Wood-Related Open-Globe Injuries

Abstract

Purpose:

This work evaluates the clinical characteristics, visual outcomes, and complications of patients treated for open-globe injuries (OGIs) caused by wooden objects.

Methods:

A retrospective review of medical records was conducted on patients presenting to a tertiary trauma center with an OGI between January 2005 and December 2017. Medical records were isolated for wounds caused by wooden objects. Patient demographics were recorded, with presenting visual acuity (VA), physical examination findings, and wound characteristics. After primary globe repair, secondary complications, need for additional surgery, and visual outcomes were noted until final examination. Main outcome measures were final VA and secondary complications. The Ocular Trauma Score (OTS) was computed and assessed for clinical relevance related to visual outcomes.

Results:

Thirty-two patients met the inclusion criteria, with 15 (47%) being injured by plant material. Thirty of the patients were men (94%). A large portion of patients presented with hand motion or worse vision (48%), and there were high rates of hyphema (59%), vitreous hemorrhage (31%), retinal detachment (28%), and endophthalmitis (9%). Two patients eventually required enucleation. At last follow-up, 19 patients achieved 20/100 VA or better (59.4%), which correlated with their OTS (P < .001).

Conclusions:

Despite the high clinical severity of wood OGIs, the potential for visual recovery remains high. The OTS appropriately assesses the severity of injuries and the likely prognosis in this cohort of patients.

Introduction

Ocular trauma is a significant cause of preventable vision loss, of which open-globe injury (OGI) composes a small fraction. The incidence of OGI in the United States has been estimated at 3.81 of 100 000. ¹ Overall, wood and plant material account for a minority of penetrating ocular injuries in developed nations, with some data demonstrating a 3.4% injury rate. ² Reports from non-US countries attribute up to 20% of OGIs to wood materials. ^3,4 There are limited analyses in the ophthalmic literature specifically investigating the visual outcomes in this setting. With prompt surgical intervention, victims of wood-related ocular injuries can maintain good vision. ⁵ However, even in the absence of globe penetration, there is still significant risk for permanent vision loss and infection in the setting of wood-related ocular trauma. ^6,7

The Ocular Trauma Score (OTS) has been used to estimate ocular injury prognosis for close to 2 decades. ⁸ This system was developed from analyzing more than 2500 eye injuries and counts globe rupture as a predominant factor correlated with poor functional outcome. Numerous studies have shown OTS predicts visual outcome. ^9,10 Owing to their relative rarity, its usefulness in grading exclusively wood-based trauma incidents has not been validated. Because wood injuries typically compose a minority of OGIs, previous studies that conduct analysis on large pools of traumatic cases might misinterpret its functionality in this subset of patients.

In this retrospective study we report the clinical characteristics, complications, and outcomes of visual recovery after wood-based penetrating ocular injury. As a secondary outcome, we aim to assess the usefulness of the OTS in evaluating this subset of trauma. To our knowledge, this is the largest report detailing the outcomes and management of exclusively wood-based ocular trauma.

Methods

A retrospective review of medical records was conducted on all individuals presenting to Vanderbilt University Medical Center between January 2005 and December 2017 with a diagnosis of OGI secondary to wooden objects. OGIs consisted of any full-thickness laceration of the cornea and/or sclera. Patients with OGIs were identified using Current Procedural Terminology codes 65280 and 65285 (repair of laceration procedures on the eyeball).

The history of present illness was reviewed and only cases containing trauma secondary to tree and plant material or engineered wood (EW) were included. Inclusion criteria also consisted of full-thickness injury as confirmed by ocular examination including Seidel sign, with potential assistance of imaging modalities such as x-ray or computed tomography scans. Wood-based mechanism of injury was determined by the initial consultation note and patient report. Exclusion criteria consisted of nonpenetrating injuries, injuries not attributed in part to wooden objects, and trauma of unknown origin. Any medical records with incomplete information to appropriately gauge outcomes were also excluded.

Patient characteristics—age, race, sex, and medical and ocular histories—were recorded. Consultation and operative notes were assessed for laceration size, laceration site, presenting visual acuity (VA), presence of relative afferent pupillary defect (RAPD), and anterior chamber status. Complications of hyphema, cataract, vitreous hemorrhage (VH), retinal detachment (RD), endophthalmitis, and intraocular foreign body (IOFB) were also assessed throughout treatment. The OTS was calculated for all patients whose presenting VA was recorded. Patients were followed for primary repair and secondary procedures including need for enucleation. VA was assessed at last follow-up visit postoperatively. Patients without at least 3 months of follow-up were excluded from the analysis.

