Prevention, readiness needed to minimize ocular trauma in variety of conditions

Cesare Forlini, MD, said trauma specialists must be able to care for all parts of the eye. Image: Forlini C

Both general and specialist ophthalmologists should be familiar with the newest, most effective treatments for ocular injuries, experts say.

Ferenc Kuhn, MD, PhD, executive vice president of the International Society of Ocular Trauma and president of the American Society of Ocular Trauma, said prevention is vital for reducing ocular injuries from common household and workplace accidents. General ophthalmologists must educate patients about eye safety, including the importance of eye protection, he said.

“Hopefully do it before, and not after [an injury],” Dr. Kuhn said. “This is something that is so important to emphasize. All of these stores that sell the tools and the equipment and materials have [eye protection] available. It’s just that people don’t make the connection.”

Recent innovations in the field of ocular trauma have helped save more eyes than in the past. The Birmingham Eye Trauma Terminology System and the Ocular Trauma Score, two systems providing a common language and scoring method for ocular trauma for all physicians, have assisted in structuring trauma treatment, Dr. Kuhn said. He helped devise both systems.

In addition, he helped plan the first symposiums at major U.S. and world meetings on ocular trauma from terrorist attacks, including the recent World Ophthalmology Congress in Berlin. He said ophthalmologists are beginning to realize that readiness for future disasters, whatever the cause, is necessary.

“There is definite interest. I think a lot of people realize this problem. They are willing to do whatever they personally can, but this is a problem that is bigger than any single ophthalmologist,” Dr. Kuhn said.

Ocular trauma: One country

A review of 10 population-based, cross-sectional studies on ocular trauma in nonindustrialized countries showed an estimated prevalence of blindness due to eye injury of 0 to 75 per 100,000 people. Bilateral vision loss per 100,000 people was estimated in the range of 30 to 137, with unilateral visual impairment between 0 and 490.

“In India, the annual incidence is 9.75 severe eye injuries per 1,000 adults. The prevalence is higher in rural areas (4.5%) than in urban areas (3.97%),” Sundaram Natarajan, MD, vice president of the Ocular Trauma Society of India, said.

The Aditya Jyot Eye Hospital in Mumbai, of which Dr. Natarajan is a founder, is a well-known center of excellence in ocular trauma, where highly qualified specialists of anterior segment, posterior segment and adnexal trauma offer top-quality services to a large population.

“There are only a few specialized centers in India, definitely inadequate to cover the needs of our large population. Rural areas, which are also densely populated, are quite neglected. We need to provide rural India with structures for emergency care, with appropriately trained manpower and facilities,” he said.

Ocular injuries necessitate a two-step approach: emergency care as soon and as near as possible, and then referral to a specialized center.

“For emergency care, the principle is, ‘The sooner you do the best, the best you get.’ And we need well-trained people to do this. The second step, in our specialized trauma centers, requires a personalized surgical approach tailored to each patient,” he said.

Eye injuries account for approximately 8% to 14% of total injuries in children and are the most common type requiring hospitalization (in up to 40% of cases). Next to amblyopia, ocular injuries are the main reason for preventable monocular visual loss in childhood.

In India, Dr. Natarajan said, cricket is a very popular sport. Children playing cricket do not usually wear eye protection and often sustain blunt injuries to their eyes from the rubber balls that are used.

“It’s a very specific kind of injury that results in a retinal tear at 6 o’clock and peripheral retinal detachment. Many times children don’t tell their parents, and treatment is delayed,” he said.

Homemade bows and arrows are another common cause of ocular injury in India.

There are two festivals in India that are common occasions for eye injury, according to Dr. Natarajan. The first, Holi, celebrates the end of the cold season, he said. People paint their faces as a sign of joy that summer is coming, fill balloons with colored water and throw them at each other.

“The number of chemical injuries from the colors, blunt injuries from the balloons and also penetrating injuries from the instruments used to paint the face is amazingly high,” Dr. Natarajan said. He said that another festival, Diwali, which is a celebration of light, poses high risks for eye injuries from lighting fireworks without taking the necessary precautions.

“We do massive awareness campaigns to prevent these accidents now,” he said.

Managing ocular trauma

General ophthalmologists should have a good working knowledge of ocular injuries, including prevention and treatment of the two most common causes, mechanical and chemical, Dr. Kuhn said. A 2009 report from the American Academy of Ophthalmology’s EyeSmart campaign found that 56% of ocular injuries were treated in ophthalmologists’ offices, and 32% were treated in a hospital emergency department or emergency room.

Emergent eye injuries are often managed by generalists or young doctors without sufficient experience, which often affects the final outcome, Cesare Forlini, MD, said.

