Characteristics of ocular injuries associated with mortality in patients admitted with major trauma.

BACKGROUND: Few ocular trauma studies have addressed mortality outcomes. We sought to determine characteristics of mortality-related ocular trauma admissions and compared them with non-fatal injuries. METHODS: A retrospective study was conducted using de-identified data of patients admitted with major trauma from the National Trauma Data Bank (2008-2014). Patients with ocular injury were identified using ICD- 9CM codes. Demographics, intention and mechanism, types of ocular and head injuries, and injury severity were documented. Mortality was determined using post-admission disposition. Statistical analysis using student t-test, chi-square, and odds ratios (OR) calculations were performed with STATA-17 software. Significance was set at P < 0.05. RESULTS: Of 316,485 patients admitted with ocular trauma, 12,233 (3.86%) were mortality related. Expired patients were older than survivors: mean (SD) of 50.1(25.5) vs. 41.5(22.8) years. White (OR = 1.32; P < 0.001), ≥ 65years old (OR = 2.25; P < 0.001), and male (OR = 1.05; P = 0.029) patients were most likely to expire than their counterparts. Common mechanisms of injury in survivors were falls (25.3%), motor vehicle traffic-occupant, MVTO (21.8%) and struck by/against (18.1%) and for fatal injuries, falls (29.7%), MVTO (21.9%) and firearms (11.5%). Traumatic brain injury (TBI) was documented in 88.2% of mortality-related admissions. Very severe injury severity scores (ISS > 24) (OR = 19.19; P < 0.001) and severe Glasgow Coma Score (GCS < 8) (OR = 19.22; P < 0.001) were most associated with mortality than survival. Firearms were most associated with very severe ISS (OR = 3.73; P < 0.001), severe GCS (OR = 4.68; P < 0.001) and mortality (OR = 5.21; P < 0.001) than other mechanisms. Patients with cut/pierce injuries had the greatest odds of survival (OR = 13.48; P < 0.001). Optic nerve/visual pathways injuries (3.1%) had the highest association with very severe ISS (OR = 2.51; P < 0.001), severe GCS (OR = 3.64; P < 0.001) and mortality (OR = 2.58; P < 0.001) than other ocular injuries. Black patients with very severe ISS (OR = 32.14; P < 0.001) and severe GCS (OR = 31.89; P < 0.001) were more likely to expire than other race/ethnicities with similar injury severity. CONCLUSIONS: Mortality-related admissions were older, male, and mostly of White race than ocular trauma admissions of survivors. Firearms were the deadliest mechanism. TBI was commonly associated and patients with optic nerve/pathway injuries, very severe ISS and severe GCS had higher mortality rates. Characteristics and demographic variations identified in this study may be useful in developing focused measures aimed at preventing trauma-related deaths.

Mechanism and outcomes of recreational and sports-related open globe injuries.

OBJECTIVES: To describe the mechanisms and visual outcomes of recreational and sports-related open globe injuries (OGIs). METHODS: A retrospective case series of eyes experiencing OGI secondary to recreational and sports-related activities at Memorial Hermann Hospital - Texas Medical Center (MHH-TMC) from January 1st, 2010 through March 31st, 2015 was conducted. Exclusionary criteria included no documented ophthalmologic examination upon presentation and repairs performed by services other than ophthalmology. A two-tailed t-test and Fisher's exact test were utilized to assess for statistical significance (p < 0.05). RESULTS: A total of 20 eyes from 20 patients experiencing OGIs secondary to recreational and sports-related activities were included. Thirteen eyes (65 %) presented with OGIs from penetrating objects while seven eyes (35 %) had injuries from blunt injuries. Males comprised most of the total study group (17 of 20 patients), and zone 3 injuries were the most common location of OGI. While eyes with OGIs from blunt trauma underwent evisceration/enucleation procedures more frequently than OGIs from penetrating mechanisms (71% vs 23 %) (p = 0.10), the final visual outcomes were similarly poor between groups. Only three eyes in this series experienced an improvement from baseline VA; all three eyes had lacked initial findings consistent with severe injury. CONCLUSIONS: Recreational and sports related OGIs most commonly occur in zone 3 and in young males, regardless of injury type. OGIs due to both penetrating and blunt trauma mechanisms implicate poor functional outcomes, but the absence of certain presenting injury features may indicate possibility of eventual visual recovery.

