Graefes Arch Clin Exp Ophthalmol DOI 10.1007/s00417-015-2929-y
TRAUMA
Open-globe injuries with motor vehicle accidents: a 12-year review Christopher K. Orr & Alain Bauza & Paul D. Langer & Marco A. Zarbin & Neelakshi Bhagat
Received: 2 September 2014 / Revised: 10 December 2014 / Accepted: 7 January 2015 # Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose To evaluate demographics, characteristics, and outcomes of open-globe injuries (OGIs) in motor vehicle accidents (MVAs). Methods Retrospective chart review of patients with OGIs related to MVAs that presented to University Hospital, Newark, from 2000 to 2012. Results Twenty-five patients were identified; the average age of the patients was 33.3 years old (range, 5–75). The majority of patients (64 %) were males. The 25 vehicles comprised 24 automobiles and one motorcycle. Ten patients (40 %) wore seatbelts, and five (20 %) did not wear seatbelts. The seatbelt status was not documented in the remaining cases. Ethanol was documented as a contributing factor in five of the accidents. In terms of open-globe classification, 15 OGIs (60 %) were ruptures, and five (20 %) were penetrating injuries; three (12 %) had intraocular foreign bodies. Ten eyes (40 %) had a final VA of 20/ 400 or worse. Fourteen eyes (56 %) achieved a final VA of 20/200 or better; seven eyes (28 %) achieved a final VA of 20/40 or better. Conclusion Fifty-six percent of eyes with an open-globe injury related to MVAs achieved a final VA of 20/200 or better in this series. No eyes developed endophthalmitis.
Keywords Airbag . Alcohol . Motor vehicle accident . open-globe injury . Seatbelt
C. K. Orr : A. Bauza : P. D. Langer : M. A. Zarbin : N. Bhagat (*) Institute of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, DOC-6100; 90 Bergen Street, Newark, NJ 07103, USA e-mail: [email protected]
Introduction An open-globe injury is the result of a full-thickness wound in the eyewall [1]. Open-globe injuries (OGIs) are one of the major causes of visual loss in urban communities [2], and occur at an estimated rate of 3.5 per 100,000 persons per year globally [3]. Blindness related to trauma accounts for 40,000 to 60,000 of the 2.4 million new eye injury cases in the United States [4, 5]. The U.S. Department of Transportation and the National Highway Traffic Safety Administration reports that 2.24 million people were involved in motor vehicle accidents (MVAs) in 2010 [6, 7]. A review of English literature in the past 20 years reveals only two published studies on eye injuries related to MVAs. McGwin et al. [8] reported on 1,231,554 eyes during the observation time 1988–2001 from the National Automotive Sampling System Crashworthiness Data Systems, and Kuhn et al. [9] reported on 150 eyes from 1982 to 1989. The purpose of this study is provide information on the demographics and presenting clinical features of OGIs related to MVAs in the United States.
Methods We secured approval from the Rutgers-New Jersey Medical School Institutional Review Board to conduct a retrospective chart review of all patients who presented with OGIs related to motor vehicle accidents (MVA) between January 2000 and December 2012. Data recorded from the retrospective chart review was in accordance with the training from the Collaborative Institutional Training Initiative (CITI) that emphasized human and animal rights. The data recorded from the medical records included: age, race, gender, type of trauma, details regarding the MVA (restrained with seatbelt, alcohol use, other substance use, airbag deployment), oral maxillofacial injuries sustained, other injuries (such as orthopedic
Graefes Arch Clin Exp Ophthalmol
injuries), duration between time of injury to surgery, length of hospital stay, ocular surgeries that were performed, past medical history, past ophthalmologic history, and duration of follow-up. Ocular examination data recorded included: type of injury, location and zone of injury, lens status, Seidel test, hyphema, presence of endophthalmitis, zone of injury, presence of an afferent pupillary defect (APD), characteristics of intraocular foreign body (IOFB) if noted, presence of retinal detachment (RD), vitreous hemorrhage (VH), hemorrhagic choroidal detachment, pre-operative fundus examination,and post-operative fundus examination. Visual acuity (VA) data were collected at presentation, and on post-operative day 1, week 1, months 1, 3, and 6, and years 1 and 2, along with the final VA and best VA recorded during the entire follow-up period. A conversion of Snellen VA to the logarithm of the minimum angle of resolution (LogMAR) was performed for statistical analysis [10]. Zone of injury was categorized into zones 1, 2, and 3, with zone 1 being limited to the cornea and limbus but not extending beyond the limbus. Zone 2 injuries were located beyond the limbus and up to 5 mm posterior to the limbus. Zone 3 injuries were located more than 5 mm posterior to the limbus. In the cases that involved more than 1 zone, the injury was documented as the highest zone to indicate the most posterior site of injury [1]. The open-globe injuries were categorized as rupture, penetrating, perforating, and intraocular foreign body (IOFB) injuries using the trauma classification set forth in the Birmingham Eye Trauma Terminology (BETT) by Kuhn et al. [11]. Trauma from blunt objects leading to a fullthickness wound was classified as a “rupture” type of injury with an “inside–out” mechanism of injury. A transient increase in intraocular pressure caused the globe to rupture at a weak point [1, 11]. The open globes caused by lacerations were “outside–in” injuries and included the categories of penetrating, perforating, and IOFB [1, 11]. Penetrating injuries typically were caused by a sharp object that resulted in a full-thickness entrance wound; however, a perforating injury was caused by an object that resulted in both a full-thickness entrance and exit wound [1, 11]. IOFBs created full-thickness entrance wounds, but were considered as distinct from penetrating injuries, since visual prognosis and clinical management interventions differ between the two groups [1, 11].