“Understanding what should and should not be done is an important first step. Sometimes it’s better to do nothing than take the risk to do something wrong,” he said.

There are emergency departments around the world that can guarantee appropriate management of ocular trauma, but they are becoming the exception rather than the rule.

“The thing is, ocular trauma can’t choose. You go to the nearest hospital, and finding someone who is really able to deal with your problem appropriately is pure chance,” Dr. Forlini said.

Challenge of eye trauma surgery

A member of the International Society of Ocular Trauma and board member for the Italian Society of Ocular Trauma, Dr. Forlini expressed concern about current trends. Not only are governments cutting back on resources, but ocular traumatology as a subspecialty could become a derelict field of practice, he said. Fewer ophthalmologists choose to specialize in ocular trauma, and fewer schools are equipped to offer the appropriate training.

“Trauma care costs far more money than it earns and is extremely demanding in terms of time, surgical skill and dedication,” Dr. Forlini said. “As a discipline, it goes against the tide, because medicine is increasingly fragmented in super-specialized areas of knowledge and intervention, while ocular trauma requires a wide, global knowledge and experience of the eye as a whole, beyond the traditional boundaries of anterior and posterior segment.”

Trauma surgery is pole-to-pole surgery, a term that Dr. Forlini has popularized. Trauma specialists must be able to care for all parts of the eye and to coordinate a complex variety of surgical actions. They must “move in the eye like a dancer, because trauma surgery is not like climbing a ladder in a linear sequence of preset maneuvers, but performing on a stage where the hand moves in all directions,” Dr. Forlini said. “Mostly, medical schools don’t prepare people to do this.”

Dr. Forlini founded the “High School of Ocular Trauma,” a small group of specialists who volunteer to train younger physicians who are interested in ocular traumatology.

“We organize symposia but need to broaden our scope and give [trainees] the opportunity to practice,” Dr. Forlini said. “Some of us periodically open our operating rooms to young specialists. They see what we do, can be involved in performing a few surgical maneuvers, but we need, of course, a more official, better and broader organization.”

Prevalence, causes, prevention

Common reasons for ocular injury in the U.S. include fireworks, motor vehicle crashes and lawn maintenance. The majority of injuries in the U.S. result from accidents, with a lesser number caused by assaults. According to the 2009 EyeSmart report, an estimated 48% of injuries in the U.S. happened in the home, and of those, about one-third were due to recreation or sports. No general ocular trauma statistics are available for Europe and the Asia-Pacific region, but numerous hospital-based surveys have been carried out in individual countries or specific areas.

A large study by Schrader analyzed the prevalence of open-globe injuries in patients treated at two university eye clinics in Germany over 2 decades. Occupational injuries decreased from 42% to 32% in that time, according to the study.

“Generally speaking, work-related eye injuries are on the decline but still highly prevalent in some countries,” Dr. Forlini said. “Compliance with safety regulations is related to several factors, such as appropriate information, awareness, risk perception, working conditions and, last but not least, supervision. Safety legislation is now quite uniform across Europe, but these factors may vary considerably.”

The same study reported that since 1984, when seat belt legislation became effective, the number of eye injuries decreased by 83%.

On the other hand, home injuries, particularly those related to do-it-yourself projects and gardening, are increasingly common. A study conducted at the University of Birmingham, U.K., found that 41.2% of penetrating ocular injuries occurred in the home. Accidents from do-it-yourself home projects or gardening were the cause of 51.5% of the cases. None of the patients were wearing eye protection at the time they were injured. The authors noted that overall, do-it-yourself stores and garden centers were inadequate at promoting eye safety in stores and on company websites.

A growing phenomenon in Europe is increased eye trauma occurring on Saturday nights, due to intoxicated driving and riots, Dr. Forlini said.

“We are dealing with an increasing number of such cases. Moreover, hospitals work with reduced forces at weekends, and this further reduces the chances of getting appropriate treatment. As a result, many young people sustain permanent damage, which is often both visual and aesthetic,” he said.

Fireworks continue to be a major cause of severe eye injury around New Year’s Day and other celebrations.

The Netherlands Society of Ophthalmology reported a total of 268 patients with 315 eye injuries caused by fireworks during New Year’s 2009. More than half of the patients were bystanders and 60% were minors between the ages of 3 years and 17 years. One-third of the eyes sustained permanent damage. In 47 eyes, the extent of the damage was such that it led to irreversible loss of vision, with complete loss of vision in 24 eyes. Fifteen of these 24 eyes were surgically removed.

According to the report, “The [Netherlands Society of Ophthalmology] believes that the current policy of tolerance regarding fireworks makes the risk of eye injuries to which the Dutch population is exposed too high. As long as consumer fireworks are allowed, the [Netherlands Society of Ophthalmology] advises that protective polycarbonate glasses should be worn while lighting and watching fireworks.”

