Important Considerations in Ocular Trauma Classification

IMPORTANT CONSIDERATIONS IN
TRAUMA
PRESENTER: Dr. KRATI GUPTA
MODERATOR: Dr. GAYATRI BHARALI

INTRODUCTION
• Damage or trauma inflicted to the eye by external means.
• The concept includes both surface injuries and intraocular injuries.
• During trauma soft tissues and bony structures around the eye maybe involved.
• Ocular trauma is a major cause of preventable monocular blindness and visual
impairment in the world, especially in the developing countries.
• Ocular trauma and resultant loss of vision leads to psychological, economical and
professional crippling of the patient.

NEED FOR CLASSIFICATION OF OCULAR TRAUMA
• Ophthalmologists are unable to unambiguously communicate with each other if
the terms they use to describe an eye injury are not standardized.
• Research cannot be conducted and the results cannot be quantified without the
risk of the data being misinterpreted.
Kuhn F, ocular traumatology.2008 :p 3

CHARACTERISTICS OF AN IDEAL EYE TRAUMA
TERMINOLOGY SYSTEM
In an ideal eye trauma terminology system, the following criteria must be satisfied:
The tissue of reference must always be obvious.
Each term must have a unique definition.

CLASSIFICATION OF OCULAR TRAUMA
• The Ocular Trauma Classification Group developed a classification system for
mechanical injuries to the eye.
• It is based on the initial examination or evaluation at the time of primary surgical
intervention.
CLASS OF INJURY
• Open-globe/penetrating: injury with full thickness wound to the cornea and
sclera.
• Closed-globe/non penetrating: injury without full thickness defect of the cornea
and sclera.

CLASSIFICATION OF OCULAR TRAUMA
• The Birmingham Eye Trauma Terminology System (BETTS) devised a
classification for ocular trauma which is accepted worldwide.
• BETT satisfies all criteria for unambiguous standard terminology by:
1. Providing a clear definition for all injury types.
2. Placing each injury type within the framework of a comprehensive system.
Kuhn F, Pieramici DJ. ocular trauma principals and practice: 2002 :p.4

TERMS AND DEFINITIONS IN BETT*

BETT: THE TERMINOLOGY OF OCULAR TRAUMA

OCULAR TRAUMA CLASSIFICATION
• The Ocular Trauma Classification Group has developed a classification system
based on BETT and features of globe injury at initial examination.
• Mechanical trauma to the eye is subdivided into open and closed globe injuries
because these have different pathophysiological and therapeutic ramifications.
• The system categorizes trauma by four parameters.

1. TYPE
• The type of the injury should be determined based on the history as reported by
the patient or witnesses regarding the circumstances of the incident.
• If a patient is unconscious or unreliable typing may be based on clinical
examination.
• If media opacity or other clinical factors preclude adequate examination,
ultrasonography, x-ray, or CT scanning may assist.

2. GRADE
• Grade, as defined by visual acuity measurement at the initial examination.
• Testing is done with a Snellen acuity chart and should be performed with the
patient’s corrective lenses if possible.
• A pinhole vision may be recorded.

3. PRESENCE/ ABSENCE OF RELATIVE AFFERENT PUPILLARY EFECT
• The presence of an APD, as measured by the swinging flashlight test is a gross
indicator of aberrant optic nerve and/or retinal function.
• If the affected eye is nonreactive for mechanical or pharmacologic reasons,
observing the consensual response in the fellow eye (i.e., looking for a “reverse”
APD) is advised.

4. EXTENT (i.e ZONE) OF THE INJURY
• Wound location in open globe injuries or the most posterior extent of damage in
closed globe injuries.
• The zone of injury depends on whether the injury is open or closed globe.

OPEN GLOBE INJURY CLASSIFICATION

CLOSED GLOBE INJURY CLASSIFICATION

CALCULATING THE OTS : VARIABLES AND RAW POINTS
Variable Raw points
Initial Vision
NLP 60
LP/HM 70
1/200- 19/200 80
20/200-20/50 90
≥20/40 100
Rupture -23
Endophthalmitis -17
Perforating Injury -14
Retinal Detachment -11
Afferent pupillary defect -10

CONVERSION OF THE RAW POINTS INTO THE OTS,
AND IDENTIFYING THE LIKELY VISUAL OUTCOME (%)
Sum of raw
points
OTS No PL PL/HM 1/200-19/200 20/200-20/50 ≥20/40
0-44 1 74% 15% 7% 3% 1%
45-65 2 27% 26% 18% 15% 15%
66-80 3 2% 11% 15% 31% 41%
81-91 4 1% 2% 3% 22% 73%
92-100 5 0% 1% 1% 5% 94%

EPIDEMIOLOGY- INTRODUCTION
• Epidemiology involves systematic observation leading to the development and
execution of a strategy.
• Subsequent observation determines whether the recommended strategy has
been successful.
• Through the development of scientific and public health models, injuries are now
defined and measured; and interventions are designed, tested for effectiveness,
and implemented if their efficacy is proved.