Results Twenty-five eyes (4 %) of the 631 eyes with OGIs treated at University Hospital between 2000 and 2012 were related to MVAs. The sample included 16 males (64 %). The average age of the patients was 33.3 years old (range, 5–75). Twelve patients (48 %) were between 20 and 40 years old. Twenty patients (80 %) had a follow-up duration of at least 3 months,
and 17 patients (68 %) were followed for 6 months or more. The average follow-up time was 18.9 months (range, 0– 97 months). African Americans comprised the largest racial group (36 %), followed by Caucasians (32 %), Hispanics (20 %), Asians (4 %), and other race or undocumented race (8 %). Of the 25 vehicles, 24 (96 %) were automobiles, and one (4 %) was a motorcycle. Among the 25 cases, 11 patients (44 %) were identified as the driver of the vehicle, and seven (28 %) were passengers. Of the 25 cases, only 15 (60 %) had documentation on the usage of a seatbelt. Ten patients (40 %) wore seatbelts, and five (20 %) did not wear seatbelts. Seven (28 %) of the 25 cases had documentation of alcohol use. Alcohol was documented as a contributing factor in five (20 %) of the accidents because of elevated blood alcohol levels. Only one (4 %) of the 25 cases had a positive urine drug screen (benzodiazepines, cannabinoids, and opioids were present). Eleven (44 %) of 25 cases had documentation of airbag status in the vehicle; six (24 %) had airbag deployments, and five cases (20 %) did not. The left eye was injured in 14 cases (56 %), and there were no patients with bilateral eye injuries. With regard to openglobe classification, rupture injuries comprised the largest group with 15 cases (60 %), followed by penetrating injuries [five cases (20 %)] and IOFB [three cases (12 %)]; two (8 %) of the open globes involved cataract wound dehiscence. Of the three IOFBs, two were glass or a piece of mirror, and one was metal. All IOFBs were diagnosed with initial clinical exam, B-scan, and computed tomography (CT scan). Nineteen (76 %) of the 25 cases had documentation of lens status. There were 13 phakic eyes (52 %); seven (54 %) of the phakic eyes had cataracts at presentation. Four eyes (16 %) were aphakic, and two (8 %) were pseudophakic. The lens status was not documented in two eyes (8 %) with hyphema. Of the seven eyes with cataract at presentation, two underwent pars plana lensectomy (PPL) during the primary globe repair with pars plana vitrectomy (PPV) for IOFBs. One eye with a subluxed anterior chamber intraocular lens (ACIOL) underwent lens removal during the primary globe repair. All 25 cases received intravenous antibiotics. The most commonly used intravenous antibiotics were ceftazidime and vancomycin [in 17 patients (68 %)] given as combination therapy. Only 22 eyes (88 %) had complete documentation of the extent of injury. According to the classification set forth by Pieramici et al. [1], the location of injury was zone 1 in nine eyes (36 %), zone 2 in seven eyes (28 %), and zone 3 in six eyes (24 %). Primary open-globe repair was performed within 24 h from the time of injury in 20 eyes (80 %). Two eyes (8 %) had the primary repair within 2–5 days after the initial injury, and one (4 %) had primary globe repair after 13 days because the patient was not medically stable. The eye that underwent a
Graefes Arch Clin Exp Ophthalmol
primary corneoscleral laceration repair after 13 days was secondarily enucleated a week later as a painful blind eye. Thirteen eyes (52 %) presented with hyphema. There were five eyes (20 %) with retinal detachment, eight eyes (32 %) with vitreous hemorrhage, three eyes (12 %) with hemorrhagic choroidal detachment, and no eyes with endophthalmitis. Four (16 %) eyes underwent enucleation: one primary and three secondary. The secondary enucleations of blind eyes were performed to reduce the risk of sympathetic ophthalmia in one case and for severe pain in the remaining two cases. Primary enucleation was only performed as a last resort option where the attending physician noted the open-globe injury was too severe for repair. Two eyes (8 %) presented with no light perception (NLP) and remained NLP after globe repair. One eye underwent enucleation as a secondary surgery. Two eyes (8 %) underwent a penetrating keratoplasty after primary repair because of corneal scars. Twenty-four eyes (96 %) underwent primary open-globe repair surgery, and one underwent primary enucleation due to the severe nature of the injury. The mean visual acuity (VA) at presentation was 1.70 logMAR (approximately, finger counting at 1 foot), and was calculated with 18 (72 %) of the total 25 eyes. Seven eyes (28 %) were not included in the mean VA at presentation since vision could not be ascertained due to patient noncompliance or sedation. The mean final VA was 1.28 logMAR (approximate Snellen VA, 20/400) and was calculated with 24 (96 %) of the total 25 eyes. The comparison of a patient’s initial visual acuity in comparison to the final visual acuity is seen in Fig. 1. Ten eyes (40 %) had a final VA of 20/400 or worse. Fourteen eyes (56 %) achieved a final VA of 20/200 or better; seven eyes (28 %) achieved a final VA of 20/40 or better.