Statistical analysis was conducted in R (version 3.3.3, R Foundation for Statistical Computing) using the standard statistical package. Analysis consisted of parametric and nonparametric univariate analyses where appropriate and included Fisher exact test or χ² for categorical comparison, Wilcoxon sign rank test or paired t test for continuous comparison, and Kruskal-Wallis test with Tukey's honestly significant difference for multiple comparisons.

Results

Thirty-two patients were identified as having OGIs related to EW or tree material between 2005 and 2017. The average age at presentation was 45 years (range, 9-97 years), with a majority older than 18 years (87.5%). Most patients were men (30 of 32, 94%), and the racial demographics included 27 white (84%), 1 African American (3%), and 4 Hispanic (13%) individuals. Comorbidities included 5 patients with diabetes (16%), 6 with hypertension (19%), and 5 with neuropsychiatric disorders (16%). The most common ocular history was refractive error (22%). Two patients had documented prior ocular trauma. Seven injuries were work-related (Table 1).

Table 1.

Patient Demographics, Medical History, and Ocular Wound Characterization.

General demographics		Frequency (%)	Racial demographics		Frequency (%)
	Male	30/32 (94)		White	27/32 (84)
	Average age, y	45 (9-97)		African American	1/32 (3)
	Right eye	14/32 (44)		Hispanic	4/32 (13)
	Work related	7/32 (22)
Ocular history			Comorbidities
	Refractive error	7/32 (22)		DM	5/32 (16)
	PCIOL	2/32 (6)		HTN	6/32 (19)
	Prior trauma	2/32 (6)		Neuropsychiatric Cancer	5/32 (16) 2/32 (6)
	Glaucoma	1/32 (3)
	Corneal ulcer	1/32 (3)
Initial vision			Final vision
	>20/50	9/31 (29)		>20/50	13/29 (45)
	20/50 to >20/200	1/31 (3)		20/50-20/200	9/29 (31)
	20/200 to CF	6/31 (19)		20/200	1/29 (3)
	HM or LP	14/31 (45)		HM or LP	5/29 (17)
	NLP	1/31 (3)		NLP	1/29 (3)
Laceration location			Material
	Cornea	14/32 (44)		Wood	16/32 (50)
	Sclera	8/32 (25)		Tree	15/32 (47)
	Corneoscleral	10/32 (31)		Wood + metal	1/32 (3)
Presenting complications
	Presence of intraocular FB	5/32 (16)
	Hyphema	19/32 (59)
	Vitreous hemorrhage	10/32 (31)

Abbreviations: CF, counting fingers; DM, diabetes mellitus; FB, foreign body; HM, hand motions; HTN, hypertension; LP, light perception; NLP, no light perception; PCIOL, posterior chamber intraocular lens.

Fifteen eyes experiencing OGIs were the result of blunt trauma with trees or tree branches, resulting typically in posterior scleral ruptures. The remaining injuries were lacerations resulting from penetration with wood and wooden materials or projectiles. In our cohort, these were always associated with some level of corneal or corneoscleral injury.

Presenting VA ranged from 20/20 to no light perception (NLP). Only 1 patient was NLP, whereas 14 patients (45%) were hand motions or light perception. Six patients presented with vision of 20/200 to counting fingers, 1 patient presented with 20/100 VA, and 9 patients presented with 20/50 vision or better.

Fifteen of the cases (47%) were due to tree material with the rest caused by EW and 1 case of EW with metal. The length of laceration was not significantly different between the 2 materials (P = .49). Fourteen lacerations were restricted to the cornea (44%), 8 involved only the sclera (25%), and 10 were combined corneoscleral laceration (31%). Five of the cases (16%) were complicated by the presence of an IOFB and 3 cases had endophthalmitis (9%). Details of the injury and interventions performed during the open-globe repair can be found in Table 2.

Table 2.

Details of Injury and Interventions Performed During Initial Repair.