A prospective survey promoted by the British Ophthalmological Surveillance Unit and involving all ophthalmologists in the U.K. registered a peak of firework injuries (81%) in October and November. A large number of victims were minors and males. Injuries were mostly severe, leading to visual acuity of 20/200 or worse in more than 50% of the cases.

Statistics from around the world show that young age and male sex are risk factors for ocular injuries of all types and in all environments and situations.

Mass-casualty incidents

Preparedness is necessary to effectively treat ocular injuries sustained in mass-casualty emergencies, including natural disasters and terrorist attacks, experts say. These injuries are likely to be treated by general ophthalmologists and subspecialists because of limited access to care outside the immediate vicinity. General ophthalmologists should have up-to-date skills in treating facial injuries, including injuries to the globe and eyelid, retired U.S. Army Col. Robert Mazzoli, MD, said.

For instance, natural disasters such as the Haitian earthquake and Hurricane Katrina have presented sudden, serious ocular trauma. Other incidents, such as the recent oil spill in the Gulf of Mexico, can present potential for ocular damage. Oculoplastic specialist Philip R. Rizzuto, MD, FACS, working with Project Medishare in conjunction with University of Miami Global Health Initiative and Bascom Palmer Eye Institute, was asked to assist with the relief effort in Haiti. He said that eye and facial injuries that he encountered related to the earthquake included superficial and complex eyelid lacerations, trauma to the lacrimal drainage system, and multiple facial lacerations. Complex injuries included facial and orbital fractures, ruptured globes, and traumatic visual loss related to blunt trauma.

“Hospital facilities, especially those in larger U.S. cities, should be prepared for mass-casualty situations,” Dr. Mazzoli said. “A working plan for ocular trauma disaster treatment is key.”

According to the 2009 report of the National Counterterrorism Center, approximately 11,000 terrorist attacks occurred in 83 countries during 2009, resulting in over 58,000 victims, including nearly 15,000 fatalities. The largest number of attacks occurred in South Asia and the Near East, which also had the highest number of casualties.

Ocular injuries are increasingly being recognized in association with terrorist acts and may be associated with anatomical and functional morbidity, Salil Mehta, MD, said.

“Despite the fact that the eye is relatively small, being only 0.1% of the frontal surface area, ocular injuries are common and may be seen in 3% [to] 10% of survivors of terrorist blasts,” Dr. Mehta said.

In a retrospective study, Dr. Mehta and colleagues reported on the ocular injuries of 28 patients who survived the Mumbai, India train bombings in July 2006. A series of seven bomb blasts took place over a period of 11 minutes on the Mumbai Suburban Railway. More than 200 people lost their lives and more than 700 were injured. Of the 28 patients seen at Lilavati Hospital, 16 (57.1%) had ocular injuries.

The most common ocular injuries were periorbital hemorrhages, eyelid burns and corneal wounds. Open-globe injuries were seen in two eyes of two patients, and one patient had a traumatic optic neuropathy.

The terrorist bombings in Madrid, Spain in March 2004 caused the largest loss of life from a single terrorist attack on European soil in modern history, killing 191 people. A total of 2,051 people were injured.

A study of the seven hospitals that received the most victims following the Madrid bombings reported that the most frequently injured body regions were the head, neck and face. Eye injuries were frequent (18%), although most were mild to moderate in severity.

“Emergency management planners and emergency physicians should be aware of these patterns of ocular injuries following mass-casualty incidents. Protocols need to include the screening of large numbers of patients in a short time, diagnostic tests and early surgery, preferably performed in the [emergency department] to allow early specific treatment and minimize the risk of missed ocular injuries,” Dr. Mehta said.

Adiel Barak

Creating a plan for treating mass casualties has assisted the ophthalmology department in the Tel Aviv Medical Center in Israel, where Adiel Barak, MD, is head of the vitreoretinal service.

Dr. Barak said that following a mass-casualty incident in Tel Aviv, all physicians report to the emergency room at the medical center. Ophthalmologists examine patients for eye injuries, especially those who have head injuries or are unconscious.

“The main thing you have to do is prepare the hospitals,” Dr. Barak said. “We speak mostly about terrorist-related injuries because that’s more that you’ll see in the West, but it can happen if you have a bus crash. … You have to find your way to work through the system and prepare for it, because as ophthalmologists, we’re not used to working with other doctors. We’re used to sitting in our quiet room and working by [ourselves].” – by Erin L. Boyle and Michela Cimberle

What should be done to ensure that non-ophthalmologist medical personnel are properly trained to recognize and treat ocular traumatic injuries? How much treatment should they administer?

