific frequency of eye injuries17-26 with some reporting a higher incidence in older children and others in younger children. A study conducted among Brazilian children found that the group aged 0 to 5 years was at greatest risk, regardless of sex, and that among those older than 5 years, eye injuries were more frequent in boys.26
Although the overall financial cost derived from ocular injuries can only be estimated, direct and indirect costs combined run into hundreds of millions of dollars per year. Developing countries carry the heaviest burden, and they are the least able to afford the costs.8
Domestic accidents (40%), industrials (13%), and street/highway accidents (13%) are the most common circumstances in which ocular injury occurs, (Fig. 1.1). Eye injuries incurred during athletic activity (13%) are becoming more common with the increasing popularity of indoor court games. A recent survey found racquetball to exceed other sports in generating ocular injuries, followed by tennis, baseball, basketball, and soccer.1
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Fig. 1.1: Places of eye injury1
The most common sources of eye injuries are blunt object (31%), sharp object (18%), and motor vehicle crash (9%), (Fig. 1.2).
While the incidence of ocular trauma has been described in the United States,6,8,12,15 United Kingdom,10 Sweden,27 and Greece,28 it has not been well studied in other industrialized countries, like Italy, where clinical research on ocular trauma is limited to the pediatric population and sportsmen.22,29,30 Available information regarding the distribution and magnitude of ocular trauma in developing countries is very scarce, and the existing data are difficult to interpret because reporting is extremely poor and especially because of the completely different settings of the occurrence of ocular trauma.3 Among other factors, underreporting and lack of standardized forms and national integrated databases make assessment of the current picture and comparisons within and across countries practically impossible.2 In addition, developing countries often lack adequate infrastructure for persons with eye injuries to reach a primary care center, when one exists, and the lack of awareness of preventive measures and/or immediate actions increases the risk for complications and consequent visual disability and blindness.8 From a public health and injury prevention perspective, current information on eye injuries rates is needed to develop effective plans for disseminating eye injury prevention materials to the public and to earmark adequate funding for these initiatives.1,2
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Fig. 1.2: Sources of eye injury1
 
New Classification
The new classification of ocular trauma has been endorsed by the Board of Directors of the International Society of Ocular Trauma, the United States Eye Injury Registry, the Hungarian Eye Injury Registry, the Vitreous Society, the Retina Society, and the American Academy of Ophthalmology. This classification system categorizes ocular injuries at the time of initial examination. It is designed to promote the use of standard terminology and assessment, with applications to clinical management and research studies regarding eye injuries (Fig. 1.3).1,2,32
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Fig. 1.3: The proposed new ocular traumatology system.1 The green boxes show the diagnoses that are used in clinical practice
The new ocular trauma terminology system.1,2,31,32 provides definitions for the commonly used eye trauma terms as follows:
  1. Eyewall—For clinical and practical purposes, the term eyewall must be restricted to the rigid structures of the sclera and cornea.
  2. Closed-globe injury—The eyewall does not have a full-thickness wound. Either there is no corneal or scleral wound at all (contusion) or is it only partial thickness (lamellar laceration).
  3. Open-globe injury—The eyewall has a full-thickness wound. The cornea and/or sclera sustained a through-through injury; depending on the inciting object's characteristics and the injury's circumstances, ruptures and lacerations are distinguished; the choroid and the retina may be intact, prolapsed or damaged.
  4. Rupture—Full-thickness wound of the eyewall, caused by a blunt object; the impact results in momentary increase of the intraocular pressure. The eyewall gives way at its weakest point (at the impact site or elsewhere; example: an old cataract wound dehisces even though the impact occurred elsewhere); the actual wound is produced by an inside-out mechanism.
  5. Laceration—Full-thickness wound of the eyewall, usually caused by a sharp object; the wound occurs at the impact site by an outside-in mechanism.
  6. Penetrating injury—Single laceration of the eyewall, usually caused by a sharp object. No exit wound has occurred; if more than one entrance wound is present, each must have been caused by a different agent.
  7. Intraocular foreign body injury (IOFB)—Retained foreign object(s) causing entrance laceration(s). An IOFB is technically a penetrating injury but is grouped separately because of different clinical implications (treatment modality, timing, endophthalmitis rate, etc.).
  8. Perforating injury—Two full-thickness lacerations (entrance and exit) of the eyewall, usually caused by a sharp object or missile. The two wounds must have been caused by the same agent.
Participation of individual treating ophthalmologists is critical to the development of comprehensive epidemiologic eye injury data. Documentation of each serious eye injury is important work, and, through this cooperative effort, will ultimately benefit all patients and physicians. It is expected that this system eventually will become the standardized international language of ocular trauma terminology, improving accuracy in both clinical practice and research, irrespective of geographic origin.
References
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