A multi-center analysis of visual outcomes following open globe injury.

The purpose of this study was to examine how demographics, etiology, and clinical examination findings are related to visual outcomes in subjects with open globe injury (OGI) across a large and generalizable sample. A retrospective cohort analysis was performed using data collected from the electronic medical records of four tertiary university centers for subjects with OGI presenting from 2018 to 2021. Demographic information, injury mechanisms, clinical exam findings, visual acuity (VA) at presentation and most recent follow-up were recorded. In subjects with bilateral OGIs, only right eyes were included. A modified ocular trauma score (OTS) using presenting VA, the presence of perforating injury, OGI, and afferent pupillary defect was calculated. The risk of subjects' demographic characteristics, ocular trauma etiology, clinical findings and modified OTS on the presence of monocular blindness at follow-up were assessed using univariable and multivariable regression models. 1426 eyes were identified. The mean age was 48.3 years (SD: ± 22.4 years) and the majority of subjects were men (N = 1069, 75.0%). Univariable analysis demonstrated that subjects of Black race were 66% (OR: 1.66 [1.25-2.20]; P < 0.001) more likely to have monocular blindness relative to White race at follow-up. OTS Class 1 was the strongest predictor of blindness (OR: 38.35 [21.33-68.93]; P < 0.001). Based on multivariable analysis, lower OTS category (OTS Class 1 OR: 23.88 [16.44-45.85]; P < 0.001) moderately predicted visual outcomes (R2 = 0.275, P < 0.001). OGI has many risks of poor visual outcome across patient groups that vary by demographic category, mechanism of injury, and clinical presentation. Our findings validate that a modified OTS remains a strong predictor of visual prognosis following OGI in a large and generalizable sample.

Recovery of Vision in Open Globe Injury Patients with Initial No Light Perception Vision.

PURPOSE: To identify clinical characteristics of injured eyes associated with visual recovery in patients with open globe injuries (OGIs) and presenting with no light perception (NLP) vision. DESIGN: Retrospective chart review. SUBJECTS: All patients presenting to Massachusetts Eye and Ear with OGI and NLP vision from January 1999 to March 2022. METHODS: Manual data extraction to collect patient demographic characteristics, preoperative, intraoperative, and postoperative characteristics of OGI injury, laceration versus rupture, history of intraocular surgery, time from injury to repair, timing of vitrectomy, lensectomy, choroidal drainage, and silicone oil placement, visual acuity (VA) at last follow-up, and subsequent B-scan ultrasound findings of retinal detachment, choroidal hemorrhage, vitreous hemorrhage, and disorganized intraocular contents. Patients with >1 week of follow-up and a documented VA at most recent follow-up were included. Exclusion criteria included age <10 years. Multivariable regression was performed. MAIN OUTCOME MEASURES: Visual acuity recovery defined as light perception or better in patients with OGI and initial NLP vision. RESULTS: One hundred forty-seven eyes with NLP vision after OGI were included. Twenty-five (17%) eyes regained vision at last follow-up. The majority of patients recovered light perception vision (n = 15, 60%) followed by 20/500 or better (n = 5, 20%), hand motions (n = 3, 12%), and counting fingers (n = 2, 8%). Most injuries were zone III (n = 102, 69%) and presented with rupture (n = 127, 86%). The mean time from OGI to surgical repair was 0.85 ± 1.7 days. B-scan was obtained in 104 (71%) cases. Pars plana vitrectomy was performed in 9 eyes (6%) with NLP at time of vitrectomy. Disorganized intraocular contents on B-scan (odd ratio, 0.170; 95% confidence interval, 0.042-0.681; P = 0.012) was the only clinical variable significantly associated with visual recovery, corresponding to a lack of visual improvement. CONCLUSIONS: Recovery of vision in OGI with NLP vision at presentation cannot be predicted based on presenting clinical features. B-scan findings of disorganized intraocular contents after initial OGI repair was the only factor negatively associated with vision recovery in this patient population. Therefore, all eyes presenting with an OGI and NLP vision should undergo primary repair in hopes of subsequent visual recovery. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Effect of time to operative repair within twenty-four hours on visual acuity outcomes for open globe injuries.

