Abstract
Background
Traumatic eye injuries are an important cause of visual impairment and can significantly affect patients’ quality of life. Accounting for approximately 7% of all bodily injuries and 10–15% of ocular diseases, traumatic eye injuries pose a substantial medical and socioeconomic burden. This study aimed to evaluate the clinical and radiological characteristics of traumatic open-globe injuries (OGIs) that resulted in either primary enucleation/evisceration or primary repair at a tertiary hospital in Mogadishu, Somalia.
Methods
This retrospective study was conducted at Mogadishu Somalia Turkey Training and Research Hospital and included 52 eyes of 51 patients treated for traumatic OGIs between January 2020 and June 2022. Twenty-four eyes underwent primary enucleation/evisceration, while 28 eyes underwent primary repair. Continuous variables were compared using independent sample t-tests, and categorical variables were analyzed with the Pearson Chi-square test. Hierarchical regression analyses were performed to assess the association between surgical approach and selected clinical and radiological parameters. Statistical significance was defined as p < 0.05.
Results
Initial regression analysis revealed that initial visual acuity, cause of injury, and concomitant orbital fracture significantly predicted the surgical approach [F(4,44) = 23.440, p < 0.001], accounting for 70.1% of the variability. Initial visual acuity (B = 0.306, p = 0.008), cause of injury (B = 0.269, p = 0.010), and orbital fracture (B=-0.508, p < 0.001) were significant predictors. A second regression model incorporating orbital wall fracture components explained 74.8% of the variability [F(8,40) = 13.600, p < 0.001], with orbital roof fracture (B=-0.343, p = 0.008) emerging as a key factor.
Conclusions
Initial visual acuity, cause of injury, and the presence of orbital fractures were significantly associated with the choice of primary surgical approach in traumatic OGIs. In particular, orbital roof fractures were identified as an important radiological factor influencing surgical decision-making.
Keywords: Open-globe injuries, Enucleation, Evisceration, Ocular trauma, Globe rupture
Background
Eye injuries are among the most prevalent causes of vision loss and play a significant role in diminishing patients’ overall quality of life [1, 2]. Even minor ocular traumas can lead to significant pain and discomfort, loss of work capacity, and increased healthcare costs [3]. Despite the advances in diagnosis and treatment methods, eye traumas remain socially and economically serious [4]. Eye traumas account for 7% of all body injuries and 10–15% of all eye diseases. Eye trauma is a significant public health concern that imposes a substantial functional, medical, and socioeconomic burden on both patients and society, yet remains largely preventable [1].
Blunt traumas such as hitting, impacting, and squeezing can damage almost all eye tissues. It may cause globe rupture due to closed globe injury. Traffic accidents, work accidents, fights, explosives, and sports injuries (tennis, boxing, etc.) are among the causes of blunt trauma. Diagnosing disorders and keeping records effectively determine post-traumatic visual prognosis [5].
Eye injuries because of ocular trauma are a major cause of unilateral blindness worldwide. A hospital-based study reported that the most common cause of monocular blindness is related to trauma complications (23.6%) in the adult Somali population [6]. To date, only one study has been reported on traumatic eye injuries in Somalia, indicating that the majority of ocular injuries following the 2019 bomb explosion consisted of open-globe injuries (OGIs) [7]. Traumatic injuries have been together with long-term sequelae, such as impaired quality of life and lack of productivity for victims [8]. OGI is an ocular emergency experienced by both general practitioners and ophthalmologists.
Recent histopathologic studies elucidate that ocular trauma has become the main indication for enucleation or evisceration (enucleation/evisceration) worldwide, followed by phthisis bulbi and endophthalmitis [9]. Violent and destroying injuries may initially or ultimately require the removal of the affected eye with enucleation/evisceration. When patients present at the emergency department with no light perception (NLP), the ophthalmologist must decide whether to go on with surgeries to salvage the globe or think about primary enucleation/evisceration. Primary enucleation/evisceration should be postponed if there is a minimal possibility to recover the globe. Nonetheless, enucleation/evisceration should be considered in patients with a visual acuity of NLP so as to avoid sympathetic ophthalmia or decrease pain [10]. However, ophthalmologists do not have accepted definitive guidelines when primary enucleation/evisceration should be considered in cases of ocular trauma [11].