Patient No.	Time to presentation, d	Laceration site	Zone	Laceration size, mm	IOFB, Y/N	Wood location	Vitrectomy at time of repair	Intraoperative antibiotics	Mode of delivery
1	0	Corneoscleral	2	11	N		N	Cefazolin	Subconjunctival
2	0	Corneoscleral	2	7	N		N	Vancomycin/Ceftazidime	Intravitreal
3	2	Corneal	1	5	N		N	Gentamicin	Subconjunctival
4	0	Corneal	1	1.5	Y	Anterior chamber	N	Vancomycin/Ceftazidime	Intravitreal
5	0	Scleral	3	12.5	N		Y	Cefazolin	Subconjunctival
6	10	Corneal	1	3	N		N	Cefazolin	Subconjunctival
7	1	Corneal	1	4	N		Y	Cefazolin	Subconjunctivala
8	0	Corneoscleral	2	15	N		N	Cefazolin	Subconjunctival
9	0	Scleral	2	3	N		N	NA	None
10	1	Corneoscleral	3	–	N		N	Cefazolin	Subconjunctival
11	1	Corneal	1	2	N		N	Cefazolin	Subconjunctival
12	0	Scleral	3	7	N		Y	Cefazolin	Subconjunctival
13	0	Scleral	2	3	N		N	Gentamicin	Subconjunctival
14	0	Corneal	1	–	Y	Anterior chamber	Y	NA	None
15	0	Corneoscleral	3	11	N		N	Cefazolin	Subconjunctival
16	0	Scleral	3	5	N		Y	Cefazolin	Subconjunctival
17	0	Scleral	3	–	N		N	Cefazolin	Subconjunctival
18	1	Corneal	1	4	N		N	Cefazolin	Subconjunctival
19	0	Corneal	1	3	Y	Iris	Y	Cefazolin	Subconjunctivala
20	0	Corneoscleral	3	14	N		N	NA	None
21	0	Scleral	2	3	N		Y	Cefazolin	Subconjunctival
22	0	Corneal	1	4	Y	Vitreous	Y	Vancomycin/Ceftazidime	Intravitreala
23	2	Corneal	1	5	N		N	Vancomycin/Ceftazidime	Intravitreal
24	1	Corneal	1	4	N		N	Cefazolin	Subconjunctival
25	0	Corneoscleral	2	7	N		Y	Cefazolin	Subconjunctival
26	0	Corneoscleral	2	9	N		Y	Cefazolin	Subconjunctival
27	0	Corneoscleral	2	–	N		N	Gentamicin	Subconjunctival
28	0	Corneal	1	2	N		N	Cefazolin	Subconjunctival
29	2	Corneal	1	3	N		Y	Vancomycin/Ceftazidime/moxifloxacin	Intravitreal
30	0	Corneoscleral	2	7	N		N	Cefazolin	Subconjunctival
31	0	Scleral	2	2	Y	Sclera	Y	Vancomycin/Ceftazidime/moxifloxacin	Intravitreal
32	2	Corneal	1	5	N		N	Vancomycin/Ceftazidime/moxifloxacin	Intravitreal

Abbreviations: IOFB, intraocular foreign body; N, no; NA, not available; Y, yes.

^a Developed endophthalmitis.

Hyphema was documented in 19 eyes on presentation; 3 of these eyes would develop RD. Ten patients had VH at the time of presentation; 6 of these patients would develop RD. Of the 9 patients who developed RD in our cohort, 2 were identified on presentation and the remaining 7 were diagnosed at subsequent follow-ups. The average time to RD surgery was 36 days from original open-globe repair (range, 14 to 55 days). Details of surgical repair can be found in Table 3. RD positively correlated with VH (P < .001), and hyphema (P = .011), and hyphema positively correlated with VH (P < .001).

Table 3.

List of Presenting Complications and Complications Documented After Initial Evaluation. Surgeries Subsequent to Initial Open-Globe Repair Are Listed.

