The Risk of Sympathetic Ophthalmia Associated with Open-Globe Injury Management Strategies: A Meta-analysis.

TOPIC: Sympathetic ophthalmia (SO) is a sight-threatening granulomatous panuveitis caused by a sensitizing event. Primary enucleation or primary evisceration, versus primary repair, as a risk management strategy after open-globe injury (OGI) remains controversial. CLINICAL RELEVANCE: This systematic review was conducted to report the incidence of SO after primary repair compared with that of after primary enucleation or primary evisceration. This enabled the reporting of an estimated number needed to treat. METHODS: Five journal databases were searched. This review was registered with International Prospective Register of Systematic Reviews (identifier, CRD42021262616). Searches were carried out on June 29, 2021, and were updated on December 10, 2022. Prospective or retrospective studies that reported outcomes (including SO or lack of SO) in a patient population who underwent either primary repair and primary enucleation or primary evisceration were included. A systematic review and meta-analysis were carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Random effects modelling was used to estimate pooled SO rates and absolute risk reduction (ARR). RESULTS: Eight studies reporting SO as an outcome were included in total. The included studies contained 7500 patients and 7635 OGIs. In total, 7620 OGIs met the criteria for inclusion in this analysis; SO developed in 21 patients with OGI. When all included studies were pooled, the estimated SO rate was 0.12% (95% confidence interval [CI], 0.00%-0.25%) after OGI. Of 779 patients who underwent primary enucleation or primary evisceration, no SO cases were reported, resulting in a pooled SO estimate of 0.05% (95% CI, 0.00%-0.21%). For primary repair, the pooled estimate of SO rate was 0.15% (95% CI, 0.00%-0.33%). The ARR using a random effects model was -0.0010 (in favour of eye removal; 95% CI, -0.0031 [in favor of eye removal] to 0.0011 [in favor of primary repair]). Grading of Recommendations, Assessment, Development, and Evaluations analysis highlighted a low certainty of evidence because the included studies were observational, and a risk of bias resulted from missing data. DISCUSSION: Based on the available data, no evidence exists that primary enucleation or primary evisceration reduce the risk of secondary SO. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Globe trauma associated with falls at Australian tertiary centres.

OBJECTIVE: Falls frequently cause globe and adnexal trauma, particularly in the elderly. The morbidity decreases confidence, independence and quality of life. We aimed to improve the understanding of fall-related globe and adnexal trauma and the involvement of ophthalmology at two tertiary trauma centres. METHODS: A retrospective medical record review was conducted at Royal North Shore Hospital and Royal Prince Alfred Hospital of patients admitted with fall-related globe and/or adnexal trauma between January 2015 and December 2019. International Classification of Disease Tenth Revision codes were used to identify patients for inclusion. Medical records were reviewed to extract data on demographics, trauma, ocular examination and referrals to ophthalmology. RESULTS: From January 2015 to December 2019, 346 patients, 186 were female (54%) and median age 76 years (interquartile range 24 years), were admitted to Royal North Shore Hospital and Royal Prince Alfred Hospital with fall-related globe and/or adnexal trauma. One hundred and twenty-five (36%) suffered globe trauma with 48 (14%) classified as severe. Patients over 65 years old had at least three risk factors contributing to falls. Alcohol and illicit substances were involved in 20% of falls and occurred predominantly in younger populations. There were significantly more patients with globe trauma if orbital/mid-facial fractures were present (55% vs 36%, P < 0.001). CONCLUSION: Fall-related globe and adnexal trauma were more common in the elderly. Alcohol and illicit substances have a role in falls in younger populations. Thorough ocular assessment is required especially in mid-facial/orbital trauma to exclude globe trauma. Further, research is required to determine the effect of fall prevention strategies in preventing globe trauma.

Burn related globe and adnexal trauma at trauma centres.

