Abstract
AIM
To identify the aetiology of open globe injuries at Hospital Universiti Sains Malaysia over a period of 10y and the prognostic factors for visual outcome.
METHODS
Retrospective review of medical records of open globe injury cases that presented from January 2000 to December 2009. Classification of open globe injury was based on the Birmingham Eye Trauma Terminology (BETT). Records were obtained with hospital permission via the in-house electronic patient management system, and the case notes of all patients with a diagnosis of open globe injury were scrutinised. Patients with prior ocular trauma, pre-existing ocular conditions affecting the visual acuity, contrast sensitivity, central vision or corneal thickness, as well as those with a history of previous intraocular or refractive surgery were excluded. Analysis of data was with SPSS version 20.0. Ordinal logistic regression analysis was used to examine the association between prognostic factors and visual outcome.
RESULTS
This study involved 220 patients (n=222 eyes). The most common place of injury was the home (51.8%), followed by the workplace (23.4%). Among children aged less than 16y of age, domestic-related injury was the predominant cause (54.6%), while in those aged 16y and above, occupational injuries were the most common cause (40.0%). Most eyes (76.5%) had an initial visual acuity worse than 3/60, and in half of these, the visual acuity improved. The visual outcome was found to be significantly associated with the initial visual acuity (P<0.005), posterior extent of wound (P<0.001), length of wound (P<0.001), presence of hyphaema (P<0.001) and presence of vitreous prolapse ((P<0.005).
CONCLUSION
The most common causes of open globe injury are domestic accidents and occupational injuries. Significant prognostic factors for final visual outcome in patients with open globe injury are initial visual acuity, posterior extent and length of wound, presence of hyphaema and presence of vitreous prolapse. Awareness of the factors predicting a poor visual outcome may be helpful during counselling of patients with open globe injuries.
Keywords: eye injuries, occupational injuries, vision disability, visual impairment, accidents, intraocular foreign body
INTRODUCTION
Ocular trauma is a prominent cause of visual disability, contributing up to 65% of cases of unilateral blindness worldwide, depending on the sample population[1]–[5]. The burden of blindness is related not only to its inevitable effect on quality of life, but also to the loss of productivity associated with the remaining blind person-years[6]. In most studies, the largest groups affected are children or young adults, resulting in even greater socioeconomic implications of this condition[7]–[10].
The epidemiology of ocular trauma is a subject of interest worldwide [3],[7],[11],[12]. The proportion of open versus closed globe injury varies in different studies[13]–[17]. However, it is generally accepted that open globe injury results in more hospitalisation and a poorer visual outcome than closed globe injury[7],[11],[18]–[21]. Among paediatric eye injury-related hospitalisations in the United States, the majority were for open wounds of the ocular adnexa, and likewise in those hospitalised for work-related ocular injury[18],[22]. Unlike in adults, where occupational injuries predominate, most trauma resulting in open globe injury in children occurs at home[3],[21]. Regrettably, a significant number of these injuries are preventable, especially in children[17],[21],[23]–[26].
Despite the significant visual disability related to open globe injuries, the circumstances in which they occur have not been thoroughly elucidated, nor the clinical features predicting a worse visual outcome. The aim of this study was to determine the aetiology of open globe injuries in our population and the prognostic factors associated with visual outcome.
SUBJECTS AND METHODS
We conducted a retrospective case review of all patients with open globe injury that presented to Department of Ophthalmology, Hospital Universiti Sains Malaysia, over a period of 10y. Methods complied with the tenets outlined in the Declaration of Helsinki. Our classification of open globe injury was based on the Birmingham Eye Trauma Terminology[27],[28]. Records were obtained with hospital permission via the in-house electronic patient management system, and the case notes of all patients with a diagnosis of open globe injury were scrutinised. Patients with prior ocular trauma, pre-existing ocular conditions affecting the visual acuity, contrast sensitivity, central vision or corneal thickness, as well as those with a history of previous intraocular or refractive surgery were excluded. Analysis of data was with SPSS version 20.0. Ordinal logistic regression analysis was used to examine the association between prognostic factors and visual outcome.
RESULTS
From 2000 to 2009, 220 patients (n=222 eyes) with open globe injury were admitted to Hospital Universiti Sains Malaysia, Kelantan, Malaysia. Approximately 4/5 of them were male (Table 1). All patients were Asian, and more than 90% of cases were of Malay ethnicity. Their ages ranged from 1 to 79 years old, with the mean and median age being 22 and 19 years old respectively. Seventy percent of cases occurred in those aged less than 30 years old, with the majority of open globe injuries (33%) occurring in the first decade (Table 2). Two patients had bilateral open globe injuries, while in the remainder, the distribution of cases showed no predilection for involvement of either eye.