IMPACT OF OCULAR TRAUMA ON HUMAN LIVES
• The eyes represent only 0.1% of the total body surface and 0.27% of the anterior
body surface.
• Their significance to individuals and society is disproportionally higher.
• Most of the information reaches humans through vision.
• Consequently, the socioeconomic impact of ocular trauma can hardly be
overestimated.

• Those affected often have to face:
Loss of career opportunities
Major lifestyle changes
Occasionally Permanent physical disfigurement
• In addition to the physical and psychological costs of eye injuries to the individual,
financial costs to society are enormous.
• The cost-effectiveness of well-planned preventive measures based on sound
epidemiologic data has repeatedly been demonstrated.
• In industrialized nations, trauma has become the most common reason for
extended hospitalization of ophthalmologic patients.

• In the United States alone there are almost 2.5 million incident cases of eye
injuries each year.
• The number of people with trauma related visual impairment was close to 1
million in 1977 .
• 40,000–60,000 incident cases of trauma related visual impairment annually.

• The WHO Programme for the Prevention of Blindness, suggests that annually.
• 55 million eye injuries restricting activities more than one day.
• 750,000 cases will require hospitalization.
• 200,000 open-globe injuries.
• Approximately 1.6 million blind from injuries.
• 2.3 million people with bilateral low vision.
• 19 million with unilateral blindness or low vision.
Internet

THE UNITED STATES EYE INJURY REGISTRY
• The prerequisite for the scientific study of injury is acquisition of data to design
appropriate preventive and therapeutic interventions.
• The same surveillance system is used to monitor the effectiveness of preventive,
and rehabilitative interventions.

THE UNITED STATES EYE INJURY REGISTRY
• Established in 1988, the USEIR satisfies the following criteria:
Collects information at hospitals and emergency rooms as well as at physicians’
offices.
Uses single-page initial and 6 months follow-up reporting forms.
Surveys all types of eye injuries—open globe, closed globe, and adnexal.
Limits data collection to injuries resulting in permanent and significant structural
or functional change to the eye.

Kuhn F, Pieramici DJ. ocular
trauma principals and practice:
2002 :p.16

OCULAR TRAUMA EPIDEMIOLOGY:
GENERAL FINDINGS
• Annual Incidence Rate of Hospitalization for Eye Injuries
The annual incidence rate of hospitalization for eye injuries is
• 8.1 in Scotland
• 12.6 in Singapore
• 13.2 in the United States
• 15.2 in Sweden

CUMULATIVE LIFETIME PREVALENCE
• The cumulative lifetime prevalence of eye injuries is 860 to 14,400
• Vats et al in their study ( Epidemiological study of ocular trauma in urban slum
population in Delhi) reported a cumulative lifetime prevalence of ocular trauma
at>/= 40 years as 4.5%.
• Incidence of ocular trauma reported by them was 2.4%
• Kuhn F, Pieramici DJ. ocular trauma principals and practice: 2002 :p.14
• Vats S, Murthy GVS, Chandra M, Gupta K, Vashist, Gogoi M. Epidemiological study of ocular trauma in an urban slum
population in Delhi, India. Indian J Ophthalmol. 2008;56:313- 6.

AGE
• The majority of those injured are young adults, with an average age
around 30 years .
• Those sustaining a serious eye injury over the age of 60 years have diﬀerent etiologies
(rate of fall: 23% if over 60 years, 2% if under 60 years, p<0.001).
• injury types (rate of rupture: 31% if over 60 years, 11% if under 60 years, p<.001).

AGE
• Sengupta et al in their study reported adults comprised 79% of the study population.
• Vats et al reported the mean age of participants was 28.21 yrs and the mean age at
which trauma was sustained was 24.2 yrs.
• Study conducted in our hospital ( Open globe injuries : A prospective study of patient
profile and prognostic factors for visual outcome following surgical treatment at a
tertiary eye institution) reported the mean age as 24.28 yrs
• Sengupta P, Mazumdar M, Gyatsho J,. Epidemiology of ocular trauma cases presenting to a tertiary care hospital in a rural area in West
Bengal, India over a period of 2 years. IOSR Journal of Dental and Medical Sciences.2016;15(3):92-97.
• Vats S, Murthy GVS, Chandra M, Gupta K, Vashist, Gogoi M. Epidemiological study of ocular trauma in an urban slum population in Delhi,
India. Indian J Ophthalmol. 2008;56:313- 6.