INTRODUCTION: Prompt management of burn-related globe trauma can prevent long term complications. Delays in diagnosis may occur when globe trauma is associated with life-threatening injuries. We aimed to improve the understanding of the epidemiology, acute assessment and management of burns-related globe and adnexal trauma admitted to two trauma centres in Sydney, Australia. METHOD: Admitted patients with burns-related globe and/or adnexal trauma were retrospectively reviewed at Royal North Shore Hospital (RNSH) and Royal Prince Alfred Hospital (RPAH) between January 2015 and December 2019. The International Classification of Disease, Tenth Revision codes was used to search and identify patients. Medical records were reviewed to extract data on demographics, injuries, ocular examination and ophthalmology involvement. RESULTS: Over the 5-years, 101 patients with globe and/or adnexal burns-related trauma were admitted to RNSH or RPAH. Median age was 37years. Most patients were male (76%) and were injured while at home or work (74%). Patients with chemical exposure were more likely to have globe trauma (100% vs 72%, p < 0.001) and severe globe trauma (54% vs 32%, p = 0.028). On initial review by emergency staff, 14 patients were not referred to ophthalmology, of these there were 2 patients where the diagnosis was delayed. CONCLUSION: Globe trauma is common in patients with chemical exposure. Thorough ocular assessment within the acute setting is vital to diagnose globe trauma. We investigated hospitals with specialised burn staff, further research is required to understand the management of globe trauma in hospitals without such resources. SYNOPSIS: Chemicals in household-products can cause severe globe trauma. Globe trauma can occur alongside large burns leading to delay in its diagnosis and management. Ophthalmology can assist in the early diagnosis and management of globe trauma.

Prognostic factors of open-globe injuries: A review.

Open-globe injuries (OGI) can lead to significant visual impairment. The Ocular Trauma Score (OTS) is the most widely recognized tool for predicting visual outcomes. This review aimed to identify prognostic factors and assess the effectiveness of the OTS in predicting visual outcomes. Twenty-one articles published on PubMed and Google Scholar were analyzed. Initial visual acuity and the zone of injury were found to be the most significant prognostic factors for OGI. Other significant prognostic factors include retinal detachment/involvement, relative afferent pupillary defect, vitreous hemorrhage, vitreous prolapse, type of injury, hyphema, lens involvement, and duration from incidence of OGI to vitrectomy. Of the 21 studies evaluated, 11 investigated the effectiveness of OTS. Four studies concluded that OTS was effective overall, while six studies suggested that it was only useful in certain OGI categories. Thus, there is a need for further research to develop an optimized ocular trauma prognosticating system.

The Use of Preoperative Prophylactic Systemic Antibiotics for the Prevention of Endopthalmitis in Open Globe Injuries: A Meta-Analysis.

TOPIC: This study reports the effect of systemic prophylactic antibiotics (and their route) on the risk of endophthalmitis after open globe injury (OGI). CLINICAL RELEVANCE: Endophthalmitis is a major complication of OGI; it can lead to rapid sight loss in the affected eye. The administration of systemic antibiotic prophylaxis is common practice in some health care systems, although there is no consensus on their use. METHODS: PubMed, CENTRAL, Web of Science, CINAHL, and Embase were searched. This was completed July 6, 2021 and updated December 10, 2022. We included randomized and nonrandomized prospective studies which reported the rate of post-OGI endophthalmitis when systemic preoperative antibiotic prophylaxis (via the oral or IV route) was given. The Cochrane Risk of Bias tool and ROBINS-I tool were used for assessing the risk of bias. Where meta-analysis was performed, results were reported as an odds ratio. PROSPERO registration: CRD42021271271. RESULTS: Three studies were included. One prospective observational study compared outcomes of patients who had received systemic or no systemic preoperative antibiotics. The endophthalmitis rates reported were 3.75% and 4.91% in the systemic and no systemic preoperative antibiotics groups, a nonsignificant difference (P = 0.68). Two randomized controlled trials were included (1555 patients). The rates of endophthalmitis were 17 events in 751 patients (2.26%) and 17 events in 804 patients (2.11%) in the oral antibiotics and IV (± oral) antibiotics groups, respectively. Meta-analysis demonstrated no significant differences between groups (odds ratio, 1.07; 95% confidence interval, 0.54-2.12). CONCLUSIONS: The incidences of endophthalmitis after OGI were low with and without systemic antibiotic prophylaxis, although high-risk cases were excluded in the included studies. When antibiotic prophylaxis is considered, there is moderate evidence that oral antibiotic administration is noninferior to IV. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Badminton-related eye injuries: a systematic review.