While several previous studies have investigated clinical features, predictive factors, and outcomes for enucleation/evisceration and primary repair in ocular traumas [12–14], none have yet compared clinical and radiological factors resulted in primary removal versus primary repair of the globe to the best of our knowledge. In our clinical experience, OGIs identified as rupture-type wounds, with concomitant orbital fractures, resulting from blunt trauma due to gunshot and/or bomb explosion tend to result in removal of the globe. This study aimed to analyze the clinical and radiological characteristics of traumatic OGIs that resulted in primary enucleation/evisceration or primary repair at a tertiary hospital in Mogadishu, Somalia.
Methods
This retrospective study was conducted at Mogadishu Somalia Turkey Training and Research Hospital, the main tertiary referral center in Mogadishu, Somalia. The hospital is also the only institution in the country providing medical residency training. The ophthalmology department manages approximately 5,000–6,000 outpatient visits annually. The study analyzed 41 patients who underwent primary enucleation/evisceration versus primary repair due to traumatic OGIs between January 2020 and June 2022.
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008. Ethics committee approval has been granted from our institution with protocol number MSTH/11,047. As this was a retrospective study, informed consent from participants was not required. Written informed consent was obtained from the patient for the publication of the anterior segment photographs and computed tomography images.
Patients were identified in the hospital’s electronic database by searching for the “enucleation/evisceration” code. Seventeen patients who underwent enucleation/evisceration for non-traumatic reasons such as blindness, painful eye, ocular malignancy, and endophthalmitis were excluded. As a comparison group, we reviewed the medical records of 31 patients who underwent primary repair during the same period. Patients were identified by “primary repair of penetrating globe injuries” coding. Three individuals with inadequate clinical information and/or radiographic imaging were excluded. Furthermore, due to the lack of sufficient clinical and demographic data prior to 2020, traumatic OGIs occurring before this date were excluded from the study. As a result, 52 eyes of 51 patients were included in the study, of which 24 eyes underwent primary enucleation/evisceration and 28 eyes underwent primary repair.
For each study group, the clinical data were reviewed including patient demographics, eye laterality, initial visual acuity, type of injury, cause of injury, location of wound, and presence of concomitant orbital fracture. To identify location of wound, the subgroups are classified according to the position of the most posterior point of the full-thickness wound of the globe: Zone 1 [the most posterior point is restricted to the cornea (involving the corneoscleral limbus)], Zone 2 [no more posterior than 5 mm from the corneoscleral limbus], Zone 3 [wound involving posterior of that in Zone 2], and Multiple Zones [cases with injuries involving at least 2 zones]. Radiological variables included the anatomical location of orbital fractures (orbital floor, medial orbital wall, lateral orbital wall, orbital roof, and orbital rim), as determined from orbital computed tomography imaging. A representative case from the study cohort was selected to illustrate the clinical and radiological findings associated with different surgical approaches (Fig. 1).
Fig. 1.
Representative case of bilateral traumatic OGI following a blast. A 35-year-old male soldier presented three days after a blast with severe bilateral ocular trauma. At presentation, visual acuity was LP in the right eye and NLP in the left eye. The patient underwent primary corneal repair, lens aspiration, anterior vitrectomy, and sulcus implantation of a three-piece intraocular lens in the right eye. Due to irreparable globe damage, primary evisceration with orbital implant placement was performed in the left eye during the same surgical session. (a) Orbital computed tomography demonstrated preserved globe contour with disruption of the crystalline lens in the right eye (white arrow), whereas the left globe showed complete structural disruption (white star). (b) Anterior segment photograph at presentation showing iris tissue incarcerated at the foreign body entry site (white arrow), traumatic cataract with anterior capsule perforation, and a retained organic foreign body in the inferior anterior chamber (white arrowhead). (c) Slit-lamp photograph of the left eye demonstrating extensive sclero-corneal rupture with complete loss of globe integrity
In cases in which intraocular foreign bodies (IOFBs) were present, the surgical decision-making followed the same principles applied to other injuries. Patients with potentially salvageable eyes underwent primary repair and were subsequently followed up. Because vitreoretinal surgical facilities were not available at our institution, patients with retained IOFBs were referred to vitreoretinal surgery centers abroad for secondary foreign body removal and further management. In eyes undergoing primary globe removal, IOFBs were removed during the same surgical procedure.
