Ophthalmic trauma – Grading, scoring, and classification – Has the orphan child grown up?

Globe injuries or ocular trauma has been and continues to be an important and frequently encountered global public health problem. The World Health Organization (WHO) estimates that approximately 55 million cases occur annually. It is estimated that 1.6 million people become blind and trauma thus accounts for 40% of all monocular blindness becoming a substantial socioeconomic burden, particularly in lower- and middle-income countries.[1] In the United States, approximately 2.4 million ocular injuries occur annually with an estimated 5 million USD spent on direct and indirect costs.[2] This results in moderate to severe visual loss and not infrequently complete blindness with resultant consequences.[3,4] While this is often unilateral, on occasion, bilateral blindness greatly affects the trauma victims and the global community. Ophthalmic trauma that includes ocular and ocular adnexal trauma on the other hand, not just ocular trauma, involves not only the globe but adnexal structures such as the eyelids and periocular area, the lacrimal drainage system, and the surrounding orbit and orbitofacial structures. Orbital trauma and associated facial fractures and deformities are significant global health concerns as well. According to the Global Burden of Disease Study 2017, facial fractures, which include orbital fractures, affected approximately 7.5 million people worldwide, with 1.8 million prevalent cases and 117,402 years lived with disability (YLDs).[5] The global incidence is approximately 98 per 100,000 people, with a prevalence of 23 per 100,000 people which can lead to significant morbidity, including vision loss, diplopia, and facial deformities. Consequences of ocular and adnexal injuries not only include visual loss, but also deformity, disfiguration, and disability with not just functional consequences, but also structural and eventually economical, psychological, and social consequences. Such disability especially in children and economically productive adults has grave implications for the affected individual and their families with the loss of economic productivity[6] adding to the global burden of residual disease further impacting society, the nation, and the world at large.[7] Among mechanisms of oculofacial trauma, the most widely reported and studied is mechanical trauma. However other severe causes, albeit with much less incidence, but with no less consequence include chemical injuries, thermal burns to the globe, adnexa and the ocular surface, and electrical injuries from natural (lightning strikes) and unnatural sources. The least reported, however, is iatrogenic trauma from routine elective surgical procedures and during complex procedures performed by both ophthalmologists and non-ophthalmologists.[8] While there are regional variations, commonly reported mechanisms and risk factors include assaults, riots and other forms of interpersonal violence, road traffic accidents, firearms, fireworks, occupational, mass casualty incidents, lower socioeconomic status, and even substance abuse.[9,10] Sadly, unlike other ophthalmologic and blinding diseases, most of these are preventable and therefore reflect not only on the weaknesses of human nature but also from apathy and lack of or poor enforcement of policies already in place to prevent them by government organizations and industry. An oft-unrecognized association is additional morbidity from traumatic brain injury (TBI) and polytrauma. Studies have shown that nearly two-thirds of ocular trauma admissions had associated TBIs.[11] While assaults and associated ocular and adnexal contusions were associated with mild TBI, optic nerve and visual pathway injuries had greater odds of severe TBI. Thus, although the mortality rate was low, increased survival with associated TBI has implications for challenging post-trauma rehabilitation and long-term disability. Similarly, high velocity, automobile, industrial, and conflict zone injuries are predisposing factors to polytrauma.[12] Implications of these include deflection of the ophthalmic trauma victim to general hospitals rather than ophthalmic centers, prioritization of not just lifesaving procedures but limb and other organ-saving procedures over globe repair and most importantly associated globe injuries often being missed until late, all of which compromise best possible visual outcomes. Ophthalmologists also frequently face challenges in prioritizing globe repair over other non-life-threatening in polytrauma victims in non-ophthalmic hospitals. For the same reason, when the ABCDEs of the trauma assessment and management by ATLS guidelines are adopted, training has been toward lifesaving and systemic assessment with rehabilitation.