OBJECTIVES: To report the nature of badminton-related eye injuries in the published literature. METHODS: A review of the literature with key word and MeSH terms: 'Eye injury', 'Ocular trauma', 'Badminton' 'Shuttlecock' using CENTRAL, MEDLINE, EMBASE and Informit Health Collection databases. Papers were reviewed to assess the circumstances of the injury, patient demographics and clinical data. RESULTS: 19 studies from 1974 to 2020 from 12 countries reported 378 monocular badminton-related eye injuries from 378 patients with a male-to-female ratio of 2.5:1. A closed globe injury was sustained in 97% of eyes and a shuttlecock responsible for 85% of injuries. Doubles play, the shuttlecock and a lack of eye protection were associated with eye injury. CONCLUSION: Vision impairment was associated with the majority of badminton-related eye injuries, and doubles play, the shuttlecock and a lack of eye protection were risk factors.

International Globe and Adnexal Trauma Epidemiology Study (IGATES): Visual outcomes in open globe injuries in rural West India.

BACKGROUND/OBJECTIVES: To evaluate the factors influencing final visual outcome after surgical repair of open globe injuries (OGIs) in a rural population using the International Globe and Adnexal Trauma Epidemiology Study (IGATES) online registry. SUBJECTS/METHODS: Retrospective cohort study of patients with OGI. OGIs were identified from the IGATES database at a tertiary referral eye care centre in rural West India over a period of 12 years. Patient demographics, clinical and pre-operative factors affecting final visual outcome was evaluated. RESULTS: A total of 791 eyes with OGIs were included in data analysis. 11 eyes that were lost to follow-up and 12 eyes with incomplete data were excluded. Most of the patients were male (559, 70.6%) and mean age of all patients was 23.9 years ± 19.4 years. Occupational hazards (including domestic housework) (307, 38.8%) and leisure play (324, 41.0%) were the leading causes of OGI. The most common mechanism of injury was being struck by a wooden stick (250, 31.6%). Univariate analysis of pre-operative variables showed initial visual acuity (VA), zone of injury, size of wound, structures involved in the injury and presence of infection were significant prognostic factors for worse final visual outcome (p < 0.001). Multivariate analysis showed VA ≤ 3/60 or worse at presentation had statistically significantly higher odds ratio of ending up with worse visual outcomes (p < 0.012). CONCLUSIONS: Males in working age groups suffer from OGIs more frequently, usually from agricultural and pastoral activities. Initial VA, zone 3 injuries, corneoscleral wound, large wound size and presence of post-traumatic infections are significant prognostic factors.

Global Current Practice Patterns for the Management of Hyphema.

Purpose: Hyphema is a sequela of ocular trauma and can be associated with significant morbidity. Management of this condition is variable and can depend on individual institutional guidelines. We aimed to summarize current practices in hyphema management across ophthalmological institutions worldwide. Methods: A cross-sectional online survey was conducted across North America, Asia, South America, Africa, Europe, and Australia from August 2020 to January 2021. The survey assessed the existing practices in the management of hyphema at each institution. Results: For layered hyphema, topical steroids were routinely administered by 34 (of 36 respondents, 94.4%) institutions, of which prednisolone was the preferred choice (n = 32, 88.9%). Topical cycloplegics were used at 34 (94.4%) institutions. No institution reported routine use of antifibrinolytics. Head elevation was the most deployed procedure to promote hyphema reabsorption (n = 31, 86.3%), followed by partial bed rest (n = 21, 58.3%). The majority of institutions (n = 25, 69.4%) did not routinely pursue admission for hyphema patients, although 75.0% of institutions (n = 27) scheduled follow-up visits within 48 hours of presentation. Additionally, few institutions performed routine sickle cell trait testing for patients presenting with hyphema (n = 6, 16.7%). The decision to perform anterior chamber washout varied and was often based on intraocular pressure and the speed of hyphema resolution. Conclusion: Unanimity of international institutions on hyphema management is lacking. As it stands, many current interventions have unconvincing evidence supporting their use. Evidence-based guidelines would be beneficial in guiding decision-making on hyphema management. Additionally, areas of consensus can be used as foundations for future standard of care investigations.