Discussion Open-globe injuries related to MVAs comprised 4 % of all OGIs that presented to University Hospital during this 12-
year time period. In comparison, May et al. [4] found that MVAs accounted for 9 % of all serious eye injuries. In our study, 64 % of the patients were male. This rate is consistent with OGIs reported by Kim et al. [2] (76.6 %), Emami-Naeini et al. [12] (76.4 %), Casson et al. [13] (80.2 %), and McCarty et al. [14] (74.4 %), but lower than the percentage of male patients reporting work-related injuries by Bauza et al. 2012 [14] (96.7 %) and assault-related injuries by Bauza et al. 2013 [15] (82.2 %). The higher percentage of males in OGI studies may be related to a greater tendency for aggressive or high-risk behavior. The average age of these patients was 33.3 years old, with 12 patients (48 %) between 20 and 40 years old. The age demographic is consistent with the average age of OGIs reported by Kim et al. [2] (38.8 years), Casson et al. [13] (41 years), Bauza et al. 2012 [14] (34.9 years), and Bauza et al. 2013 [15] (35.9 years). Also, this mean age is consistent with the average age of serious eye injuries in motor vehicle crashes reported by Kuhn et al. [9] (29 years). Previous studies in the Western Hemisphere have shown that one-fifth of all OGIs are related to alcohol [16–19]. In a previous study on ocular injury related to all-terrain vehicle accidents, 38 % of adult cases involved alcohol [20]. In the present study, only seven cases had documentation of alcohol use, and in five cases (71 %), alcohol was believed to be a contributing factor to the MVA (Table 1). Precise levels of the magnitude of alcohol intoxication through quantitative tests, such as blood alcohol content, were not available for most of our patients, and further analysis could not be performed regarding severity of intoxication and extent of injury. Mandatory seatbelt laws have lowered the incidence of penetrating eye injuries in road traffic accidents [21, 22]. Seatbelt use is a modifiable risk factor for patient safety. In the present study, patients who wore seatbelts had a mean final VA of LogMAR 0.97 (approximately, Snellen VA, 20/200) in contrast to a LogMAR of 2.23 (approximately, VA in the LP to hand motion range) in patients who did not wear seatbelts (Table 1). Rao et al. [23] reported that the use of seatbelts in MVAs was associated with less severe ocular injuries and better visual acuity outcomes. Airbag deployment has proven to be a point of interest in motor vehicle accidents and ocular trauma. Airbags have been shown to decrease bodily trauma related to MVAs [24]. Table 1
Mean final visual acuity in different demographic subgroups
Demographic data
Seatbelt use Alcohol as a contributing factor Fig. 1 Comparison of Initial VA and Final VA
Yes (n=10) No (n= 4) Yes (n=5) No (n=2)
Mean final VA (logMAR)
Mean final VA (Snellen)
0.97 2.23 1.70 0.8
20/200 20/3,000 20/1,000 20/125
Graefes Arch Clin Exp Ophthalmol
Although airbags protect against fatal injuries, a study performed by McGwin et al. [8] suggests that airbags also may cause significant injuries. Independent of other factors, occupants in the front seat of vehicles were 2 times as likely to experience an eye injury in the event of a frontal airbag deployment [8]. These authors also ascertained that frontal air bags were the most common cause of eye injury in occupants of vehicles since 1993, which was the year vehicle manufacturers were required to begin equipping models with frontal air bags [8]. Deployment of airbags can cause blunt ocular trauma from the airbag inflation or laceration from the dispersion of sharp objects (mirrors or glass) during the deployment process [25]. Irrespective of airbag deployment, OGIs due to MVAs are associated with poor visual outcome [26, 27]. It is not the intent of this article to state that airbags are harmful in inducing ocular trauma