Eye injury is a major cause of ocular morbidity in children, and a leading cause of noncongenital unilateral blindness in children.1 Long-term effect on the quality of life even after managing an ocular trauma is a big concern to the children’s parents. Approximately 18% of people who have visual disorders due to trauma are blind in 1 eye.2
Ocular injury occurs in the 3 following forms: open globe, closed globe, and chemical injuries. Prompt measures are essential to save the sight. Open globe injuries are one of the common emergencies in ophthalmologic clinics and require immediate surgery.3 The site of the injury and the causative factors are critical for visual recovery. By identifying any of the underlying factors in the etiology of serious injuries, it may be possible to design effective methods for reducing the incidence of visually damaging trauma.4
Open globe injuries are among the most serious types of ocular trauma, and up to 43% of these injuries are reported to occur in individuals younger than 16 years.5 Preoperative evaluation of children is often hindered by inadequate history and poor patient cooperation and assessment of visual outcome during the physical examination. In addition, follow-up is often short, particularly in eyes with less severe injuries. Complex open globe injuries can lead to vitreous hemorrhage, causing tractional retinal detachment and occlusion amblyopia.6
Kuhn et al7 described the ocular trauma score (OTS) as a simplified categorical system for standardized assessment in a large series including both pediatric and elderly patients. This score is a useful tool for forecasting a possible outcome related to visual acuity (VA) after managing the ocular trauma effectively.
The purpose of this study was to analyze the prognostic value of OTS in children (4–16 years) with open globe injuries, so that parents could be informed of the prognosis of the ocular trauma experienced by their child. This also gave them the opportunity to make better efforts in saving the eyesight of their children after an injury.
MATERIALS AND METHODS
This prospective observational study was conducted in Dhaka, Bangladesh, during the period of January 2010 to December 2012. A total of 210 patients with unilateral ocular injury were enrolled for the study by nonrandomized purposive sampling. Of the 210 eyes, 123 were right eyes and 87 were left eyes. The patients were aged between 4 and 16 years, with mean ± SD age of 9.30 ± 3.29 years. Patients with initial VA for OTS variables (Table 1) were all included in the study after taking a detailed history and conducting thorough physical and ocular examinations.
Children younger than 4 years were excluded because an accurate assessment of their presenting VA data was considered unreliable. Patients with other ocular diseases affecting visual function and previous intraocular surgeries were also excluded from this study.
Management of each category was done according to standard protocol. Refractive abnormalities such as regular astigmatism were treated with spectacle lenses.
Ocular trauma scoring was done for all patients by adding up the variables shown in Table 1. Based on of the total score, 5 OTS categories were formed as shown in Table 2.
The VA of all patients was determined on the first examination after injury. Subsequently, VA was determined on further follow-up at intervals of 1 week, 1 month, and 6 months. The outcome was evaluated for final best corrected VA measured at the last visit.
The probability of attending specific VA after 6 months of follow-up was compared with the OTS model as shown in Table 3.
The study patients ranged from 4 to 16 years. The mean age was 9.30 ± 3.29 years. A total of 90 (42.86%) patients were included in the 4 to 8 years age group (Supplemental Digital Content 1, http://links.lww.com/APJO/A49).
Among the 210 patients, 140 (66.67%) were boys and 70 (33.33%) were girls. The causes of ocular injury were recorded (Figure 1). The place where the ocular injury took place was also recorded (Figure 2).
Patients were categorized into 5 groups according to the OTS model. Of the 210 patients, 30 (14.28%) were in category 1, 52 (24.77%) in category 2, 40 (19.05%) in category 3, another 40 (19.04%) in category 4, and 48 (22.86%) in category 5 (Fig. 3). Patients of each OTS category were followed up for 6 months for their visual outcome. Table 4 shows the number of patients with final visual outcome in each category. No patients from categories 1, 2, 3, or 4 achieved the best VA (≥20/40). Best VAs (≥20/40) were obtained from 43 patients in category 5. Patients of other categories did not show any significant visual improvement, and 80% of all the patients with no perception of light (NPL) was in category 1. No patient from category 1 achieved a VA of 20/40 or greater. A total of 35 (16.7%) patients remained in the condition of NPL, 28 of which are from category 1 and 7 of which are from category 2.
Ocular trauma is one of the major causes of impaired vision that may even lead to unilateral blindness. Ocular morbidity due to injury generates significant human suffering and loss of productivity. However, nearly 90% of eye injuries can be prevented by relatively simple measures.8,9 Open globe injuries representing a typical clinical character that creates difficulty in determining a management plan. It is also important to predict a visual prognosis after the injury.
The study conducted by Saxena et al10 showed that most pediatric ocular injuries occur in children aged 5 years or older. Serrano et al11 showed that most of the patients with pediatric ocular trauma were boys (64.9%). Both studies reported findings that were comparable to ours.
The OTS is used to estimate the final visual prognosis 6 months after injuries. It was initially reported that the OTS was not sufficient to estimate visual prognosis, but more recent series show adequate correlations between their visual results and those estimated by the OTS. Lima-Gómez et al12 show that OTS can be used to estimate the visual prognosis of almost every injured eye during the initial evaluation in a trauma room without the evaluation of an ophthalmologist. This gives the OTS a greater prognostic value than other classifications proposed for primary-level care.