Table 1. Patient demographics and open globe injury-related circumstances.
| Variables | n=222 (%) |
| Gender | |
| M | 175 (78.8) |
| F | 47 (21.2) |
| Ethnicity | |
| Malay | 207 (93.2) |
| Chinese | 9 (4.1) |
| Indian | 2 (0.9) |
| Others | 4 (1.8) |
| Site of injury | |
| Home | 115 (51.8) |
| Workplace | 52 (23.4) |
| Street | 41 (18.5) |
| School | 6 (2.7) |
| Others | 2 (0.9) |
| Not documented | 6 (2.7) |
| Causes of injury | |
| Domestic-related | 83 (37.4) |
| Occupational injury | 52 (23.4) |
| Motor vehicle accident | 39 (17.6) |
| Animal/agriculture-related | 28 (12.6) |
| Others | 20 (9.0) |
| Mechanism of injury | |
| Sharp | 183 (82.4) |
| Intraocular foreign body | 20 (9.0) |
| Blunt | 14 (6.3) |
| Blast | 5 (2.3) |
| Objects causing injury | |
| Metal | 61 (27.5) |
| Glass | 35 (15.8) |
| Sticks | 23 (10.4) |
| Tools | 18 (8.1) |
| Animal | 18 (8.1) |
| Stone | 10 (4.5) |
| Explosives | 8 (3.6) |
| Wire | 5 (2.2) |
| Toys | 1 (0.4) |
| Others | 29 (13.1) |
| Unknown | 14 (6.3) |
Table 2. Causes of open globe injury by age.
| Causes of injury | Age groups (a), n=222 |
Total | |||||||
| 1-5 | 6-10 | 11-15 | 16-25 | 26-35 | 36-45 | 46-55 | >55 | ||
| Domestic-related | 21 | 25 | 7 | 8 | 8 | 3 | 6 | 5 | 83 |
| Occupational | 0 | 0 | 2 | 19 | 15 | 7 | 9 | 0 | 52 |
| Motor vehicle accidents | 2 | 1 | 2 | 16 | 7 | 3 | 5 | 3 | 39 |
| Animal/agriculture-related | 8 | 9 | 6 | 1 | 1 | 1 | 2 | 0 | 28 |
| Others/Not documented | 0 | 7 | 7 | 1 | 3 | 1 | 1 | 0 | 20 |
| Total | 31 | 42 | 24 | 45 | 34 | 15 | 23 | 8 | 222 |
The most common place of injury was the home (51.8%), followed by the workplace (23.4%) and the street (18.5%). Besides domestic-related open globe injury, which was the significant type of injury (37.4%), other types included occupational injuries (23.4%), motor vehicle accidents (17.6%), and animal-related injuries (12.6%).
Among children aged less than 16y of age, domestic-related injury was the predominant cause of open globe injury (54.6%), followed by animal/agriculture-related injuries (23.7%). This differs in the group aged 16y and older, where occupational injuries were the most common cause (40.0%), followed by motor vehicle accidents (27.2%) and domestic accidents (24.0%). Among domestic-related injuries, most of them (44.6%, n=37) occurred while playing, followed by do-it-yourself activities (21.7%, n=18) and falls (8.4%, n=7), while the remainder were sustained in a variety of different ways. The object causing open globe injury was most often metal (27.5%).
The most frequent mechanism of injury was sharp injury (82.4%), followed by intraocular foreign bodies (IOFB) blunt injury, and blast injury. In the 20 patients who had a retained IOFB, all but one of these were acquired via ocular laceration wounds. Removal of IOFB was successful in 17 out of these 20 cases.
Extension of the wound posteriorly was restricted to the cornea in 50.4% (Table 3). In approximately 70% of eyes, the length of the wound was less than 8 mm. About half of the cases had a hyphaema. Involvement of intraocular tissues (e.g. uvea, lens, vitreous) occurred in 83.8%, with uveal prolapse being the most common finding. Most cases were managed by primary surgical closure of the eye wall wound. Complications were uniformly distributed between the anterior segment, lens and posterior segment. Twenty one patients (14.0%) developed phtisis bulbi, and 2 developed sympathetic ophthalmia.