Predictive value and applicability of ocular trauma scores and pediatric ocular trauma scores in pediatric globe injuries.

AIM: To evaluate the predictive value and applicability of Ocular Trauma Score (OTS) and Pediatric Ocular Trauma Score (POTS) for closed and open globe injuries in the pediatric group. METHODS: A retrospective study of closed and open globe injuries in children age of 0-18-year-old between 2012-2019 was conducted. Medical records were collected, and injuries were classified using Birmingham Eye Trauma Terminology System (BETTS). The predictive value and applicability of both OTS and POTS to final visual acuity (VA) were analyzed. RESULTS: Of 84 patients, 59 (70.2%) presented with closed globe injuries (CGI) and 25 (29.8%) with open globe injuries (OGI). The mean of initial VA was 0.832±0.904 logMAR. OTS and POTS was calculated. Initial VA (P<0.001) and traumatic cataract (P<0.001) were significantly associated with visual outcome, followed by organic/unclean wound (P=0.001), delay of surgery (P=0.001), iris prolapse (P=0.003), and globe rupture (P=0.008). A strong correlation between OTS and POTS and final VA (r=-0.798, P<0.001; r=-0.612, P<0.001) was found. OTS was more applicable in all age group of pediatric and in contrast to POTS, it was designed for 0-15 years old. POTS requires eleven parameters and OTS six parameters. Even though initial VA was not available, we could still calculate into POTS equation. CONCLUSION: OTS and POTS are highly predictive prognostic tools for final VA in CGI and OGI's in children.

Globe and Adnexal Trauma Terminology Survey.

Importance: Ocular trauma terminology should be periodically updated to enable comprehensive capturing and monitoring of ocular trauma in clinical and research settings. Objective: To update terminology for globe and adnexal trauma. Design, Setting, and Participants: A 2-round modified Delphi survey was conducted from January 1 to July 31, 2021, using an expert panel, including 69 ophthalmologists identified through their membership in ophthalmology (globe and adnexal trauma) societies. Consensus was defined as at least 67% expert agreement. A steering committee developed questions after identifying gaps in the current terminology via a targeted literature review. Round 1 sought consensus on existing and newly proposed terminology, and round 2 focused on unresolved questions from round 1. Experts included ophthalmologists who had managed, on average, 52 globe or adnexal trauma cases throughout their careers and/or published a total of 5 or more globe or adnexal trauma-related peer-reviewed articles. Main Outcomes and Measures: Expert consensus on ocular and adnexal terms. Results: A total of 69 experts participated in and completed round 1 of the survey. All 69 participants who completed round 1 were asked to complete round 2, and 58 responses were received. Consensus was reached for 18 of 25 questions (72%) in round 1 and 4 of 7 questions (57%) in round 2. Existing Birmingham Eye Trauma Terminology system terminology achieved consensus of 84% (58 of 69 experts) in round 1 and 97% (56 of 58 experts) in round 2. Experts agreed on the need for further refinement of the definition of zones of injury (55 of 69 [80%]), as the zone affected can have a substantial effect on visual and functional outcomes. There was consensus that the mechanism of injury (52 of 69 [75%]) and status of the lacrimal canaliculi (54 of 69 [78%]), nasolacrimal ducts (48 of 69 [69%]), lens (46 of 58 [80%]), retina (42 of 58 [73%]), and central and paracentral cornea (47 of 58 [81%]) be included in the revised terminology. Conclusions and Relevance: There was consensus (defined as at least 67% expert agreement) on continued use of the existing Birmingham Eye Trauma Terminology system definitions and that additional terms are required to update the current ocular trauma terminology.

Global Current Practice Patterns for the Management of Open Globe Injuries.