Statistical analysis
Patient data collected within the scope of the study were analyzed with the IBM Statistical Package for the Social Sciences (SPSS) for Windows 23.0 (IBM Corp., Armonk, NY) package program. Frequency and percentage for categorical data and mean and standard deviation for continuous data were given as descriptive values. For group comparisons, an independent sample t-test was applied to continuous variables between two groups, while categorical variables were analyzed using the Pearson Chi-square test. Statistical significance was defined as a p-value less than 0.05. Additionally, hierarchical regression analyses were conducted to evaluate the association between the primary surgical approach (enucleation/evisceration vs. primary repair) and selected clinical and radiological parameters, with significance again set at p < 0.05.
Results
Twenty-four eyes underwent primary enucleation/evisceration, and 28 eyes underwent primary repair surgery. Most patients in both groups were male (for primary enucleation/evisceration, n = 21, 87.5%; for primary repair, n = 19, 67.8%). The mean age of the patients was 24.62 ± 14.0 years (range 1–65 years). There were no significant differences between primary enucleation/evisceration and primary repair groups regarding gender (p = 0.094) and laterality (p = 0.797). Baseline demographics of patients involved in our study are denoted in Table 1.
Table 1.
Characteristics of traumatic OGIs by age, gender, and laterality
| Total eyes (n = 52) | Primary enucleation/ evisceration (n = 24) | Primary repair (n = 28) | p-value | |
|---|---|---|---|---|
| Age, mean years (SD) | 24.62 (14.0) | 27.21 (10.59) | 22.39 (16.35) | 0.438 |
| Range | (1–65) | (2–61) | (1–65) | |
| Gender, n (%)a | 0.094 | |||
| Male | 40 (76.9) | 21 (87.5) | 19 (67.8) | |
| Female | 12 (23.1) | 3 (12.5) | 9 (32.2) | |
| Laterality, n (%) | 0.797 | |||
| Right | 27 (51.9) | 12 (50.0) | 15 (53.5) | |
| Left | 25 (48.1) | 12 (50.0) | 13 (46.5) |
a Gender distribution is reported according to the number of affected eyes
SD: Standard deviation
The most common causes of injury were gunshots (n = 11, 45.8%) and bomb explosions (n = 10, 41.6%) in the primary enucleation/evisceration group and home accidents (n = 10, 35.7%) and bomb explosions (n = 9, 32.1%) in primary repair group. A representative case of bilateral traumatic OGI following a blast is presented in Fig. 1. A significant relationship was found between injury causes and surgical approach [X2(5, 52) = 27.239, p < 0.001]. The most frequent type of injury was rupture (n = 14, 58.5%) in the primary enucleation/ evisceration group. It was revealed as penetration (n = 15, 53.5%) in the primary repair group. The type of injury was significantly determined by surgical approach in both groups [X2(3, 52) = 19.344, p < 0.001].
On average, the primary enucleation/evisceration group had worse initial visual acuities than the primary repair group. All eyes (n = 24, 100%) undergoing primary enucleation/evisceration had NLP vision. 64% of eyes (n = 18) undergoing primary repair had light perception (LP) to hand movement (HM) vision, followed by NLP vision in five (17.8%) eyes, counting fingers (CF) to 20/200 vision in three (10.7%) eyes, and > 20/40 vision in two (7.1%) eyes, respectively. A significant relationship was found between initial visual acuity and surgical approach [X2(3, 52) = 35.350, p < 0.001].
The location and extent of OGIs differed between primary enucleation/evisceration and primary repair groups. In all eyes in the primary enucleation/evisceration group, the location of the wound was involved in both Zone 2 (100.0%, n = 24) and multiple zones (100.0%, n = 24), followed by Zone 3 in 20 (83.3%) eyes and Zone 1 in 18 (75.0%) eyes. Zone 1 was the most affected location (n = 17, 60.7%) in eyes undergoing primary repair, followed by Zone 2 in 16 (57.1%) eyes, Multiple Zones in 7 (25.0%) eyes, and Zone 3 in 3 (10.7%) eyes. Except for Zone 1 injury, a significant relationship was found between the location of the wound and surgical approach [(Zone 2:X2(1, 52) = 13.371, p < 0.001), (Zone 3:X2(1, 52) = 27.628, p < 0.001), (multiple zones: X2(1, 52) = 30.194, p < 0.001)].