Table 3. Clinical data related to open globe injuries.
| Variables | n=222 (%) |
| Extension of wound posteriorly | |
| Restricted to the cornea | 112 (0.4) |
| Anterior to recti insertion | 79 (35.6) |
| Anterior to equator | 21 (9.5) |
| Posterior to equator | 10 (4.5) |
| Length of the wound | |
| 1-4 mm | 79 (35.6) |
| 5-8 mm | 81 (36.5) |
| 9-12 mm | 26 (11.7) |
| ≥13 mm | 36 (16.2) |
| Hyphaema | |
| None | 105 (47.3) |
| Hyphaema <50% | 68 (30.6) |
| Hyphaema >50% | 49 (22.1) |
| Involvement of intraocular structures | |
| None | 36 (16.2) |
| Uveal tissue prolapse only | 80 (36.0) |
| Lens involvement only | 26 (11.7) |
| Vitreous prolapse only | 9 (4.1) |
| Involvement of ≥2 structures noted above | 71 (32.0) |
| Surgical management | |
| Primary closure of eye wall wound alone | 194 (87.4) |
| Primary closure of eye wall wound combined with anterior segment surgery only | 21 (9.5) |
| Primary closure of eye wall wound combined with posterior segment surgery | 5 (2.3) |
| Evisceration/enucleation | 2 (0.9) |
| Complications | |
| Anterior segment complications1 | 72 (32.4) |
| Lens-related complications2 | 61 (27.5) |
| Posterior-segment complications | 56 (25.2) |
| Phtisis bulbi | 21 (14.0) |
| Sympathetic opthalmia | 2 (0.9) |
1E.g. corneal scar, iris damage, secondary glaucoma; 2E.g. vitreous hemorrhage, retinal detachment, optic neuropathy.
Unfortunately, the visual acuity at presentation was documented in only 115 eyes. Likewise, due to defaulters, the visual acuity at 6mo post operation was only available in 142 eyes. Most eyes (76.5%) had an initial visual acuity worse than 3/60, but many of them showed improvement postoperatively (Table 4). Overall, the final best corrected visual acuity at 6mo post operation was better than 6/12 in 35.2% of cases. This final visual acuity was found to be significantly associated with the initial visual acuity, posterior extent of wound, length of wound, presence of hyphaema and presence of vitreous prolapse (Table 4).
Table 4. Ordinal logistic regression analysis on factors affecting final visual outcome in open globe injuries.
| Variables | Coef. | Wald | 95% CI | P |
| Initial visual acuity (n=115) | ||||
| >6/12 | -3.155 | 8.175 | (-5.317; -0.992) | 0.004 |
| 6/12-3/6 | -2.135 | 13.304 | (-3.282; -0.988) | <0.000 |
| <3/60a | ||||
| Mechanism of injury (n=142) | ||||
| Sharp injury | -1.435 | 1.272 | (-3.930;1.059) | 0.259 |
| IOFB | -4.766E-008 | 0.000 | (-2.690;2.690) | 1.000 |
| Blunt injury | -0.102 | 0.005 | (-2.829; 2.624) | 0.941 |
| Blast injury a | ||||
| Posterior extent of wound (n=142) | ||||
| Restricted to the cornea | -20.506 | 868.619 | (-21.869; -19.142) | <0.000 |
| Anterior to recti insertion | -20.424 | 809.496 | (-21.831; -19.017) | <0.000 |
| Anterior to equator | -18.724 | - | (-18.724; -18.724) | - |
| Posterior to equator a | ||||
| Length (n=142) | ||||
| 1-4mm | -2.526 | 18.637 | (-3.673; -1.379) | <0.000 |
| 5-8mm | -2.097 | 13.543 | (-3.215; -0.980) | <0.000 |
| 9-12mm | -1.162 | 2.967 | (-2.484; 0.160) | 0.085 |
| >13mm a | ||||
| Hyphaema (n=142) | ||||
| None | -2.488 | 25.018 | (-3.464; -1.513) | <0.000 |
| Hyphaema <50% | -1.882 | 13.374 | (-2.890; -0.873) | <0.000 |
| Hyphaema >50% a | ||||
| Presence of vitreous prolapse (n=142) | ||||
| None | -1.305 | 10.529 | (-2.094; -0.517) | 0.001 |
| Present a |
aReference level; P <0.05 is significant.