AGE

GENDER
• The typical male:female ratio is 4:1
• In the USEIR, 79% of injured persons
are males.
• Sengupta et al reported 83.7% of
injured were male.
• Our hospital study reported 74% of
the ocular trauma patients were
males.
• Kuhn F, ocular traumatology.2008 :p 54-55
• Sengupta P, Mazumdar M, Gyatsho J,. Epidemiology of ocular trauma cases presenting to a tertiary care hospital in a rural
area in West Bengal, India over a period of 2 years. IOSR Journal of Dental and Medical Sciences.2016;15(3):92-97.

SOCIOECONOMIC STATUS
• The lower on the societal “ladder” a person is, the higher his risk of suffering an
eye injury is.
• The breaking of rules/laws (e.g., traffic violations, alcohol, or drug use) or
unsettled social status (e.g., unemployment) also signifies an elevated risk.

LITERACY
• Vats et al reported 23.4% of the patients were illiterate.
• Sengupta et al reported 90.6% of patients were literate.
• The study conducted in our hospital reported 26% of the patients were illiterate.
• Sengupta P, Mazumdar M, Gyatsho J,. Epidemiology of ocular trauma cases presenting to a tertiary care hospital in a rural area in West
Bengal, India over a period of 2 years. IOSR Journal of Dental and Medical Sciences.2016;15(3):92-97.
• Vats S, Murthy GVS, Chandra M, Gupta K, Vashist, Gogoi M. Epidemiological study of ocular trauma in an urban slum population in Delhi,
India. Indian J Ophthalmol. 2008;56:313- 6.

RACE
• Among those aged 25-65 years in the U.S., blacks and Hispanics have a 40-60%
higher risk than whites
• In the U.S., blacks have a risk twice as high as whites and a more than twice as
high risk of having visual impairment from injury.
• Per mile traveled, 13 to 19 year-old black and Hispanic male teenagers have a
nearly twice as high risk of dying in an MVC than white teenagers of the same
age.
• Race and socioeconomics have a combined eﬀect.

PLACE
• The significant shift from the
workplace to the home,
identified first by USEIR
researchers
• In some rural areas in developing
countries the workplace remains
the most important site .
Kuhn F, ocular traumatology.2008 :p 56-57

PLACE
• Sengupta et al reported 41.1% of patients suffered injuries at the workplace
including agricultural activities .
• Vats et al reported 33.1% of injuries were sustained at workplace.
• Our hospital study reported most common place of injury was home followed by
workplace

PLACE
Sengupta P, Mazumdar M, Gyatsho J,. Epidemiology of ocular trauma cases presenting to a tertiary care hospital in a rural
area in West Bengal, India over a period of 2 years. IOSR Journal of Dental and Medical Sciences.2016;15(3):92-97

SOURCE
• What the most common object causing a serious eye injury is largely depends on
the location of the study.
• The significance of the study site is also shown by the very diﬀerent national
scenes (U.S., Hungary, Mexico) when comparing injuries caused by pressurized
bottles or by the proportion of injuries inﬂicted by champagne bottle corks.

SOURCE
• Vats et al reported blunt
trauma in 41% of patients.

INTENT
• Assault was the cause in 15% of injuries in the USEIR .
• 1% was self-inﬂicted.
• Firearms were responsible for 71% of all self-inﬂicted ocular trauma.
Kuhn F, ocular traumatology.2008 :p 59-60

INTENT
• As per Vats et al
Assault was the cause in
10.4% of cases
Accidents -81.1%
Self inflicted- 2.5%
• As per Sengupta et al
Assault was the cause in 9%
of cases
Road Accidents -11.2%

OPEN GLOBE V/S CLOSED GLOBE
• Sengupta et al reported
• Closed globe injuries were the commonest 72.2% type of injury.
• Among open globe injuries (27.8%), rupture of the globes was the most common.
Sengupta P, Mazumdar M, Gyatsho J,. Epidemiology of ocular trauma cases presenting to a tertiary care hospital in a rural
area in West Bengal, India over a period of 2 years. IOSR Journal of Dental and Medical Sciences.2016;15(3):92-97

PREVENTION
• It is human nature to presume that although “eye injuries happen, they happen
to somebody else.”
• To be eﬀective, it is this mindset that prevention must change.
• All ophthalmologists have a responsibility to contribute to the fight for preventing
eye injuries by identifying risk factors in general and risky behaviors in particular.