The presence of concomitant orbital fracture was significantly different between two groups [(for primary enucleation/evisceration n = 21, 87.5%), (for primary repair n = 3, 10.7%), p < 0.001]. Medial orbital wall was the most commonly affected (n = 19, 79.1%) in the primary enucleation/evisceration group, followed by orbital roof (n = 17, 70.8%), orbital floor (n = 13, 54.1%), lateral orbital wall (n = 13, 54.1%), and orbital rim (n = 7, 29.1%). Characteristics of traumatic OGIs in patients undergoing primary enucleation/evisceration or primary repair are elaborated in Table 2.
Table 2.
Characteristics of traumatic OGIs in patients undergoing primary enucleation/evisceration or primary repair
| Total Eyes (n = 52) | Primary Enucleation/ Evisceration (n = 24) | Primary Repair (n = 28) | p-value | |
|---|---|---|---|---|
| Cause of injury, n (%) | < 0.001 | |||
| Blast | 19 (36.5) | 10 (41.6) | 9 (32.1) | |
| Gunshot | 11 (21.2) | 11 (45.8) | 0 (0.0) | |
| Motor vehicle accident | 4 (7.7) | 1 (4.2) | 3 (10.8) | |
| Assault with a sharp object | 3 (5.8) | 2 (8.4) | 1 (3.6) | |
| Home Accident | 10 (19.2) | 0 (0.0) | 10 (35.7) | |
| Undefined | 5 (9.6) | 0 (0.0) | 5 (17.8) | |
| Type of injury, n(%) | < 0.001 | |||
| Rupture | 19 (36.5) | 14 (58.5) | 5 (18.0) | |
| Penetration | 17 (32.7) | 2 (8.3) | 15 (53.5) | |
| IOFB | 12 (23.1) | 4 (16.6) | 8 (28.5) | |
| Perforation | 4 (7.7) | 4 (16.6) | 0 (0.0) | |
| Visual acuity at presentation, n (%) | < 0.001 | |||
| NLP | 29 (55.8) | 24 (100.0) | 5 (17.8) | |
| LP to HM | 18 (34.6) | 0 (0.0) | 18 (64.4) | |
| CF to 20/200 | 3 (5.8) | 0 (0.0) | 3 (10.7) | |
| > 20/40 | 2 (3.8) | 0 (0.0) | 2 (7.1) | |
| Location of the wound, n(%)a | ||||
| Zone 1 | 35 (67.3) | 18 (75.0) | 17 (60.7) | 0.274 |
| Zone 2 | 40 (76.9) | 24 (100.0) | 16 (57.1) | < 0.001 |
| Zone 3 | 23 (44.2) | 20 (83.3) | 3 (10.7) | < 0.001 |
| Multiple zones | 31 (59.6) | 24 (100.0) | 7 (25.0) | < 0.001 |
| Concomitant orbital fracture, n (%)b | 24 (46.2) | 21 (87.5) | 3 (10.7) | < 0.001 |
| Orbital Floor | 16 (30.8) | 13 (54.1) | 3 (10.7) | 0.001 |
| Medial Orbital Wall | 22 (42.3) | 19 (79.1) | 3 (10.7) | < 0.001 |
| Lateral Orbital Wall | 14 (26.9) | 13 (54.1) | 1 (3.5) |
< 0.001 < 0.001 0.002 |
| Orbital Roof | 17 (32.7) | 17 (70.8) | 0 (0.0) | |
| Orbital Rim | 7 (13.5) | 7 (29.1) | 0 (0.0) |
Note: a Many patients have more than one zone b Many patients have more than one orbital wall fracture. NLP, no light perception; LP, light perception; HM, hand movement; CF, counting fingers; IOFB, intraocular foreign body
The first regression model including initial visual acuity, type of injury, cause of injury, and the presence of concomitant orbital fracture accounted for 70.1% of the variance in the surgical approach [F(4,44) = 23.440, p < 0.001] (Table 3). In this model, initial visual acuity (B = 0.306, t = 2.794, p = 0.008), cause of injury (B = 0.269, t = 2.679, p = 0.010), and the presence of concomitant orbital fracture (B=-0.508, t=-4.425, p < 0.001) were significant predictors of the primary surgical approach.
Table 3.