PURPOSE: Convention is to perform open globe injury (OGI) repair within 24 h to minimize risk of endophthalmitis. However, there are limited data assessing how time to operative repair (OR) within 24 h impacts postoperative visual acuity (VA). METHODS: Manual retrospective chart review of 633 eyes at Massachusetts Eye and Ear (MEE) with a diagnosis of OGI between 2012 and 2022. Inclusion criteria were primary repair ≤ 24 h after injury and ≥1 month follow-up. Multivariate regression analysis was conducted with postoperative VA as primary outcome. RESULTS: Of the subjects, 489 (77.3%) were male and 496 (78.4%) were white. Demographics of OGI wounds included 320 (50.6%) rupture and 313 (49.4%) laceration; 126 (19.9%) with rAPD, 189 (29.9%) zone 3 injuries, 449 (71.2%) uveal prolapse, and 110 (17.4%) intraocular foreign body. Final postoperative LogMAR VAs consisted of 31% with a VA < 1.7, 9% with a VA of 1.9, 18% with a VA of 2.3, 27% with a VA of 2.7, and 11% with a VA of 3.0. Multivariate analysis showed no significant correlation between time to OR and postoperative VA (p = 0.800) [95%CI: -0.01,0.01]. Older age (p < 0.001) [95%CI: 0.00,0.01], worse presenting VA (p < 0.001) [95%CI: 0.17,0.32], rAPD (p < 0.001) [95%CI: 0.65,1.0], mechanism of rupture (p < 0.001) [95%CI: 0.19,0.54], higher zone of injury (p < 0.001) [95%CI: 0.25,0.45], and uveal prolapse (p = 0.003) [95%CI: 0.09,0.42] were significantly associated with worse final VA. CONCLUSIONS: Time to repair of OGIs within 24 h does not influence final VA. Optimization of surgical and patient factors may contribute more significantly to final VA than prioritizing more rapid time to OR.

Henry Jacob Bigelow (1818-1890): A Champion for Anesthesia and Catalyst for the Advancement of Surgery.

Prior to the advent of anesthesia, surgery was limited in scope due to the excruciating pain experienced by patients. This raised challenges for surgeons who were distressed by the inadvertent suffering caused by surgery. The first successful use of ether anesthesia by William Thomas Green Morton (1819-1868) in 1846 at Massachusetts General Hospital was a turning point for the profession. The innovation and proliferation of operations catalyzed by the introduction of anesthesia altered the landscape of surgical practice. Initially, the introduction of ether into the field was met with hesitation and resistance by several parties in the medical field. It took the efforts of prominent surgeons to ensure that ether achieved its full potential. The greatest supporter of ether during this epoch was the young surgeon Henry Jacob Bigelow (1818-1890), who spent 30 years of his career advocating for and experimenting with anesthesia. The efforts of Bigelow, a gifted surgeon renowned for his contributions to orthopedic surgery, were instrumental in the promotion of anesthesia and the advancement of the surgical profession. In this article, we discuss the life, career, and contributions of Bigelow, particularly in the context of the introduction of modern anesthesia.

Julia Gordon Arrowood (1900 - 1984): A Brilliant Anesthesiologist and a Woman of Many Firsts in Medicine.

After a brief "golden age" in the late 1800s, the patriarchal establishment fought back and women faced increasing restrictions in practicing medicine. In 1900, 18.2% of all physicians in the city of Boston were women, but this number decreased to 8.7% by 1930. The relatively young field of anesthesiology was one of the more welcoming specialties for women during this time. History has been unkind to these early female trailblazers who have often been overlooked in favor of the men in their fields. Julia Gordon Arrowood (1900-1984) was a forerunner for women in medicine and a prominent anesthesiologist in Boston from the 1930s until the 1950s. Her work included not only clinical medicine, but also research and teaching. She attended Boston University School of Medicine, graduating as valedictorian in the class of 1933. She interned at Belmont Hospital in Worcester, MA where she decided on a career in anesthesiology. She was accepted as a resident at Massachusetts General Hospital (MGH) by chief-anesthetist Henry Beecher in 1935, thereby becoming the first woman anesthesiology resident in Massachusetts. She remained at MGH and was named Acting Chief of Anesthesia in 1943. In 1944, she became president of the New England Society of Anesthesiologists, another first for a woman. In 1946, she joined Reginald Smithwick's team as Chief of Anesthesia at Massachusetts Memorial Hospital, Boston, and concurrently held the position of Professor of Anesthesiology at Boston University School of Medicine. Arrowood led many of the earliest studies on spinal anesthesia, muscle relaxants, and spinal headaches. In 1957, she moved to Kentucky and joined the United Mine Workers hospital system where she worked until her retirement in 1970. Women such as Julia Arrowood remain underrepresented in the annals of the history of medicine. Much work is needed to recognize the many contributions made by women physicians and to provide equal opportunities, pay, and status.