PURPOSE: To determine global current practice patterns for the management of open globe injuries and identify areas of variation. DESIGN: Cross-sectional survey. METHODS: An online survey assessed global management paradigms for open globe injuries from August 2020 to January 2021. Responses were collected from experts at eye trauma centers and emergency departments worldwide who manage ≥1 open globe injury per month. The survey assessed the use/selection of antibiotics and steroids, procedural and imaging decisions, and admission practices for open globe injuries. RESULTS: Responses were received from representatives of 36 of 42 institutions (85.7%), of which 33 (78.6%) had sufficient trauma volume to be included. Included responses were distributed across North America (n=12, 36.4%), Asia (n=12, 36.4%), South America (n=4, 12.1%), Africa (n=3, 9.1%), Europe (n=1, 3.0%), and Australia (n=1, 3.0%). Preoperative systemic antibiotics for open globe injuries were administered by 75.8% (n = 25/33) of institutions, while 30.3% (n = 10/33) administered preoperative topical antibiotics. Intraoperative ophthalmic antibiotics for open globe injuries were used by 54.5% (n = 18/33) of experts. Most institutions also administered postoperative systemic antibiotics (n = 23 [69.7%]) and topical steroids (n = 29 [87.9%]), although specific medication choices diverged. At 19 responding centers (61.3% of the 31 that had trainees), residents participated in surgical repairs. Many institutions discharged patients after repair, but 54.5% (n = 18/33) of locations routinely admitted them for observation. CONCLUSIONS: Preferred management practices for open globe injuries vary widely. To ensure the highest standard of care for all patients, evidence-based international guidelines for the treatment of these injuries are needed.

Eye injuries from fireworks used during celebrations and associated vision loss: the international globe and adnexal trauma epidemiology study (IGATES).

PURPOSE: To report on the factors associated with severe vision loss from fireworks-related ocular trauma during celebrations, including festivals. METHODS: Tertiary eye care hospitals in 5 countries and private ophthalmology practices in the Netherlands. Patients included received treatment for fireworks-related ocular trauma during celebrations. Demographic and clinical data for patients affected were analyzed and associations with severe vision loss reported. RESULTS: Of 388 patients, 71 (18.3 %) had severe vision loss (worse than 6/60) at 4-week follow-up due to fireworks-related ocular trauma. Mean age overall was 20.6 years (range 2 to 83 years), and there was a male predominance of 4:1. Clinical factors associated with severe vision loss included penetrating injury (OR 4.874 [95% CI 1.298-18.304; p = 0.02]) and lens injury (OR 7.023 [95% CI 2.378-20.736; p = 0.0004]). More patients with closed-globe injuries (CGIs) had improved vision after 4 weeks (OR 3.667, 1.096-12.27) compared to those with open-globe injuries (OGI) (p = 0.035). Eye protection use was reported by 7 patients, and 39.4% patients < 18 years were unsupervised by an adult at the time of injury. CONCLUSIONS: Severe vision loss from fireworks-related ocular trauma occurred during celebrations in a variety of countries and was associated with penetrating and/or lens injury and poor presenting vision. New initiatives are needed to prevent severe vision loss associated with these injuries.

The application of clinical registries in ophthalmic trauma-the International Globe and Adnexal Trauma Epidemiology Study (IGATES).

Ophthalmic trauma is a leading cause of preventable monocular blindness worldwide. The prevalence of ophthalmic trauma varies considerably based on geographic location, socio-economic status, age groups, occupation, and cultural practices such as firework celebrations. Clinical registries are known to be valuable in guiding the diagnosis, management, and prognostication of complex diseases. However, there is currently a lack of a centralized international data repository for ophthalmic trauma. We draw lessons from past and existing clinical registries related to ophthalmology and propose a new suitable international multicenter clinical registry for ophthalmic trauma: the International Globe and Adnexal Trauma Epidemiology Study (IGATES). IGATES is hosted on a secure web-based platform which exhibits user-friendly smart features, an integrated Ocular Trauma Score (OTS) prognosis calculator, efficient data collection points, and schematic graphical software. IGATES currently has 37 participating centers globally. The data collected through IGATES will be primarily used to develop a more robust and improved ophthalmic trauma prognostic classification system, the Ocular Trauma Score-2 (OTS-2), which builds on previous systems such as the Birmingham Eye Trauma Terminology System (BETTS) and Ocular Trauma Score (OTS). Furthermore, IGATES will act as a springboard for further research into the epidemiology, diagnosis, and management of ophthalmic trauma. Ultimately, IGATES serves to advance the field of ophthalmic trauma and improve the care that patients with ophthalmic trauma receive.