[13] For ophthalmic trauma champions, it is heartening to note that owing to constant efforts and strong advocacy, globe injuries shall be included in the upcoming guidelines in the ATLS 2025 edition.[14] While all age groups are affected, the most common ophthalmic trauma victims are children and young adults in the working and most economically productive age group. In fact, a study in Ethiopia found that children accounted for 65.67% of ocular trauma cases, followed by adolescents (25.37%).[15] Not surprisingly, both boys and men are more likely to experience ocular and orbitofacial trauma with a male-to-female ratio of 3:1. Children, the future economic and intellectual engines of the world are not uncommon victims of ophthalmic trauma. Injuries may occur at home and domestic environments, schools, and from sports-related activities. Unlike adults, children as trauma victims are often at risk of amblyopia despite best intervention which makes management challenging for the ophthalmologist. Studies have shown that with monocular potentially blinding injury, while children can still study, pursue education, perform well, and progress academically, when they become adults residual blindness and deformity have a huge impact in their employment, socialization, professional success, and also with economic consequences.[16] How do we do the best that we can for the ophthalmic trauma victim? Of course, education (children, adults, workplaces), robust labor laws and protective regulations, enforcement, and advocacy are the most important to prevent ocular and adnexal trauma and its consequences. A comprehensive assessment of the ophthalmic trauma victim by general and subspecialty ophthalmologists and non-ophthalmologists such as emergency room physicians, general surgeons, and allied health care workers is the first step in not only in making a diagnosis but also prioritizing, communicating, and planning care. A good preoperative assessment is not only essential for medical records but also extremely important for patient and family counseling, institute prompt and appropriate management, while pursuing and ensuring short-term and long-term rehabilitation of the patient – medically, psychosocially, esthetically, and thus toward economic and professional rehabilitation as well. When good management along with rehabilitation is instituted, final outcomes should also be measured and reported objectively with the goal of patient-related outcomes (PROMs) and physician-reported outcomes (PROMs) being complementary. Likewise, policies and measures taken including the timing of intervention, technological, and surgical costs along with secondary rehabilitation should also be assessed and reported as value derived outcomes (VDOs).[17] The use of big data, machine learning, and artificial intelligence can further bolster high-volume and complex data to draw meaningful information that will guide local and national trauma management and prevention policies. So, what universal standards can and should be adopted by ophthalmologists and emergency healthcare professionals in the initial assessment of the ophthalmic trauma victim? Any assessment should be universal, easily applicable, time-tested, proposed by experienced clinical practitioners, and applied with minimal training by ophthalmologists and non-ophthalmologists.[18] The Glasgow Coma Scale (GCS) and the Injury Severity Score (ISS) have transformed life-threatening emergency care, early stratification and communication, prognosticate, deliver care, and monitor progress and outcomes. Similarly, the Asia Pacific Ophthalmic Trauma Society (APOTS) has recently introduced and adopted the Pocket Ophthalmic Trauma Reckoner which includes classification of the globe, ocular surface injuries, and orbitofacial fractures [Fig. 1]. A brief overview of the Ocular Trauma Score, Dua’s Classification for Grading and Prognostication of Ocular Surface Chemical injuries, and the Sundar’s Practical Classification of Orbital and Orbitofacial fractures is presented below.Figure 1: APOTS ophthalmic trauma ready reckoner (Acknowledgements: Andres Rousselot, Sandi Soederman)Globe injuries are assessed, scored, and prognosis counseled based on the Ocular Trauma Score (OTS) proposed by Kuhn et al.,[19] a modification of the initial scoring system by Pieramici et al.[20] While the modified OTS is time-tested and validated in predicting final visual acuity with presenting visual acuity as a major predictor in numerous studies,[10,21] there are some limitations including some factors not included which could be considered and potential modifiers to final outcome.