Demographic, Etiological, and Clinical Characteristics of Eyelid Lacerations.

Objectives: To evaluate the demographic, etiological, and accompanying clinical factors in eyelid lacerations (EL). Materials and Methods: The records of patients who presented to our clinic between 2018 and 2022 with eyelid trauma were retrospectively reviewed. Age, gender, cause of injury, clinical findings, accompanying ocular findings, and additional complications were analyzed. Results: The study included 135 patients (106 male, 29 female) with a mean age of 37.0±18.6 years. Among the patients, 29 (21.4%) were 18 years old or younger, 93 (68.8%) were between 19 and 64 years old, and 13 (9.6%) were 65 years old or older. EL were most caused by various sharp objects in 44 patients (33%), blunt trauma in 40 patients (30%), falls in 30 patients (22%), and traffic accidents in 21 patients (15%). Fifteen eyes (11.1%) had foreign bodies at the wound site. Thirty patients (22.2%) (20 lower eyelid, 10 upper eyelid) had accompanying canalicular lacerations. Twenty-three (17%) patients had accompanying conjunctival lacerations, 14 (10.3%) had open-globe injury, 10 (7.4%) had corneal epithelial defects, 9 (6.6%) had intravitreal hemorrhage, 6 (4.4%) had hyphema, and 5 (3.7%) had retinal detachment. Four patients had lid notching and 1 patient (0.7%) had ectropion. Five patients (3.7%) required suturing. No additional complications were observed. Conclusion: EL are more commonly seen in young adulthood and in males. The most common mechanism of injury is impact by various objects. Eyelash margin and canalicular lacerations frequently accompany these injuries. Serious ocular pathologies such as hyphema and open-globe injury can accompany eyelid trauma.

Visual-functional impact of people affected by severe ocular trauma during social protests in Chile in 2019.

PURPOSE: To determine the impact on the functionality associated with visual loss (VFIP) in people with severe ocular trauma (SOT) caused by kinetic impact projectiles used in police crowd control through a prioritization tool in people admitted to a rehabilitation program in Santiago de Chile from December 02, 2019, to November 13, 2020. METHODS: A cross-sectional descriptive study of SOT victims (N = 85), average age 31.4 ± 11.9. The data were recorded through a new 9-item screening instrument for assessment and prioritization of rehabilitation created for this emergency scenario. RESULTS: The impact of the use of kinetic weapons resulted in monocular blindness in the majority of those affected (n = 68; 80.0%). The highest VFIP observed was among young men from lower social strata. There were extreme difficulties in the performance of productive tasks (occupational and/or educational) (n = 42; 49.4%) and the pursuit of hobbies and pastimes (n = 23; 27.1%), as well as a high difficulty in adapting to changes in brightness (n = 29; 34.1%) and handling objects accurately (n = 22; 25.9%). CONCLUSION: The use of kinetic weapons for crowd control resulted in high and extreme VFIP and, in most cases, monocular blindness, causing major difficulties in work, study, and development of hobbies and pastimes in the affected population, highlighting the urgent need for effective rehabilitative care, which requires special attention in order to generate an adequate rehabilitation program. The use of kinetic weapons for crowd control contravenes international goals, policies, and plans set by the WHO and the International Agency for the Prevention of Blindness on strategies to prevent avoidable blindness worldwide until 2020. It is essential to ban the use of these weapons in Chile and worldwide, as well as to revise police protocols for crowd control.

A potential role for inflammatory cytokines in a rare late-onset capsular block syndrome: a case report.