Patient	Presenting VA	Final VA	Ocular Trauma Score	Age, y	Presenting complications	Additional findings	Subsequent surgical procedures
1	LP	NLP	1	53	Hyphema, RD, VH, cataract	RAPD	Enucleation with subsequent implant exchange
2	20/100	20/20	3	56	Hyphema, VH, cataract
3	20/400	20/30	2	75
4	20/20	20/20	3	35	AC IOFB
5	NA	HM	a	76	Hyphema, PCIOL	RD, VH	25 g PPV/PPL/silicone oil placement 25 g PPV/scleral buckle/PVR peeling/silicone oil placement 25 g PPV/silicone oil removal/IOL placement Penetrating keratoplasty
6	HM	20/70	2	24	Cataract		CE with PCIOL insertion
7	20/800	20/30	2	38	Cataract	Endophthalmitis	25 g PPV/PPL/ACIOL IOL exchange
8	NLP	NLP	1	61	Hyphema, OFB	RD	Bilateral upper eyelid blepharoplasty, pentagonal wedge excision, lateral tarsal strip, myocutaneous advancement flap, lateral tarsorrhaphy, shell prosthesis
9	20/40	20/25	3	24	Hyphema
10	CF 1 ft	HM	1	27	Hyphema, RD, VH
11	HM	20/60	2	36	Cataract		CE with PCIOL insertion
12	HM	20/100	1	14	Hyphema	RD, VH, RAPD, lens subluxation	23 g PPV 23 g PPV/scleral buckle/SF6 23 g PPV/PPL/silicone oil placement 23 g PPV/silicone oil removal
13	20/20	20/25	3	19
14	LP	20/150	2	29	Hyphema, AC IOFB, cataract	VH, RAPD	23 g PPV, PPL with PCIOL insertion, iridodialysis repair with synechiolysis
15	LP	LP	1	49	Hyphema, traumatic cataract	RAPD
16	20/200	20/60	2	50	Hyphema, OFB	RD, VH	25 g PPV/silicone oil placement 25 g PPV/scleral buckle/PVR peeling/silicone oil placement 25 g PPV/silicone oil removal/IOL placement IOL exchange
17	LP	Prosthetic	1	73	Hyphema	RD, OFB	Enucleation with removal of retained OFB, and ectropion repair
18	20/20	20/30	3	35
19	LP	20/70	1	64	Hyphema, cataract	AC IOFB, endophthalmitis	23 g PPV, AC washout with IOFB removal Lensectomy with scleral-fixated IOL Glaucoma tube shunt
20	LP	NLP	1	45	Hyphema, AC IOFB	RAPD, VH
21	LP	20/150	1	97	Hyphema, traumatic aphakia	RD, VH	23 g PPV/SF6
22	HM	20/50	2	45	Hyphema, vitreous IOFB	Endophthalmitis, VH	PPV with endolaser photocoagulation
23	20/20	20/40	3	35
24	CF 2 ft	20/30	1	16	Cataract		CE with PCIOL insertion
25	HM	HM	2	73	Hyphema	Cataract	CE with PCIOL 23 g PPV with scleral-fixated IOL replacement
26	HM	HM	2	60	Lens subluxation		23 g PPV, PPL with PCIOL insertion
27	20/20	20/25	3	60	Hyphema
28	20/20	20/25	3	40	Traumatic cataract
29	20/25	20/30	3	9	Traumatic cataract		23 g PPV with PCIOL and synechiolysis
30	LP	20/30	1	11	Hyphema, cataract		CE with PCIOL and synechiolysis
31	20/200	20/400	2	55	Hyphema, AC IOFB, cataract	RD	CE with PCIOL 23 g PPV/scleral buckle/PVR peeling/silicone oil placement
32	20/30	20/50	3	49		Cataract

Abbreviations: AC, anterior chamber; CE, cataract extraction; CF, counting fingers; HM, hand motion; IOFB, intraocular foreign body; IOL, intraocular lens; LP, light perception; NA, not available; NLP, no light perception; OFB, orbital foreign body; PCIOL, posterior chamber intraocular lens; PPL, pars plana lensectomy; PPV, pars plana vitrectomy; PVR, proliferative vitreoretinopathy; RAPD, relative afferent pupillary defect; RD, retinal detachment; SF₆, sulfur hexafluoride; VA, visual acuity; VH, vitreous hemorrhage.

^aUnable to calculate OcularTrauma Score.

Nineteen patients required 1 to 4 additional surgical procedures. A lower OTS was predictive of more procedures (P = .005). Cataract removal was the most common subsequent procedure (13 total). Eight intraocular lenses were placed in the posterior capsule, 2 were fixated in the sclera, 2 in the anterior chamber, and 1 in the sulcus. One intraocular lens was replaced from a cataract operation prior to trauma. Twelve eyes (37.5%) eventually required pars plana vitrectomy surgery (see Table 3). Two eyes eventually required enucleation.