or other bodily trauma. It is known by the automobile and healthcare industries that safe driving habits are paramount in automobile occupant safety. After safe driving habits, seatbelts and then airbags respectively are tools and technology that benefit survival in MVAs. Driving habits are a qualitative metric. It is difficult to assess and discuss a patient’s driving habits in the setting of a retrospective study. However, future studies may collect information on a patient’s driving habits and safety in the form of questionnaires. Fourteen (54 %) of 25 eyes needed secondary surgeries, such as cataract extraction with intraocular lens placement, PPV with or without membrane peel or endolaser or silicone oil, revision of primary repair, penetrating keratoplasty, and secondary enucleation, after the primary open-globe repair. This number is consistent with 51 % reported by Hill et al. [28] and 45 % by Andreoli et al. [29], but was higher than the 24 % reported by Rostomian et al. [30]. Assault and workrelated OGIs from the same institution also noted that half of the eyes underwent secondary ocular surgeries, with 53.6 % reported by Bauza et al. 2012 [14], and 58.7 % reported by Bauza et al. 2013 [15]. In the setting of a retrospective study, there are variables that are difficult to control in the data analysis. It has been reported that the Ocular Trauma Score (OTS) is a prognostic indicator of visual outcome after an open-globe injury [31, 32]. However, the majority of eyes on initial clinical presentation did not have the status of an afferent pupillary defect (APD) documented, and thus, an OTS score could not be calculated. There were no cases of endophthalmitis in this retrospective study. All 25 cases were treated aggressively with systemic antibiotics and early primary globe repair [33, 34]. In this study, seven eyes (28 %) achieved final VA of 20/40 or better, and four eyes (16 %) presented with an initial VA of 20/40 or better. In comparison, in the study performed by Kim et al. [2] 36.5 % of patients achieved a final VA of 20/40 or better, while 5 % of eyes had an initial VA of 20/40 or better. In the study performed by May et al. [4] with the United States
Eye Injury Registry (USEIR), 42 % of patients achieved a final VA of 20/40 or better, while 17 % of eyes had an initial VA of 20/40 or better. In contrast, in the assault-related openglobe injuries study by Bauza et al. 2013 [15], 18 % of eyes achieved a final VA of 20/40 or better, while 4 % of eyes had an initial VA of 20/40 or better. Much poorer visual outcomes in Bauza et al. 2013 [15] may be due to the fact that over half the eyes (55.4 %) experienced zone 3 injuries, which have been known to predispose to a poor visual prognosis [35–37]. In the work-related OGIs study by Bauza et al. 2012 [14], 38.5 % of eyes achieved a final VA of 20/40 or better, while 12.9 % presented with an initial VA of 20/40 or better. Zone 3 injuries were noted in only 17.5 % of cases in the Bauza et al. 2012 [14] study.
Conclusion To our knowledge, this study provides the largest compilation of epidemiologic data on OGIs related to MVAs. The retrospective nature of this study creates limitations with missing recorded patient data in some cases. Seatbelt use may be the strongest modifiable risk factor for MVA-associated eye injuries [8]. Safer driving habits and the avoidance of driving after consumption of alcohol or after illicit drug use merits emphasis in educational classes. Acknowledgments Supported in part by Research to Prevent Blindness, Inc., and The Lions Eye Research Foundation of New Jersey. Conflict of interest C. Orr, none; A. Bauza, none; P. Langer, none; M. Zarbin, Consultant (Calhoun Vision, Inc., Genentech, Helios KK, Inc., Imagen Biotech, Inc., Novartis, Pfizer, Roche); N. Bhagat, none Informed consent This study was approved by Rutgers’ Institutional Review Board’s guidelines.