BACKGROUND: Late-onset capsule block syndrome (CBS) is a rare complication of cataract phacoemulsification and the implantation of a posterior chamber intraocular lens (PCIOL), which manifests six months to years after surgery. The hallmark of CBS is the formation of an opaque liquid substance between the implanted intraocular lens (IOL) and the posterior capsule. However, its pathogenesis remains unclear. CASE PRESENTATION: A 64-year-old female patient with chronic angle-closure glaucoma (axis length < 21 mm) underwent trabeculectomy surgery combined with phacoemulsification and PCIOL. After a 4-year follow-up, a decline in visual acuity occurred in her right eye due to the location of opaque fluid in the visual axis and distension of the capsular bag. The initial course of action was to release the trapped fluid. Neodymium: yttrium-aluminum-garnet (Nd: YAG) laser capsulotomy could not be employed due to her non-dilating pupil and high extension of the posterior capsule. Subsequently, anterior capsule peeling and anterior segment vitrectomy surgery were performed. The depth of the anterior chamber (ACD), the distance between the face of the retro-IOL and the posterior capsule, the best-corrected visual acuity (BCVA), and the visual quality (VQ) were measured both before and after surgery. Inflammatory cytokine levels in the opaque substances (OS) trapped between the PCIOL and the posterior capsule were assessed using a flow cytometer and compared to normal statistical data in aqueous humor. After surgery, the patient experienced a significant improvement in BCVA and VQ. The distance between the face of the retro-IOL and the posterior capsule was on the verge of disappearing. However, ACD did not differ between pre- and post-operatively. Interleukin-8 (IL-8) and basic fibroblast growth factor (BFGF) concentrations were higher in the OS than in aqueous humor, especially in the former. However, the concentration of vascular cell adhesion molecule (VCAM) in the OS was lower than in aqueous humor. CONCLUSIONS: Anterior segment vitrectomy surgery proved to be a successful treatment for late-onset CBS, presenting a challenging case. In the human lens, inflammatory cytokines originating from the opaque substances may contribute to abnormal metabolism in the sealed area, a consequence of late-onset CBS.

Clinical outcomes of traumatic globe rupture in corneal graft patients.

PURPOSE: This study reports the mechanisms, complications and graft survival following sight-threatening traumatic globe rupture in patients having previously undergone corneal transplantation in the same eye. METHODS: A retrospective, observational, single-center consecutive cohort study at the Royal Victoria Infirmary, Newcastle upon Tyne, UK over a 20-year period. Medical records and Newcastle Corneal Transplantation Service electronic database (eNCTS) review was undertaken of all consecutive patients who underwent corneal transplantation with a history of traumatic globe rupture. Main outcome measures include mechanism of injury, final best-corrected distance visual acuity (BCDVA), graft survival and complications. RESULTS: A total of 921 keratoplasties were undertaken between 1997 and 2017 with 24 (3.0%) patients identified with a history of traumatic globe rupture. A bimodal relationship of age and mechanism of trauma was observed. The mean age (SD) of individuals reporting cause as a fall was 71.5 (14.8) years, and 45.3 (20.8) years (P < 0.05) amongst individuals reporting accidental trauma or assault. The pre- and post-trauma mean (SD) LogMAR BCDVA was 0.6 (0.9) and 1.7 (1.0), respectively (P = 0.001). The overall graft-failure rate was 60.9% (11 grafts) during a mean (SD) follow-up period of 3.5 (4.1) years. Globe rupture with lens damage was associated with poorer final BCDVA (P < 0.05). CONCLUSIONS: This study represents the first published series from England for this type of patient cohort. Overall visual outcomes were poor with a bimodal relationship of age and mechanism of trauma. Worse prognostic factors included lens and posterior segment complications. Re-grafting in these select group of patients may prove valuable.

Clinical profile and management of ocular superglue injuries: Case series and review of literature.

PURPOSE: To describe the clinical profile and management of patients with ocular superglue injury (OSI). METHODS: This retrospective study included all patients with OSI who presented at a tertiary eye care institute between 2016 and 2020. Data regarding demographics, clinical profile, and management were collected. RESULTS: A total of 66 eyes of 58 patients (24 children, 34 adults) with a median age of 22.5 years [interquartile range (IQR): 11.3-31] were included. All cases sustained accidental injuries, with domestic injury at home being the most common location of injury among children (79%) and adults (53%) ( P = 0.39). The median visual acuity at presentation was worse in children [0.3 logMAR (IQR: 0.2-0.4)] as compared to adults [0.1 logMAR (IQR: 0.1-0.3)] ( P = 0.03)]. The most common clinical sign at presentation was conjunctival congestion in 77% of eyes (51/66) followed by polymerized glue stuck to the eyelashes and eyelids in 52% of eyes (34/66). The median duration from the time of injury to presentation was 2 hours in both groups. All eyes resolved with medical management. Examination under anesthesia was required in three children (13%) to evaluate the extent of OSI. None of the patients had long-term ocular complications. CONCLUSION: Improper and careless handling of superglue in the domestic setting may cause accidental ocular injuries that require immediate medical attention. OSI represents less severe ocular injuries that respond to medical therapy alone and is not associated with long-term visual morbidity. Modifications in the packaging of superglue containers and awareness about their deleterious effects could prevent these injuries.