Hierarchical regression analysis of factors associated with surgical approach
| Model | Independent variables | B | t | p | F | df | R 2 | Model p |
|---|---|---|---|---|---|---|---|---|
| 1 | Initial Visual Acuity | 0.306 | 2.794 | 0.008 | 23.440 | 4, 44 | 0.701 | < 0.001 |
| Cause of Injury | 0.269 | 2.679 | 0.010 | |||||
| Concomitant Orbital Fracture | -0.508 | -4.425 | 0.000 |
Note: Surgical approach is the dependent variable (0 = primary repair, 1 = primary enucleation/evisceration)
The reference category is primary repair
The second regression model, which additionally incorporated orbital wall fracture components, accounted for 74.8% of the variance in the surgical approach [F(8,40) = 13.600, p < 0.001] (Table 4). Initial visual acuity, cause of injury, and the presence of orbital roof fracture significantly predicted the primary surgical approach, with respective coefficients of (B = 0.309, t = 3.035, p = 0.004), (B = 0.246, t = 2.476, p = 0.018), and (B=-0.343, t=-2.788, p = 0.008).
Table 4.
Hierarchical regression analysis including orbital wall fracture components
| Model | Independent variables | B | t | p | F | df | R 2 | Model p |
|---|---|---|---|---|---|---|---|---|
| 1 | Initial Visual Acuity | 0.309 | 3.035 | 0.004 | 13.600 | 8, 40 | 0.748 | < 0.001 |
| Cause of Injury | 0.246 | 2.476 | 0.018 | |||||
| Orbital Roof Fracture | -0.343 | -2.788 | 0.008 |
Note: Surgical approach is the dependent variable (0 = primary repair, 1 = primary enucleation/evisceration)
The reference category is primary repair
Discussion
We investigated the demographic, clinical, and radiological characteristics of traumatic OGIs that resulted in primary enucleation/evisceration or primary repair at a tertiary care hospital in Mogadishu, Somalia. It is the only tertiary hospital where most traumatic injuries in and around Mogadishu are referred. To the best of our knowledge, no prior study has examined the association between enucleation/evisceration and traumatic OGIs in this region of Africa. Our findings indicate that blast and gunshot-related injuries, as well as rupture-type injuries, are significantly more likely to necessitate primary globe removal.Visual acuity with NLP at presentation, a posterior location of globe injury (Zone 2 and/or Zone 3 and multiple zones), and concomitant orbital fracture were also independently associated with primary globe removal. In addition, hierarchical regression analysis showed that initial visual acuity, cause of injury, and the presence of concomitant orbital fracture were significantly associated with the likelihood of primary enucleation/evisceration. In the model incorporating orbital wall fracture components, orbital roof fracture also emerged as a significant predictor of primary surgical approach.
In most cases with OGIs, primary globe removal should be avoided at initial presentation whenever there is a reasonable possibility of globe salvage. Patients and their families may find it difficult to accept the permanent loss of a vital organ, and primary repair may save the patient time in deciding on subsequent enucleation/evisceration. One study found that 14% of patients got a final visual acuity of between 20/50 and 20/200 [15]. Contrary to this, 58% of patients who underwent primary globe repair presented with NLP vision, and none regained vision after the repair in another study [16]. In our research, most patients (n = 24/29) who presented with NLP vision underwent primary enucleation/evisceration. This high rate of primary globe removal in our study might be related to the high number of OGIs due to gunshots and blasts, which are often difficult or impossible to repair caused by extensive loss of intraocular contents, similar to the report by Vaca et al. [17].
While blasts and gunshots were the most prevalent etiology in the primary enucleation/evisceration group, home accidents and blasts were more common in the primary repair group. Blasts or explosions usually account for a small percentage of perforating globe injuries in civilian trauma [18]. Most injuries occur at home and the workplace, as defined in the literature [19]. In contrast, assault and gunshots were reported as the most common etiological factors in trauma-related globe removal surgeries in the USA [20].
Due to the prolonged civil conflict and recurrent terrorist incidents in Somalia, the majority of severe eye injuries are attributed to bomb explosions and gunshot-related assaults. Unlike home and workplace injuries, bullet fragments or shrapnel entering the eye have a greater force, which can cause substantially more ocular damage. Other studies have indicated that blast-related injuries result in poor functional outcomes because of the surgical complexities and extensive blunt ocular damage [21]. In light of this, our study found that blast and gunshot-related OGIs most likely result in primary globe removal in Somalia.