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22. Johnston PB, Armstorng MFJ (1986) Eye injuries in Northern Ireland two years after seat belt legislation. Br J Ophthalmol 70:460–462 23. Rao SK, Greenberg PB, Filipopoulos T, Scott IU, Katsoulakis NP, Enzer YR (2008) Potential impact of seatbelt use on the spectrum of ocular injuries and visual acuity outcomes after motor vehicle accidents with airbag deployment. Ophthalmology 115:573–576 24. Braver ER, Ferguson SA, Greene MA, Lund AK (1997) Reductions in deaths in frontal crashes among right front passengers in vehicles equipped with passenger air bags. JAMA 278:1437–1439 25. Pearlman JA, Au Eong KG, Kuhn F, Pieramici DJ (2001) Airbags and eye injuries: epidemiology, spectrum of injury, and analysis of risk factors. Surg Ophthalmol 46:234–243 26. Kuhn F, Morris R, Witherspoon CD (1995) Eye injury and the air bag. Curr Opin Ophthalmol 6:38–44 27. Kuhn F, Morris R, Witherspoon CD, Byrne JB, Brown S (1993) Air bag: friend or foe? Arch Ophthalmol 111:1333–1334 28. Hill JR, Crawford BD, Lee H, Tawansy KA (2006) Evaluation of open globe injuries of children in the last 12 years. Retina 26:65–68 29. Andreoli MT, Andreoli CM (2012) Surgical rehabilitation of the open globe injury patient. Am J Ophthalmol 153:856–860 30. Rostomian K, Thach AB, Isfahani A, Pakkar A, Pakkar R, Borchert M (1998) Open globe injuries in children. J Am Assoc Pediatr Ophthalmol Strabismus 2:234–238 31. Weber SL, Ribeiro LG, Ducca BL, Kasahara N (2012) Prospective validation of the ocular trauma score as a prognostic model to predict vision survival in injured adult patients from a developing country. Eur J Trauma Emerg Surg 38:647–650 32. Yu Wai Man C, Steel D (2010) Visual outcome after open globe injury a comparison of two prognostic models—the Ocular Trauma Score and the Classification and RegressionTree. Eye 24:84–89 33. Zhang Y, Zhang MN, Jiang CH, Yao K (2010) Br J Ophthalmol 94: 111–114 34. Ahmed Y, Schimel AM, Pathengay A, Colyer MH, Flynn HW Jr (2012) Endophthalmitis following open-globe injuries. Eye 26:212–217 35. Entezari M, Rabei HM, Badalabadi MM, Mohebbi M (2006) Visual outcome and ocular survival in open-globe injuries. Injury 37:633– 637 36. Rao LG, Ninan A, Rao KA (2010) Descriptive study on ocular survival, visual outcome and prognostic factors in open globe injuries. Indian J Ophthalmol 58:321–323 37. Knyazer B, Levy J, Rosen S, Belfair N, Klemperer I, Lifshitz T (2008) Prognostic factors in posterior open globe injuries (zone-III injuries). Clin Exp Ophthalmol 36:836–841
TRAUMA
Open-globe injuries with motor vehicle accidents: a 12-year review Christopher K. Orr & Alain Bauza & Paul D. Langer & Marco A. Zarbin & Neelakshi Bhagat
Received: 2 September 2014 / Revised: 10 December 2014 / Accepted: 7 January 2015 # Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose To evaluate demographics, characteristics, and outcomes of open-globe injuries (OGIs) in motor vehicle accidents (MVAs). Methods Retrospective chart review of patients with OGIs related to MVAs that presented to University Hospital, Newark, from 2000 to 2012. Results Twenty-five patients were identified; the average age of the patients was 33.3 years old (range, 5–75). The majority of patients (64 %) were males. The 25 vehicles comprised 24 automobiles and one motorcycle. Ten patients (40 %) wore seatbelts, and five (20 %) did not wear seatbelts. The seatbelt status was not documented in the remaining cases. Ethanol was documented as a contributing factor in five of the accidents. In terms of open-globe classification, 15 OGIs (60 %) were ruptures, and five (20 %) were penetrating injuries; three (12 %) had intraocular foreign bodies. Ten eyes (40 %) had a final VA of 20/ 400 or worse. Fourteen eyes (56 %) achieved a final VA of 20/200 or better; seven eyes (28 %) achieved a final VA of 20/40 or better. Conclusion Fifty-six percent of eyes with an open-globe injury related to MVAs achieved a final VA of 20/200 or better in this series. No eyes developed endophthalmitis.
Keywords Airbag . Alcohol . Motor vehicle accident . open-globe injury . Seatbelt
C. K. Orr : A. Bauza : P. D. Langer : M. A. Zarbin : N. Bhagat (*) Institute of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, DOC-6100; 90 Bergen Street, Newark, NJ 07103, USA e-mail: [email protected]
Introduction An open-globe injury is the result of a full-thickness wound in the eyewall [1]. Open-globe injuries (OGIs) are one of the major causes of visual loss in urban communities [2], and occur at an estimated rate of 3.5 per 100,000 persons per year globally [3]. Blindness related to trauma accounts for 40,000 to 60,000 of the 2.4 million new eye injury cases in the United States [4, 5]. The U.S. Department of Transportation and the National Highway Traffic Safety Administration reports that 2.24 million people were involved in motor vehicle accidents (MVAs) in 2010 [6, 7]. A review of English literature in the past 20 years reveals only two published studies on eye injuries related to MVAs. McGwin et al. [8] reported on 1,231,554 eyes during the observation time 1988–2001 from the National Automotive Sampling System Crashworthiness Data Systems, and Kuhn et al. [9] reported on 150 eyes from 1982 to 1989. The purpose of this study is provide information on the demographics and presenting clinical features of OGIs related to MVAs in the United States.