PREVENTION
• The contribution can range from warning a single individual of the dangers in a
given situation to initiating legislation against a more general threat.
• Using common sense in daily life is also crucial.
• Several published reports have identified areas amenable for the introduction of
preventive measures and showed the benefits of such measures.

MVC-RELATED DEATHS AND INJURIES
• Although the number of drivers increased sixfold between 1925 and 1997 in the
U.S., the annual death rate has declined from 18 to 1.7 per 100 million vehicle
miles traveled (a 90% decrease) in the same period.
• Several factors (e.g., better road design, improved driver education, energy
absorbing vehicle systems, the use of laminated, not heat-toughened,
windshields) contributed to the improvement.
• It was primarily the introduction of seat belts and air bags that must be credited.

• Seat belt laws reduced the number of eye injuries by 47-65% and facial fractures
by 9 percentage points in the U.S. where 82% of drivers buckle up.
• Air bags reduce the risk of sustaining an eye injury during a crash by 2.5 times.
• Although air bags may themselves be a source of ocular trauma, this risk is
minimal, especially when compared with the risk of death in the crash.
• In the USEIR, the rate of MVC-related serious eye injuries decreased from 12% in
1995 to 8% in 2005.
MVC-RELATED DEATHS AND INJURIES

SPORTS-RELATED OCULAR TRAUMA
• Ice hockey is a prototype success story.
• Among Canadian youth players, 283 eye injuries were seen in the 1974-1975
season.
• After face visors were mandated, the number of eye injuries dropped by 68%,
and not a single eye was injured if the player wore full-face protection.
• Baseball is a major source in the U.S.
• In one study, a 28% reduction was achieved with a protective device.

SPORTS-RELATED OCULAR TRAUMA
• Racquetball and squash.
• The proportion of these games among all sport-related injury cases was reduced
from 73% in 1982 to 38% in 1987 as proper protective devices were introduced.
• Paintball, an increasingly popular sport, represents a very significant risk of
causing permanent visual loss.
• Proper eye protection is very efficient in preventing it-if the device is actually
worn.
• Golf is not a common cause of eye injury, but if either the club or, more often,
the ball does cause injury, it is very serious, resulting in a 40% enucleation rate.

WAR-RELATED TRAUMA
• The rate of eye injuries among all war-related trauma has steadily increased since
the mid-19th century .
• 1.76% in the Crimean War [1854-1856]
• 6.8% in the Lebanon War [1982]
• 16% in Iraq [2004]
• Not a single eye injury occurred among Israeli Defense Forces soldiers wearing
proper goggles.

FIREWORKS-RELATED OCULAR TRAUMA
• In the USEIR database, 4% of cases are caused by fireworks, and 80% of these
result from bottle rockets.
• States that prohibit private fireworks have a 50-fold reduction in the rate of
injuries as compared to states without such regulation.
• Fireworks can result in very severe injury.

HAMMERING
• In the USEIR database, 4% of all serious trauma are sustained while hammering.
• This statistically significant diﬀerence is most probably due to increased public
awareness in the U.S., emphasizing the danger of this activity and the benefits of
protective devices.

PROTECTIVE EYEWEAR
The ideal device is:
Tailored to a specific purpose (i.e., diﬀerent designs are necessary for
soccer and for racquetball).
 Resistant against major impact (made of 3- or even 4-mm polycarbonate) as well
as against scratching.
Held by a proper frame that does not break or let go.

PROTECTIVE EYEWEAR
Oﬀering frontal as well as side protection without interfering with the field of
view.
Designed to prevent fogging.
 Readily available (e.g., prominently displayed at the checkout counter in home-
improvement stores).
Aﬀordable.

REHABILITATION
• If complete restoration of the injured eye’s visual functions cannot be achieved,
rehabilitation becomes necessary so that the person can utilize his remaining
vision to the fullest extent possible.
• If vision cannot be improved, the person needs rehabilitation.
• e.g. vocational training, psychological support.

SUMMARY
• Collecting epidemiological data on the occurrence of eye injuries allows identification
of trends and societal risk factors and injuries.
• Can help the ophthalmologist play a key role in successfully preventing ocular trauma.
• The USEIR model has proved to be an efficient epidemiological tool.
• Use of this model in other countries has allowed research involving between regions and
even countries.
• Such comparisons have highlighted injury patterns in different geographical areas,
pinpointing areas where prophylaxis (e.g., legislation, public campaigns) was effective.
• If the eye’s functional capability remains seriously depressed despite all reasonable treat
ment eﬀorts, rehabilitation must planned.

Important Considerations in Ocular Trauma Classification

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