In our study, rupture-type injury portended a higher risk of primary enucleation/evisceration. Similar results were also reported by Ojuok et al. [22]. They identified rupture-type injury as three times more risky for globe removal than penetrating injury. Another study on OGIs stated that eyes with ruptures were significantly more likely to be enucleated than those with injuries leading to lacerations [23]. Because of this poor visual prognosis, rupture-type injury is used as a prognostic variable to estimate the ocular trauma score [24].
Our study identified that concomitant orbital fractures and posterior wound location in traumatic OGIs were significantly more prevalent in the primary enucleation/evisceration group, consistent with the findings reported by Gaier et al. [25]. In our cohort, all patients who underwent primary globe removal (n = 24/24) sustained ocular injuries involving Zone 2 and multiple anatomical zones. Previous studies have reported that patients with orbital roof fractures are more likely to present with injuries involving multiple globe zones [25, 26]. In our study, no patients in the primary repair group presented with orbital roof fractures, whereas 70.8% of those who underwent primary enucleation/evisceration had such fractures. Compared to the orbital floor and medial wall, greater force is required to create orbital roof fracture. Consequently, involvement of the orbital roof may inherently be associated with more severe and extensive ocular injuries. Blunt trauma mechanisms associated with blasts and gunshots directed at the periorbital region are more likely to result in rupture-type injuries, characterized by extensive posterior scleral involvement and uveal prolapse. As a result, Zone 2 and Zone 3 injuries were significantly more prevalent among patients who underwent primary enucleation/evisceration.
Recent studies have employed regression analysis to identify prognostic factors influencing visual outcomes in OGIs [27, 28]. It has been shown that concomitant orbital fracture, poor initial visual acuity, zone 3 injury, and rupture-type injury were poor prognostic factors in final visual acuity. We wanted to analyze these clinical data in patients with traumatic OGI undergoing primary enucleation/evisceration or primary repair. Hierarchical regression analysis of the demographic and clinical characteristics in our cohort demonstrated that initial visual acuity, cause of injury, and the presence of concomitant orbital fracture were statistically significant predictors of the selected primary surgical approach (R2: 0.701, p < 0.001). Consistent with our findings, Ojuok et al. reported that rupture-type injuries were associated with a higher likelihood of enucleation compared to penetrating injuries [22].
Several limitations should be considered when interpreting the findings of this study. First, the retrospective design may have resulted in incomplete documentation and potential information bias. Second, this was a single-center study conducted at a tertiary referral hospital that receives a high proportion of severe ocular trauma cases, which may limit the generalizability of the results. Finally, the exact time interval between injury and surgical intervention could not be reliably determined for all patients and was therefore not included in the analysis.
Conclusions
In patients presenting with severe ocular trauma, identifying factors associated with an increased likelihood of primary globe removal may assist surgeons in clinical decision-making. In our cohort, rupture-type injuries, NLP vision at presentation, posterior zone involvement, and concomitant orbital fractures were more frequently observed in eyes that underwent primary enucleation/evisceration. Initial visual acuity, cause of injury, and the presence of concomitant orbital fractures were also associated with the choice of primary surgical approach in traumatic OGIs.
Acknowledgements
The authors would like to thank Samet Kose (MD, PhD, Assoc. Prof. of Psychiatry and Neuroscience) for statistical analysis.
Abbreviations
- OGI
Open-globe injury
- NLP
No light perception
- LP
Light perception
- HM
Hand movement
- CF
Counting fingers
- IOFB
Intraocular foreign body
Author contributions
KC conceptualized the study, designed the methodology, organized and supervised the manuscript process, and took responsibility for the literature review, research, and writing of the article. HMM and AAY contributed to data acquisition and literature review. CC performed the evaluation of radiological imaging.
Funding
There is no specific funding related to this research.
Data availability
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008. Since this study was based on retrospective data, the requirement for informed consent was waived by the Institutional Review Board. The Ethics Committee of Mogadishu Somalia Turkey Training and Research Hospital has granted ethics committee approval with protocol number MSTH/11047.
Consent for publication
Written informed consent was obtained from the patient for the publication of the anterior segment photographs and computed tomography images.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Kenan Calisir, Email: calisirknn@gmail.com.
Hassan Muhumed Mohamed, Email: xasanfooley@gmail.com.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.