Methods We secured approval from the Rutgers-New Jersey Medical School Institutional Review Board to conduct a retrospective chart review of all patients who presented with OGIs related to motor vehicle accidents (MVA) between January 2000 and December 2012. Data recorded from the retrospective chart review was in accordance with the training from the Collaborative Institutional Training Initiative (CITI) that emphasized human and animal rights. The data recorded from the medical records included: age, race, gender, type of trauma, details regarding the MVA (restrained with seatbelt, alcohol use, other substance use, airbag deployment), oral maxillofacial injuries sustained, other injuries (such as orthopedic
Graefes Arch Clin Exp Ophthalmol
injuries), duration between time of injury to surgery, length of hospital stay, ocular surgeries that were performed, past medical history, past ophthalmologic history, and duration of follow-up. Ocular examination data recorded included: type of injury, location and zone of injury, lens status, Seidel test, hyphema, presence of endophthalmitis, zone of injury, presence of an afferent pupillary defect (APD), characteristics of intraocular foreign body (IOFB) if noted, presence of retinal detachment (RD), vitreous hemorrhage (VH), hemorrhagic choroidal detachment, pre-operative fundus examination,and post-operative fundus examination. Visual acuity (VA) data were collected at presentation, and on post-operative day 1, week 1, months 1, 3, and 6, and years 1 and 2, along with the final VA and best VA recorded during the entire follow-up period. A conversion of Snellen VA to the logarithm of the minimum angle of resolution (LogMAR) was performed for statistical analysis [10]. Zone of injury was categorized into zones 1, 2, and 3, with zone 1 being limited to the cornea and limbus but not extending beyond the limbus. Zone 2 injuries were located beyond the limbus and up to 5 mm posterior to the limbus. Zone 3 injuries were located more than 5 mm posterior to the limbus. In the cases that involved more than 1 zone, the injury was documented as the highest zone to indicate the most posterior site of injury [1]. The open-globe injuries were categorized as rupture, penetrating, perforating, and intraocular foreign body (IOFB) injuries using the trauma classification set forth in the Birmingham Eye Trauma Terminology (BETT) by Kuhn et al. [11]. Trauma from blunt objects leading to a fullthickness wound was classified as a “rupture” type of injury with an “inside–out” mechanism of injury. A transient increase in intraocular pressure caused the globe to rupture at a weak point [1, 11]. The open globes caused by lacerations were “outside–in” injuries and included the categories of penetrating, perforating, and IOFB [1, 11]. Penetrating injuries typically were caused by a sharp object that resulted in a full-thickness entrance wound; however, a perforating injury was caused by an object that resulted in both a full-thickness entrance and exit wound [1, 11]. IOFBs created full-thickness entrance wounds, but were considered as distinct from penetrating injuries, since visual prognosis and clinical management interventions differ between the two groups [1, 11].
Results Twenty-five eyes (4 %) of the 631 eyes with OGIs treated at University Hospital between 2000 and 2012 were related to MVAs. The sample included 16 males (64 %). The average age of the patients was 33.3 years old (range, 5–75). Twelve patients (48 %) were between 20 and 40 years old. Twenty patients (80 %) had a follow-up duration of at least 3 months,
and 17 patients (68 %) were followed for 6 months or more. The average follow-up time was 18.9 months (range, 0– 97 months). African Americans comprised the largest racial group (36 %), followed by Caucasians (32 %), Hispanics (20 %), Asians (4 %), and other race or undocumented race (8 %). Of the 25 vehicles, 24 (96 %) were automobiles, and one (4 %) was a motorcycle. Among the 25 cases, 11 patients (44 %) were identified as the driver of the vehicle, and seven (28 %) were passengers. Of the 25 cases, only 15 (60 %) had documentation on the usage of a seatbelt. Ten patients (40 %) wore seatbelts, and five (20 %) did not wear seatbelts. Seven (28 %) of the 25 cases had documentation of alcohol use. Alcohol was documented as a contributing factor in five (20 %) of the accidents because of elevated blood alcohol levels. Only one (4 %) of the 25 cases had a positive urine drug screen (benzodiazepines, cannabinoids, and opioids were present). Eleven (44 %) of 25 cases had documentation of airbag status in the vehicle; six (24 %) had airbag deployments, and five cases (20 %) did not. The left eye was injured in 14 cases (56 %), and there were no patients with bilateral eye injuries. With regard to openglobe classification, rupture injuries comprised the largest group with 15 cases (60 %), followed by penetrating injuries [five cases (20 %)] and IOFB [three cases (12 %)]; two (8 %) of the open globes involved cataract wound dehiscence. Of the three IOFBs, two were glass or a piece of mirror, and one was metal. All IOFBs were diagnosed with initial clinical exam, B-scan, and computed tomography (CT scan). Nineteen (76 %) of the 25 cases had documentation of lens status. There were 13 phakic eyes (52 %); seven (54 %) of the phakic eyes had cataracts at presentation. Four eyes (16 %) were aphakic, and two (8 %) were