All patients received preoperative intravenous antibiotics and all but 3 received intravitreal or subconjunctival antibiotics at the time of open-globe repair. Three eyes in this series developed clinical endophthalmitis (no growth was obtained on vitreous culture). Of the 3 eyes that developed endophthalmitis, 2 received subconjunctival antibiotics at the time of initial open-globe repair and 1 received intravitreal antibiotics. One of these patients presented to the emergency department the day after the injury; the other 2 presented immediately following the injury. Two of these 3 patients presented with an IOFB. Endophthalmitis developed within 1 week in 2 patients (5 days and 7 days). The third patient developed endophthalmitis 35 days after the initial injury despite an uneventful postoperative course. All patients with endophthalmitis improved to 20/70 or better at time of final follow-up.

The OTS was calculated for all but 1 patient who was intubated and sedated on admission. Eleven patients scored 1 (35%), 10 patients scored 2 (32%), and 10 patients scored 3 (32%). No patients had an OTS of 4 or 5. There was no relation between the severity of the OTS and the mechanism of injury (P = .13). Average final logMAR VA was 1.22 (range, 0.20-3.0; Snellen equivalent, 20/332) for OTS = 1, 1.164 (range, 0.20-3.0; Snellen, 20/292) for OTS = 2, and 0.146 (range, 0.00-0.40; Snellen, 20/28) for OTS = 3 (Figure 1A). Lower OTS patients demonstrated a larger VA recovery by 1-way analysis of variance (OTS 1 compared to OTS 3, P = .007) (Figure 1B). Of note, RAPD was difficult to assess in patients presenting with significant hyphema. Two patients were unable to be assessed at time of initial evaluation, and 4 had RAPD documented at a later date after hyphema cleared. Excluding RAPD would have changed only 4 individuals’ classifications from OTS 1 to OTS 2.

Figure 1.

The Ocular Trauma Score correlation with (A) final visual acuity (logMAR transformed) and (B) visual acuity recovered between initial and final visit (logMAR_initial – logMAR_final). NS, not significant.

The average length of follow-up was 15 months. At the time of final follow-up, 13 patients had 20/50 or better VA (41%). Nine patients (28%) were between 20/50 and 20/200, 5 patients (16%) were hand motions or light perception, and 2 patients were NLP (see Table 1). The final VA was not significantly different between mechanisms of injury (P = .67); however, the final VA was significantly worse when eyes developed VH (P = .011), RD (P = .005), and hyphema (P = .013).

Conclusions

To our knowledge, this is the largest report specifically detailing the clinical outcomes of wood-related OGIs. From this case series, we have determined that OGI secondary to wood is associated with significant ocular morbidity due to complications of RD (28.1%), endophthalmitis (9.4%), VH (31.3%), hyphema (59.4%), and enucleation (6.25%). Despite the apparent gravity of wood OGIs, the patients in this cohort achieved excellent visual recovery. Nineteen patients achieved 20/100 VA (59.4%) or better, and 2 elected to undergo enucleation because of the presence of a blind, painful eye. One other patient was fitted for a shell prosthesis and another was NLP after intervention. The average vision at final evaluation is encouraging compared with other modes of injury.

Most of the patients in this cohort were men older than 18 years. It was unexpected that there would be few pediatric cases in this cohort. One possible explanation is that wood trauma tends to occupy the extraocular spaces in children ¹¹ and that adults may not have the same robust reflex to hyperextend the neck to avoid injury. ¹² Higher rates of wood OGIs have been described in rural settings and foreign countries and are ascribed to the predominance of agriculture in these regions. ^3,4,13

It was anticipated that there would be a significantly higher rate of IOFBs caused by wood because of its tendency to fragment in orbital injuries, necessitating multiple periorbital surgical debridements, ¹² but this was not observed. The rate of wooden IOFBs was 16%, slightly lower than the 28.6% rate of wood IOFBs reported by Zhang et al, who analyzed 4968 OGIs. ¹⁴ Although we failed to note a higher incidence in IOFBs, there was a high rate of endophthalmitis associated with IOFBs (40.0%), but this was not statistically different from patients without IOFBs (P = .060). It is controversial whether the material of the IOFB can increase the risk of endophthalmitis. Endophthalmitis resulting from wood can range from 26.9% to 55% of IOFB cases, ^{15 -17} much higher than the incidence with metal (up to 16.3%). Other reports state there is no significant difference based on material type. ^14,18