References:

• Barak A, Verssano D, Halpern P, Lowenstein A. Ophthalmologists, suicide bombings and getting it right in the emergency department. Graefes Arch Clin Exp Ophthalmol. 2008;246(2):199-203.
• Bhogal G, Tomlins PJ, Murray PI. Penetrating ocular injuries in the home. J Public Health (Oxf). 2007;29(1):72-74.
• De Faber JT. Fireworks injuries treated by Dutch ophthalmologists New Year 2008/’09. Ned Tijdschr Geneeskd. 2009;153:A507.
• Knox FA, Chan WC, Jackson AJ, Foot B, Sharkey JA, McGinnity FG. A British Ophthalmological Surveillance Unit study on serious ocular injuries from fireworks in the UK. Eye (Lond). 2008;22(7):944-947.
• Frykberg ER. Medical management of disasters and mass casualties from terrorist bombings: how can we cope? J Trauma. 2002;53(2):201–212.
• Kuckelkorn R, Schrage N, Keller G, Redbrake C. Emergency treatment of chemical and thermal eye burns. Acta Ophthalmol Scand. 2002;80(1):4-10.
• Kuhn F, Morris R, Witherspoon CD, Mester V. The Birmingham Eye Trauma Terminology system (BETT). J Fr Ophtalmol. 2004;27(2):206-210.
• Kuhn F, Maisiak R, Mann L, Mester V, Morris R, Witherspoon CD. The Ocular Trauma Score (OTS). Ophthalmol Clin North Am. 2002;15(2):163-165, vi.
• Larque-Daza AB, Peralta-Calvo J, Lopez-Andrade J. Epidemiology of open-globe trauma in the southeast of Spain. Eur J Ophthalmol. 2010;20(3):578-583.
• Mines M, Thach A, Mallonee S, Hildebrand L, Shariat S. Ocular injuries sustained by survivors of the Oklahoma City bombing. Ophthalmol. 2000;107(5):837-843.
• Mehta S, Agarwal V, Jiandani P. Ocular injuries of improvised explosive devices (IED) in commuter trains. BMC Emerg Med. 2007;7:16.
• Schrader WF. Epidemiology of open globe eye injuries: analysis of 1026 cases in 18 years. Klin Monbl Augenheilkd. 2004;221(8):629-635.
• Smith GS, Barss P. Unintentional injuries in developing countries: the epidemiology of a neglected problem. Epidemiol Rev. 1991;13:228-266.
• Thach A. Eye injuries associated with terrorist bombings. Dept. of the Army; 2003:421-429.
• The National Counterterrorism Center. 2009 NCTC Report on Terrorism. http://www.nctc.gov/witsbanner/docs/2009_report_on_terrorism.pdf. Published April 30, 2010.
• Turégano-Fuentes F, Caba-Doussoux P, Jover-Navalón JM, et al. Injury patterns from major urban terrorist bombings in trains: the Madrid experience. Wold J Surg. 2008;32:1168-1175.

• Adiel Barak, MD, is head of vitreoretinal service at the Tel Aviv Medical Center in Israel. He can be reached at +972-3-6973408; e-mail: adielbarak@gmail.com.
• Cesare Forlini, MD, is head of the Ophthalmology Department, Hospital Santa Maria delle Croci, Viale Randi 43, 48100 Ravenna, Italy. He can be reached at +39-0544-270385; fax: +39-0544-280049; e-mail: forlinic@forlinic.it.
• Ferenc Kuhn, MD, can be reached at 1201 11th Ave. South, Suite 300, Birmingham, AL 35202, U.S.A.; +1-205-558-2588; fax: +1-205-933-1341; e-mail: fkuhn@mindspring.com.
• Robert Mazzoli, MD, can be reached at robert.mazzoli@comcast.net.
• Salil Mehta, MD, can be reached at Department of Ophthalmology, Lilavati Hospital and Research Centre, Mumbai, India; e-mail: doc@retinaconsultant.com.
• Sundaram Natarajan, MD, can be reached at Aditya Jyot Eye Hospital, Plot No. 153, Road No. 9, Major Parmeshwaran Road, Opp S.I.W.S. College Gate No. 3, Wadala, Mumbai 400 031, India; +91-22-24181001; fax: + 91-22-24177630; e-mail: cmdajeh@gmail.com.
• Philip R. Rizzuto, MD, FACS, is clinical assistant professor of surgery, the Warren Alpert Medical School of Brown University and Ophthalmic Plastic Surgery. He can be reached at 120 Dudley St., Suite 301, Providence, RI 02905, U.S.A.; +1-401-274-6622; fax: +1-401-490-7051; e-mail: prizzuto@eyeplasticri.com.