Pars Plana Vitrectomy in the Treatment of Rhegmatogenous Retinal Detachment.

AIM: The aim of the study is to retrospectively evaluate the anatomical success rate and functional results of 25G+ PPV in the treatment of newly diagnosed rhegmatogenous retinal detachment (RRD). MATERIAL AND METHODS: The set consists of 152 eyes of 152 patients, of which 71 (47%) were men, average age 54 years, operated on by one surgeon for RRD at the Eye Clinic of the University Hospital and Medical Faculty of Masaryk University Brno from 1.7.2019 to 4.5.2021 using the 25G+ PPV technique. 25G+ PPV with pre-equatorial cerclage was performed on 7 patients. The patients' anamnesis included blunt ocular trauma and uncomplicated cataract surgery with implantation of a posterior chamber intraocular lens. The cause of RRD was retinal tear/s, regardless of their number and location. The transparency of the anterior segment of the eye enabled reliable visualization of the posterior segment. Preoperative proliferative vitreoretinopathy (PVR) grade A-D2 was admissible. Patients with a history of penetrating ocular trauma were excluded. The postoperative findings and functional outcomes of the patients were evaluated 1-3 months after PPV. The operation was anatomically successful if the retina was fully attached. Final visual acuity (VA) was evaluated for each patient. The final visual acuity examination was carried out typically on a Snellen optotype, either without correction, with the patient's own spectacle correction or with correction according to the current values on the autorefractometer. The arithmetic average was used for the numerical expression of the attained results, and the numerical values were also expressed in percentages. Since the different groups were not compared with each other, no statistical test was necessary to analyze the results. RESULTS: In 150 (98.7%) of the 152 patients in the group, we achieved complete retinal reattachment, in 2 (1.3%) patients the retina remained detached, and we recorded anatomical failure of the treatment. Fifty (33%) patients achieved VA ≥ 4/8. CONCLUSION: In 133 (87.5%) patients, we are able to state anatomical success even without the presence of intraocular tamponade in the operated eye. These patients can be considered completely cured. 25G+ PPV has demonstrated its contribution to resolving RRD.

Zone 1 trauma: wound dehiscence compared to primary trauma.

PURPOSE: The study aims to assess if Zone 1 globe injuries hold a favorable prognosis for all situations, including wound dehiscence, or just primary traumatic injuries. METHODS: Retrospective cross-sectional chart review of patients who underwent open globe repair from 1/1/2019 to 12/1/2020 at an urban hospital setting was evaluated for final visual outcomes, associated ocular pathology, long-term complications, and need for further surgeries. RESULTS: Fifty-eight eyes were identified-38 primary trauma and 20 dehisced wounds (11 penetrating keratoplasties, five clear corneal incisions, one laceration, one extracapsular cataract extraction, one radial keratotomy, and one tectonic graft). Dehisced wounds had more posterior segment pathology vs primary trauma, i.e., hemorrhagic choroidal, vitreous hemorrhage, retinal detachment, choroidal effusion (all 20% vs 2.63%, 5.26%, 5.26%, and 0%, respectively), vitreous prolapse (20% vs 2.63%), and uveal prolapse (80% vs 36.84%). Dehisced wounds had more traumatic aphakia (40% vs 0%) and dislocated lenses (15% vs 0%). Primary trauma was more likely to have traumatic cataracts (55.26% vs 10%) or no lens changes (44.74% vs 25%). About 10% dehisced wounds required enucleation (0% primary trauma). Cataract/secondary intraocular lens surgery was performed in 34% of the primary traumas (10% in dehisced wounds). Primary traumas achieved 20/40 vision or better in 44.74% (10% dehisced wounds). About 7.89% of patients with wound dehiscence ended with no light perception (none in primary trauma). CONCLUSION: Zone 1 open globe injuries due to wound dehiscence may exhibit worse prognosis compared to primary trauma open globe injury. More important than the zone of injury may be the source.