In this study, the OTS was used to evaluate the visual outcome in all patients. The OTS was calculated by assigning a raw point value for the initial VA and then subtracting the appropriate raw points for each diagnosis of globe rupture, endophthalmitis, perforating injury, retinal detachment, and a relative afferent pupillary defect. In this study, a good correlation has been found between OTS categories and the final visual outcome. By analyzing the final visual outcome, it was shown that OTS category 1 had the worst prognosis (93.3% patients in category 1 had a final VA of NPL), and category 5 had the best outcome (89.6% patients of category 5 had a final VA of >20/200; Table 4). With an early categorization of the patients according to their OTS, the severity of an injury can be assessed with reasonable accuracy and intervened accordingly.
Man and Steel13 reported in their study that an initial VA of NPL was associated with poor visual outcome, accounting for 60.9% of the no-vision group and only 1.3% of the vision survival group. In contrast, all patients with an initial VA of 6/60 or better in their series had good visual outcome. Our study also shared similar findings.
Uysal et al14 described in their study of 42 patients with penetrating ocular injuries that an initial VA of perception of light or worse showed poor visual outcome, which was similar to what we found out for category 2.
Shah et al15 also observed good correlation of OTS with final visual outcome, and they recommended that OTS may be a reliable tool to predict visual outcome in pediatric trauma cases.
Unver et al16 found that OTS may provide a gross prediction of final VA in pediatric patients with open globe injuries. In their study, there was a proportional increase in final VA in categories 4 and 5 only, while no proportional increase was detected in the first 3 categories. Their results are similar to our present study.
Acar et al17 used pediatric OTS in pediatric eye injuries. They also found that the most important factor that determined the final visual outcome was the initial VA. They con sidered patients’ age and wound location as important parameters. Several study results suggest that a higher OTS is typically associated with a better prognosis.18–20 Final visual outcome of pediatric open globe injuries correlates significantly with OTS categories. Ocular trauma score has good prognostic significance if proper evaluation, early surgery, and periodic follow-up can be ensured.
1. Parver LM. Eye trauma. The neglected disorder. Arch Ophthalmol
. 1986; 104: 1452–1453.
2. Macewen CJ. Eye injuries: a prospective survey of 5671 cases. Br J Ophthalmol
. 1989; 73: 888–894.
3. Zagelbaum BM, Tostanoski JR, Kerner DJ, et al. Urban eye trauma. A one-year prospective study. Ophthalmology
. 1993; 100: 851–856.
4. Ervin-Mulvey LD, Nelson LB, Freeley DA. Pediatric eye trauma. Pediatr Clin North Am
. 1983; 30: 1167–1183.
5. De Juan E Jr, Sternberg P Jr, Michels RG. Penetrating ocular injuries. Types of injuries and visual results. Ophthalmology
. 1983; 90: 1318–1322.
6. Ferrone PJ, de Juan E Jr. Vitreous hemorrhage in infants. Arch Ophthalmol
. 1994; 112: 1185–1189.
7. Kuhn F, Morris R, Witherspoon CD, et al. The Birmingham Eye Trauma Terminology system (BETT). J Fr Ophtalmol
. 2004; 27; 206–210.
8. Pizzarello LD. Ocular trauma: time for action. Ophthalmic Epidemiol
. 1998; 5: 115–116.
9. 9. American Academy of Ophthalmology. Important facts about eye injury. Available at: http://archopht.jamanetwork.com/article.aspx?articleid=415755 Accessed 2002.
10. Saxena R, Sinha R, Purohit A, et al. Pattern of pediatric ocular trauma in India. Indian J Pediatr
. 2002; 69: 863–867.
11. Serrano JC, Chalela P, Arias JD. Epidemiology of childhood ocular trauma in a northeastern Colombian region. Arch Ophthalmol
. 2003; 121: 1439–1445.
12. Lima-Gómez V, Blanco-Hernández DM, Rojas-Dosal JA. Ocular trauma score
at the initial evaluation of ocular trauma. Cir Cir
. 2010; 78: 209–213.
13. 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 (Lond)
. 2010; 24: 84–89.
14. Uysal Y, Mutlu FM, Sobaci G. Ocular Trauma Score
in childhood open-globe injuries. J Trauma
. 2008; 65: 1284–1286.
15. Shah MA, Shah SM, Applewar A, et al. Ocular Trauma Score
: a useful predictor of visual outcome at six weeks in patients with traumatic cataract. Ophthalmology
. 2012; 119: 1336–1341.
16. Unver YB, Acar N, Kapran Z, et al. Visual predictive value of the ocular trauma score
in children. Br J Ophthalmol
. 2008; 92: 1122–1124.
17. Acar U, Tok OY, Acar DE, et al. A new ocular trauma score
in pediatric penetrating eye injuries. Eye (Lond)
. 2011; 25: 370–374.
18. Groessl S, Nanda SK, Mieler WF. Assault-related penetrating ocular injury. Am J Ophthalmol
. 1993; 116: 26–33.
19. Knyazer B, Levy J, Rosen S, et al. Prognostic factors in posterior open globe injuries (zone-III injuries). Clin Experiment Ophthalmol
. 2008; 36: 836–841.
20. Cillino S, Casuccio A, Di Pace F, et al. A five-year retrospective study of the epidemiological characteristics and visual outcomes of patients hospitalized for ocular trauma in a Mediterranean area. BMC Ophthalmol
. 2008; 8: 6.
“The best doctors in the world are Doctor Diet, Doctor Quiet, and Doctor Merryman.”
— Jonathan Swift