DISCUSSION
This study showed that males were more commonly involved than females, making up 78.8% of the total sample. Other studies in this field also demonstrated a male preponderance; Falcao et al[29] found that 76.0% of cases of traumatic open globe injury were males[26],[30]. The possible reasons for the higher incidence of eye injuries in this group may be due to gender-based behaviour and male involvement in accident-prone industries.
The mean age of open globe injury in this study was 22.2y of age, which is lower than that of other studies in this area[31]–[33]. This variability may be a result of inter-population differences in culture, lifestyle, occupation and socioeconomic status, and has special implications with regard to proper implementation of a safe working environment.
The majority of open globe injuries occurred in the home (51.8%). This data is consistent with other large population studies related to open globe injuries, in which home-based accidents occurred in 38%-71% of cases[26],[29]. In a study by Kadappu et al[21], the home was also the most common place of injury in children, which correlates with the findings of our study. However, Tok et al[34] and El-Sebaity et al[13] found that the home came second to the street in paediatric cases. Meanwhile, in adults, the most frequently associated cause in our series was occupational injury, which corresponds to results described in previous literature[32],[35],[36].
Sharp injuries contributed to 82.4% of cases in our study, which is higher than the proportion of 67.7% noted by Yalcin et al[32]. Although the most common mechanism of injury in our study was sharp injury, ordinal logistic regression analysis revealed that mechanism of injury was not significantly associated with final visual acuity (P>0.05). With regard to the object causing injury, metal and glass were most commonly implicated in this series, making up 43.3%, which is consistent with a study by Framme et al[26]. However, we found no association between the causative agent and the final outcome. Of greater significance was the impact of the object in terms of wound extension and damage to intraocular structures.
Posterior extension and length of the wound are important prognostic factors affecting the final visual outcome, as demonstrated by Thevi et al[35]. This relationship was likewise seen in our study, where posterior extension of wound was significantly associated with final visual acuity (P<0.001). In fact, subjects who had a wound extending posterior to the equator had 20 times the risk of having a final visual acuity less than 3/60 when compared with those whose wounds were anterior to the recti insertions or restricted to the cornea.
Han et al[31] established that a larger wound (>10 mm) was related to a poorer final visual acuity. Inversely, this study showed that the shorter the wound length, the better the final visual acuity. This suggests that the size of lacerations has not only therapeutic, but also prognostic implications; increase in length of laceration is significantly correlated with a worse visual outcome (P<0.001).
Other factors such as the presence of hyphaema or vitreous prolapse also play a role in final visual acuity. Subjects who did not have hyphaema were twice less likely to have a final visual acuity of less than 3/60 compared with subjects having hyphaema. However, this finding differed from that of Thevi et al[35], who found no significant effect of hyphaema on visual outcome. A similar finding was noted in subjects with vitreous prolapse, where those with vitreous prolapse had twice the risk of a final visual acuity less than 3/60 compared with those without vitreous prolapse (P<0.005). Yalcin et al[32] also found vitreous prolapse to be a significant prognostic factor influencing final visual acuity.
Presenting visual acuity has been found to be associated with visual outcome in multiple studies[31]–[33],[35],[37]. In a study by Rao et al[38], a visual acuity of <5/200 (equivalent to <1/60) was found to be the most important factor contributing to poor visual outcome. This study also noted initial visual presentation and visual outcome to be statistically significant, where subjects who had an initial visual acuity of >6/12 had three times less risk of having a final visual acuity worse than 3/60 (P=0.004).
The limitations of our study are related to insufficient documentation, especially in the area of presenting visual acuity. This may be related to circumstances surrounding the patient's admission to hospital, where inability to assess the visual acuity was due to medically unfit patients.
To sum up our findings, the most common causes of open globe injuries are domestic accidents and occupational injuries. Predictors of good visual outcome are initial visual acuity, posterior extent and length of wound, presence of hyphaema and presence of vitreous prolapse. An understanding of these prognostic factors may assist us in providing our patients with realistic expectations of final visual acuity. As yet, no organized efforts have been undertaken in the matter of primary prevention of open globe injuries. This data thus suggests a need to educate the public about safety precautions not only at work, but in the home. It also highlights the need to establish, implement and monitor compliance to guidelines in occupational safety and health.
Acknowledgments
The authors would like to thank Dr. Mohd Zulkarnain Sinor for his help in statistical analysis.
Conflicts of Interest: Madhusudhan, None; Evelyn-Tai LM, None; Zamri N, None; Adil H, None; Wan-Hazabbah WH, None.
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