Cauterization-mediated restriction from penetrating orbital trauma.

A healthy 32-year-old woman presented with binocular diplopia immediately after sustaining a penetrating injury to the left periocular adnexa with a hot metal skewer. Examination revealed an incomitant esotropia, with complete limitation of abduction of the left eye with downshoot in left gaze and normal afferent visual function. Computed tomography and magnetic resonance imaging demonstrated no fracture, but there was mild thickening of the medial rectus muscle and associated fat stranding. Lack of orbitomuscular tethering or hematoma led to the presumptive diagnosis of thermal cauterization injury causing left medial rectus restriction. Given the lack of literature on this mechanism of injury, the patient was monitored closely. She exhibited remarkable spontaneous improvement in motility over 6 months, with near orthophoria in primary gaze. However, bothersome residual esotropic diplopia in left gaze prompted a left medial rectus recession, with a good outcome. This case demonstrates that isolated extraocular muscle thermal injuries and consequential strabismus can recover spontaneously; longitudinal observation before surgical intervention may be appropriate in such cases.

Modified technique for reconstruction of large cyclodialysis cleft with capsular tension ring and continuous and cerclage sutures without scleral flaps.

To present a modified technique for the reconstruction of a large cyclodialysis cleft with capsular tension ring (CTR) and continuous and cerclage sutures without scleral flaps in 12 cases. The mean visual acuity was 0.75 ± 0.47 logarithm of the minimal angle of resolution (logMAR), and the average intraocular pressure (IOP) was 3.35 ± 0.41 mmHg before surgery. Ultrasound biomicroscopy (UBM) revealed a ciliary cleft of 4.3 ± 3.5 clock hours. We performed the modified technique for the reconstruction of a large cyclodialysis cleft. Postoperative visual acuity improved to 0.48 ± 0.26 logMAR, and the IOP improved to 15.88 ± 3.81 mmHg. Postoperative UBM showed that cyclodialysis disappeared in the whole circumference of 12 eyes. The postoperative complications included 42% (5 eyes) with a temporary elevation of IOP and 16% (2 eyes) with a posterior shift of the ciliary body. No other complications were detected during the follow-up. Based on the results, our modified technique might be useful for most cyclodialysis clefts.

Orbital Trapdoor Fracture With Extraocular Muscle Entrapment in Adults: A Case Series.

PURPOSE: To report adult patients with an orbital trapdoor fracture with extraocular muscle entrapment. METHODS: We retrospectively reviewed 566 adult patients (>18 years) with a pure orbital fracture who were referred to us from January 2016 to May 2023. The following data were collected: age, sex, affected side, causes of injury, concomitant ocular injury and nasal bone fracture, presence or absence of oculocardiac reflex and infraorbital nerve hypesthesia, period from injury to surgery, follow-up period, and pre- and postoperative limitation of extraocular muscle motility and fields of a binocular single vision. RESULTS: We found 5 patients (0.9%) with an orbital trapdoor fracture with extraocular muscle entrapment (age range, 19-47 years; all males; 2 right and 3 left). Causes of injury included performing a bench press, fall, assault, boxing, and bicycle accident. Entrapment of the inferior and medial recti muscles was seen in 2 and 3 patients, respectively. None of the patients had any sign of oculocardiac reflex. After surgical reduction, the field of binocular single vision became normal in 3 patients and was incompletely recovered in 2 patients, in whom consultation with us was delayed. CONCLUSION: Adults with extraocular muscle entrapment may not present with an oculocardiac reflex. Urgent release of an entrapped muscle is, however, still recommended to avoid permanent limitation of extraocular muscle motility.

Long-term sequelae of photic eye injury from a solar eclipse.

Photic ocular injuries are secondary traumatic injuries resulting from the toxic effects of the interaction between light and the eye, particularly the retina. We report the cases of two patients who experienced photic macular injury from their early childhood due to observing a solar eclipse without protection. The retinal lesions are mainly macular; these can be serious and irreversible. They are the consequence of photochemical, photomechanical and photothermal reactions. OCT is very useful for the diagnosis of these foveal lesions. The visual prognosis of solar retinopathy is generally favorable. However, some patients may develop permanent sequelae with a decrease in visual acuity. Management remains empirical and controversial. Thus, prevention and public education remain the only effective ways to avoid this type of trauma.