pseudophakic. The lens status was not documented in two eyes (8 %) with hyphema. Of the seven eyes with cataract at presentation, two underwent pars plana lensectomy (PPL) during the primary globe repair with pars plana vitrectomy (PPV) for IOFBs. One eye with a subluxed anterior chamber intraocular lens (ACIOL) underwent lens removal during the primary globe repair. All 25 cases received intravenous antibiotics. The most commonly used intravenous antibiotics were ceftazidime and vancomycin [in 17 patients (68 %)] given as combination therapy. Only 22 eyes (88 %) had complete documentation of the extent of injury. According to the classification set forth by Pieramici et al. [1], the location of injury was zone 1 in nine eyes (36 %), zone 2 in seven eyes (28 %), and zone 3 in six eyes (24 %). Primary open-globe repair was performed within 24 h from the time of injury in 20 eyes (80 %). Two eyes (8 %) had the primary repair within 2–5 days after the initial injury, and one (4 %) had primary globe repair after 13 days because the patient was not medically stable. The eye that underwent a
Graefes Arch Clin Exp Ophthalmol
primary corneoscleral laceration repair after 13 days was secondarily enucleated a week later as a painful blind eye. Thirteen eyes (52 %) presented with hyphema. There were five eyes (20 %) with retinal detachment, eight eyes (32 %) with vitreous hemorrhage, three eyes (12 %) with hemorrhagic choroidal detachment, and no eyes with endophthalmitis. Four (16 %) eyes underwent enucleation: one primary and three secondary. The secondary enucleations of blind eyes were performed to reduce the risk of sympathetic ophthalmia in one case and for severe pain in the remaining two cases. Primary enucleation was only performed as a last resort option where the attending physician noted the open-globe injury was too severe for repair. Two eyes (8 %) presented with no light perception (NLP) and remained NLP after globe repair. One eye underwent enucleation as a secondary surgery. Two eyes (8 %) underwent a penetrating keratoplasty after primary repair because of corneal scars. Twenty-four eyes (96 %) underwent primary open-globe repair surgery, and one underwent primary enucleation due to the severe nature of the injury. The mean visual acuity (VA) at presentation was 1.70 logMAR (approximately, finger counting at 1 foot), and was calculated with 18 (72 %) of the total 25 eyes. Seven eyes (28 %) were not included in the mean VA at presentation since vision could not be ascertained due to patient noncompliance or sedation. The mean final VA was 1.28 logMAR (approximate Snellen VA, 20/400) and was calculated with 24 (96 %) of the total 25 eyes. The comparison of a patient’s initial visual acuity in comparison to the final visual acuity is seen in Fig. 1. Ten eyes (40 %) had a final VA of 20/400 or worse. Fourteen eyes (56 %) achieved a final VA of 20/200 or better; seven eyes (28 %) achieved a final VA of 20/40 or better.
Discussion Open-globe injuries related to MVAs comprised 4 % of all OGIs that presented to University Hospital during this 12-
year time period. In comparison, May et al. [4] found that MVAs accounted for 9 % of all serious eye injuries. In our study, 64 % of the patients were male. This rate is consistent with OGIs reported by Kim et al. [2] (76.6 %), Emami-Naeini et al. [12] (76.4 %), Casson et al. [13] (80.2 %), and McCarty et al. [14] (74.4 %), but lower than the percentage of male patients reporting work-related injuries by Bauza et al. 2012 [14] (96.7 %) and assault-related injuries by Bauza et al. 2013 [15] (82.2 %). The higher percentage of males in OGI studies may be related to a greater tendency for aggressive or high-risk behavior. The average age of these patients was 33.3 years old, with 12 patients (48 %) between 20 and 40 years old. The age demographic is consistent with the average age of OGIs reported by Kim et al. [2] (38.8 years), Casson et al. [13] (41 years), Bauza et al. 2012 [14] (34.9 years), and Bauza et al. 2013 [15] (35.9 years). Also, this mean age is consistent with the average age of serious eye injuries in motor vehicle crashes reported by Kuhn et al. [9] (29 years). Previous studies in the Western Hemisphere have shown that one-fifth of all OGIs are related to alcohol [16–19]. In a previous study on ocular injury related to all-terrain vehicle accidents, 38 % of adult cases involved alcohol [20]. In the present study, only seven cases had documentation of alcohol use, and in five cases (71 %), alcohol was believed to be a contributing factor to the MVA (Table 1). Precise levels of the magnitude of alcohol intoxication through quantitative tests, such as blood alcohol content, were not available for most of our patients, and further analysis could not be performed regarding severity of intoxication and extent of injury. Mandatory seatbelt laws have lowered the incidence of penetrating eye injuries in road traffic accidents [21, 22]. Seatbelt use is a modifiable risk factor for patient safety. In the present study, patients who wore seatbelts had a mean final VA of LogMAR 0.97 (approximately, Snellen VA, 20/200) in contrast to a LogMAR of 2.23 (approximately, VA in the LP to hand motion range) in patients who did not wear seatbelts (Table 1). Rao et al. [23] reported that the use of seatbelts in MVAs was associated with less severe ocular injuries and better visual acuity outcomes. Airbag deployment has proven to be a point of interest in motor vehicle accidents and ocular trauma. Airbags have been shown to decrease bodily trauma related to MVAs [24]. Table 1