Global Current Practice Patterns for the Management of Exogenous Endophthalmitis: A Survey by the American Society of Ophthalmic Trauma.

OBJECTIVE: To investigate the global practice patterns for the management of exogenous endophthalmitis. METHODS: This cross-sectional study was conducted to assess global practice patterns for the management of exogenous endophthalmitis. An online survey comprised of questions regarding the management of exogenous endophthalmitis was distributed to institutions who are members of International Globe and Adnexal Trauma Epidemiology Study Group (IGATES) or invited affiliates of the American Society of Ophthalmic Trauma and the Asia Pacific Ophthalmic Trauma Society. Responses were gathered from August 2020 to January 2021. RESULTS: Of 42 institutions, 36 responses were received (86% response rate), of which 33 (79%) were included in the analysis. Included centers were from Asia (36%), North America (36%), South America (12%), Africa (9%), Europe (3%), and Australia (3%). Oral antibiotics were administered in 19 (58%) institutions, with moxifloxacin as the preferred agent (n = 9, 27%). The preferred method for obtaining cultures was vitreous tap (n = 25, 76%). Most institutions (n = 26, 79%) routinely administered intravitreal vancomycin and ceftazidime, while intravitreal steroids were routinely administered at 11 centers (33%). Indications for performing vitrectomy included; decreased visual acuity (n = 14, 39%); all cases of exogenous endophthalmitis (n = 4, 12%); non-response to medical therapy (n = 4, 12%); or no view of the fundus (n = 4, 12%), indicating significant variation in surgical indications. More than half (n = 17, 52%) of responding institutions routinely admitted patients with exogenous endophthalmitis to the hospital. Institutions in the United States were less likely to administer oral antibiotics (27% vs. 73%, P = .024) and to admit patients (9% vs. 73%, P < .001) compared to other countries. CONCLUSIONS: This study highlights the global variations in the management of exogenous endophthalmitis, especially as it pertains to surgical indications. Further establishment of evidence-based guidelines may be beneficial to provide more uniform guidance to optimize outcomes.

Ophthalmic Trauma Correlation Matrix (OTCM): a potential novel tool for evaluation of concomitant ocular tissue damage in open globe injuries.

PURPOSE: To introduce a novel tool to investigate the correlation between concomitant injuries and primary open globe injury (OGI) in the setting of ophthalmic trauma, the "Ophthalmic Trauma Correlation Matrix" (OTCM). METHODS: Retrospective cohort review, performed at a tertiary referral eye care center in Eastern Nepal, involving all eyes with OGI meeting the inclusion criteria from 2015-2018. Clinical data including details of primary injury, concurrent injuries, and clinical course were noted from hospital medical records. A correlation matrix chart was devised using matrix correlation and Pearson's correlation coefficient. This chart was then used to evaluate the association of the various injuries in the setting of OGI. RESULTS: A total of 109 eyes with OGI were included. Majority of the eyes (78, 71.6%) had zone I injuries, while most of the eyes (66, 60.6%) had penetrating injury. The most frequent concomitant injuries in all zones of OGI were traumatic lens injury (77, 70.64%), followed by hyphema (48, 44.03%), and vitreous hemorrhage (35, 32.11%). The most common concomitant injury associated with zone I was hyphema (0.873), while traumatic subluxation/cataract (0.894) and vitreous hemorrhage (0.972) were commonly associated with zone II and III, respectively. CONCLUSIONS: OTCM could be a useful tool to manage injuries related to the primary ocular injury. This additional information will aid in the prognostication, planning, and management of OGI and potentially prevent repeat surgeries and inadequate treatments.