We also observed that there was no significant difference in endophthalmitis between patients injured by plant or EW materials, but our study might have been underpowered to detect a true difference. Regardless, the porous nature of wood allows for transport of soil contaminant, which has been associated with increased risk. ^13,19,20 Metal IOFBs are often acquired because of combustive or high-velocity impacts that have the potential to self-sterilize, resulting in a reduced viable inoculum and lower rates of endophthalmitis. ^{19,21 -23}

RD was a frequently encountered complication (28.1%), comparable in incidence to other OGI reports. ^{24 -27} The Retinal Detachment after OGI (RD-OGI) score ²⁷ can be a helpful predictor to anticipate which patients are at highest risk for developing RD following open-globe trauma. Using the zone of injury, presenting vision, and presence of VH, points can be assigned to gauge the probability of subsequent RD. Of the 9 patients who developed RD in our cohort, the average RD-OGI was 1.83, which correlated to slightly less than a 7% probability of RD. Overall, the RD-OGI score did not correlate in our cohort with subsequent development of RD (P = .37).

RD is frequently associated with posterior IOFB, ^14,26 which does not account for the high rates seen in this population. Instead, wood OGIs tend to suffer blunt, low-velocity impact with a high prevalence of hyphema and VH that might initiate a cycle of vitreous contraction, cyclitic membranes, and tractional RD. ²⁵ Hyphema was present in 59.4% of the cases, significantly higher than the average for OGIs according to Zhang et al (13.44%). ¹⁴ Sudhalkar and colleagues proposed that high rates of hemorrhage result from blunt injury with larger sticks, ²⁸ and blunt trauma is associated with high rates of hyphema in pediatric ocular trauma cases. ^29,30 The data from this cohort are consistent with a high degree of blunt trauma, with 46.9% of injuries resulting in a flat, nonself-sealing anterior chamber.

The OTS is a validated tool used to estimate prognosis of final VA following ocular trauma. ^{31 -33} The range of ocular trauma was evenly distributed between OTS 1, 2, and 3 in this population. This is a similar or prognostically worse distribution compared with other studies that do not solely focus on wood injuries ^{33 -35} but better than injuries caused by high-velocity impact, as is the case with BB guns. ²¹ The OTS correlated with final visual outcomes in wood injuries (P < .001) but was statistically similar between patients falling into the OTS 1 and 2 categories (see Figure 1A). Those in OTS 3 showed good final VA, averaging 0.146 logMAR at final measure; however, this group started with good VA at presentation (average VA = 0.128 logMAR). OTS 1 and 2 showed large VA changes between presentation and final measurement (see Figure 1B). This indicates the advances in surgical and medical management of OGIs and overall good prognosis in this subset of patients. Not only was the OTS prognostic for final VA, but it also correlated with the need for additional surgical procedures (P = .005), proving its usefulness in evaluating wood OGIs.

Prior studies have shown excellent predictive value of the OTS without the use of RAPD. ^30,36 Acar et al ³⁶ noted the need for a pediatric version of the OTS (POTS) because of the inherent differences in assessing pediatric ocular trauma. This version completely lacks the RAPD variable and still shows excellent agreement with outcomes. Schörkhuber and colleagues ³⁰ tested the relative predictive value of both the OTS system without RAPD and the POTS system and found a strong correlation with final vision (OTS Spearman correlation: r = 0.6 and POTS Spearman correlation: r = 0.54).

Similarly, in pediatric cases there also high rates of hyphema. ^30,36,37 There are also reports of hyphema up to a rate of 68.47% in adults. ³² In this study hyphema correlated with the presence of VH (P < .001), RD (P = .011), lower OTS (P = .016), and final VA (P = .013). Hyphema has been analyzed in other studies and was found to be predictive of worse visual outcomes, including one study that found hyphema and VH gave similar odds ratios for vision survival compared with factors that are included in the OTS system. ^{2,30,32,37,38} The presence of complete hyphema might be used as a proxy for RAPD or as an accessory variable in the OTS for evaluating wood-based injuries.

In summary, this retrospective study of 32 wood-based OGIs is the largest study detailing clinical outcome to date. OGIs due to wood are associated with good visual outcome (41% with final vision better than 20/50) despite high rates of complication from endophthalmitis, traumatic hemorrhage, and RD. Wood-based injuries tend to result in blunt trauma when compared with findings from metal OGIs. The OTS appropriately assessed the severity of injury in these patients and correlated with final visual outcomes. Similarly to other studies, the RAPD variable was difficult to assess in the presence of hyphema and was found to not correlate with visual outcomes.