Mean final visual acuity in different demographic subgroups
Demographic data
Seatbelt use Alcohol as a contributing factor Fig. 1 Comparison of Initial VA and Final VA
Yes (n=10) No (n= 4) Yes (n=5) No (n=2)
Mean final VA (logMAR)
Mean final VA (Snellen)
0.97 2.23 1.70 0.8
20/200 20/3,000 20/1,000 20/125
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Although airbags protect against fatal injuries, a study performed by McGwin et al. [8] suggests that airbags also may cause significant injuries. Independent of other factors, occupants in the front seat of vehicles were 2 times as likely to experience an eye injury in the event of a frontal airbag deployment [8]. These authors also ascertained that frontal air bags were the most common cause of eye injury in occupants of vehicles since 1993, which was the year vehicle manufacturers were required to begin equipping models with frontal air bags [8]. Deployment of airbags can cause blunt ocular trauma from the airbag inflation or laceration from the dispersion of sharp objects (mirrors or glass) during the deployment process [25]. Irrespective of airbag deployment, OGIs due to MVAs are associated with poor visual outcome [26, 27]. It is not the intent of this article to state that airbags are harmful in inducing ocular trauma or other bodily trauma. It is known by the automobile and healthcare industries that safe driving habits are paramount in automobile occupant safety. After safe driving habits, seatbelts and then airbags respectively are tools and technology that benefit survival in MVAs. Driving habits are a qualitative metric. It is difficult to assess and discuss a patient’s driving habits in the setting of a retrospective study. However, future studies may collect information on a patient’s driving habits and safety in the form of questionnaires. Fourteen (54 %) of 25 eyes needed secondary surgeries, such as cataract extraction with intraocular lens placement, PPV with or without membrane peel or endolaser or silicone oil, revision of primary repair, penetrating keratoplasty, and secondary enucleation, after the primary open-globe repair. This number is consistent with 51 % reported by Hill et al. [28] and 45 % by Andreoli et al. [29], but was higher than the 24 % reported by Rostomian et al. [30]. Assault and workrelated OGIs from the same institution also noted that half of the eyes underwent secondary ocular surgeries, with 53.6 % reported by Bauza et al. 2012 [14], and 58.7 % reported by Bauza et al. 2013 [15]. In the setting of a retrospective study, there are variables that are difficult to control in the data analysis. It has been reported that the Ocular Trauma Score (OTS) is a prognostic indicator of visual outcome after an open-globe injury [31, 32]. However, the majority of eyes on initial clinical presentation did not have the status of an afferent pupillary defect (APD) documented, and thus, an OTS score could not be calculated. There were no cases of endophthalmitis in this retrospective study. All 25 cases were treated aggressively with systemic antibiotics and early primary globe repair [33, 34]. In this study, seven eyes (28 %) achieved final VA of 20/40 or better, and four eyes (16 %) presented with an initial VA of 20/40 or better. In comparison, in the study performed by Kim et al. [2] 36.5 % of patients achieved a final VA of 20/40 or better, while 5 % of eyes had an initial VA of 20/40 or better. In the study performed by May et al. [4] with the United States
Eye Injury Registry (USEIR), 42 % of patients achieved a final VA of 20/40 or better, while 17 % of eyes had an initial VA of 20/40 or better. In contrast, in the assault-related openglobe injuries study by Bauza et al. 2013 [15], 18 % of eyes achieved a final VA of 20/40 or better, while 4 % of eyes had an initial VA of 20/40 or better. Much poorer visual outcomes in Bauza et al. 2013 [15] may be due to the fact that over half the eyes (55.4 %) experienced zone 3 injuries, which have been known to predispose to a poor visual prognosis [35–37]. In the work-related OGIs study by Bauza et al. 2012 [14], 38.5 % of eyes achieved a final VA of 20/40 or better, while 12.9 % presented with an initial VA of 20/40 or better. Zone 3 injuries were noted in only 17.5 % of cases in the Bauza et al. 2012 [14] study.
Conclusion To our knowledge, this study provides the largest compilation of epidemiologic data on OGIs related to MVAs. The retrospective nature of this study creates limitations with missing recorded patient data in some cases. Seatbelt use may be the strongest modifiable risk factor for MVA-associated eye injuries [8]. Safer driving habits and the avoidance of driving after consumption of alcohol or after illicit drug use merits emphasis in educational classes. Acknowledgments Supported in part by Research to Prevent Blindness, Inc., and The Lions Eye Research Foundation of New Jersey. Conflict of interest C. Orr, none; A. Bauza, none; P. Langer, none; M. Zarbin, Consultant (Calhoun Vision, Inc., Genentech, Helios KK, Inc., Imagen Biotech, Inc., Novartis, Pfizer, Roche); N. Bhagat, none Informed consent This study was approved by Rutgers’ Institutional Review Board’s guidelines.
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