Custom Iris Prosthesis for Subtotal Traumatic Aniridia From Combat Ocular Trauma.

Traumatic aniridia from combat ocular trauma can cause visual disability. A 41-year-old male Army Veteran was referred for evaluation of light sensitivity and glare secondary to subtotal traumatic aniridia of his left eye from an improvised explosive device blast. A custom-made artificial iris prosthesis was implanted in the ciliary sulcus and secured using Gore-Tex sutures. After surgery, the patient reported improvement of his light sensitivity and quality of life. The custom iris prosthesis is a surgical option for visual disability resulting from traumatic aniridia from combat ocular trauma.

Randomised controlled trial of adjunctive triamcinolone acetonide in eyes undergoing vitreoretinal surgery following open globe trauma: The ASCOT study.

BACKGROUND/AIMS: To investigate the clinical effectiveness of adjunctive triamcinolone acetonide (TA) given at the time of vitreoretinal surgery following open globe trauma (OGT). METHODS: A phase 3, multicentre, double-masked randomised controlled trial of patients undergoing vitrectomy following OGT comparing adjunctive TA (intravitreal and subtenons) against standard care (2014-2020). The primary outcome was the proportion of patients with at least 10 Early Treatment Diabetic Retinopathy Study (ETDRS) letter improvement in corrected visual acuity (VA) at 6 months. Secondary outcomes included: change in ETDRS, retinal detachment (RD) secondary to PVR, retinal reattachment, macular reattachment, tractional RD, number of operations, hypotony, elevated intraocular pressure and quality of life. RESULTS: 280 patients were randomised over 75 months, of which 259 completed the study. 46.9% (n=61/130) of patients in the treatment group had a 10-letter improvement in VA compared with 43.4% (n=56/129) of the control group (difference 3.5% (95% CI -8.6% to 15.6%), OR=1.03 (95% CI 0.61 to 1.75), p=0.908)). Secondary outcome measures also failed to show any treatment benefit. For two of the secondary outcome measures, stable complete retinal and macular reattachment, outcomes were worse in the treatment group compared with controls, respectively, 51.6% (n=65/126) vs 64.2% (n=79/123), OR=0.59 (95% CI 0.36 to 0.99), and 54.0% (n=68/126) vs 66.7% (n=82/123), OR=0.59 (95% CI 0.35 to 0.98), for TA vs control. CONCLUSION: The use of combined intraocular and sub-Tenons capsule TA is not recommended as an adjunct to vitrectomy surgery following OGT. TRIAL REGISTRATION NUMBER: NCT02873026.

TRAUMATIC LENS SUBLUXATION FROM PICKLEBALL INJURY: A CASE SERIES.

PURPOSE: The purpose of this study was to describe two cases of traumatic lens subluxation resulting from pickleball injury. METHODS: This is a case series. RESULTS: A 77-year-old man presented with worsening vision and was noted to have subluxation of his intraocular lens 10 days after being struck in the eye with a pickleball. The patient underwent a lens exchange with scleral fixation. A 76-year-old woman presented with blurry vision on the same day as her injury and was noted to have subluxation of her crystalline lens. She also underwent a lens insertion with scleral fixation. However, she experienced additional complications of postoperative cystoid macular edema and traumatic glaucoma. CONCLUSION: We recommend increased use of eye protection in pickleball.

Indirect cylopexy in cases with cyclodialysis using flanged prolene cylopexy technique.

This study aims to describe a new technique of indirect cyclopexy in the treatment of cyclodialysis. Cases who had cyclodialysis for more than 3 h of extent and were resistant to medical treatment underwent flanged prolene cyclopexy (FPC) technique. Five cases were included in this study. Mean duration between the initial surgery and FPC was 4.6 ± 4.3 months. Hypotony maculopathy was present in all cases. All cases underwent FPC in combination with pars plana vitrectomy and silicone oil injection. Circumferential FPC was applied in four cases, while focal FPC was performed in one case. Postoperatively, no complications occurred, visual acuity increased in four cases, and cyclodialysis closed in all cases. In the follow-up, silicone oil was removed in three cases, but silicone oil could not be removed in two cases with ongoing hypotony. Preliminary results showed that FPC is a promising technique in the surgical treatment of cyclodialysis.