[22,23] Some of these include the zone of injury, associated lens injury,[24] presence of intraocular foreign bodies, and timing of surgical intervention. While studies mention enucleation as a potential definitive therapeutic procedure, risk factors for the same include wound length greater than 10 mm, Uveal prolapse, higher zone of injury, presence of IOFB RAPD, globe rupture, and OTS score below 49[25] An important contribution to predicting the risk of retinal detachment following open globe injury was the RD-OGI score. The RD-OGI score is composed of three variables: presenting visual acuity (pVA), zone of injury, and presence of vitreous hemorrhage (VH).[26-28] Where available, Vofo et al.[29] have shown the predictive value of visual evoked potential (VEP) along with OTS as predictors of final visual acuity, although the technology is not readily and universally available, especially in acute situations. Despite the above limitations, the OTS remains the most widely used globe trauma evaluation and prognostication tool [Table 1].Table 1: Ocular Trauma Score (OTS)Likewise, while other classifications exist with advanced computing required by ophthalmologists, the Dua Classification of Ocular Surface Chemical injuries is a simple and practical classification widely in use today [Table 2].[30-32] A more recently proposed E-PIX model based on ischemia, epithelial defect, intraocular pressure, and exposure holds promise but awaits more extensive use.[33]Table 2: Grading and prognosis of ocular chemical injuriesFinally, orbital trauma commonly encountered but often neglected by the comprehensive ophthalmologist and not infrequently managed by non-ophthalmology colleagues where oculoplastic surgeons are either unavailable or poorly trained, has been extensively classified for clinical and research purposes by craniomaxillofacial colleagues. A recently proposed Practical Classification of orbital and orbitofacial fractures[34] of relevance to the ophthalmologist and oculoplastic surgeons along with the patient-specific modifiers (PSM) has provided an easy platform to classify, define indications, threshold, timing of intervention, and the required disciplines that may be involved in delivering timely accurate care[35] minimizing morbidity of the affected individual [Tables 3 and 4] .Table 3: Practical classification of orbital and orbitofacial fracturesTable 4: Patient-specific modifiers (ABCDEFGHI) to determine threshold, timing, and interventionFinally, what can and should the ophthalmic community do? Acknowledge Ocular Trauma and Ocular Adnexal trauma as components of Ophthalmic trauma and treat patients holistically. We should develop and adopt universal classifications with language, communication, standards, and reporting outcomes with regular audits. We need to embrace and practice more effective education, advocacy, and prevention starting in schools and higher educational institutions, workplaces, and to the public. Ophthalmologists to adopt appropriate triaging, grading, scoring, with good patient and family counseling. Clinicians to ensure better and complete data collection with national and global ophthalmic trauma registries. Eg I-GATES[36] Institutions to ensure immediate and accurate emergency care of the ophthalmic trauma victim by trained dedicated professionals with early referral for secondary procedures and further rehabilitation. Enucleation and evisceration of the globe as the primary surgical procedures should be avoided regardless of the severity of injury and guarded prognosis. Ophthalmologists, ophthalmic departments and institutes, and general and multispecialty hospitals should ensure dedicated ophthalmic, and ophthalmic trauma teams take ownership of the victim with integrated ophthalmic trauma units within multidisciplinary trauma teams and institutions.[37] Ophthalmologists become members of Regional, National, and International Ophthalmic Trauma societies, collaborate, and serve humanity under a Global Ophthalmic Trauma Consortium. Finally, with the rallying cry of our pioneers in ocular and adnexal trauma, an increasing number of ophthalmologists are now trained in advanced tertiary care management of the ophthalmic trauma victim. Roping in the services of the Allied Health in rehabilitating patients to premorbid functional status, it is time to make a rally call for ophthalmic trauma as a dedicated subspecialty within ophthalmology to serve patients better and advocate for our patients in hospitals and organizations striving to prevent of needless blinding, disfiguring, and disabling consequences of ophthalmic trauma. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.About the author Gangadhara Sundar, DO, FRCSEd Diplomate, The American Board of Ophthalmology Head, Orbit & Oculofacial Surgery, Ophthalmic Trauma and Oncology, Dept of Ophthalmology National University Hospital, Singapore Adj Assoc Professor, Dept of Ophthalmology, National University of Singapore. [email protected] / [email protected] Dr Ganga obtained his basic training from Chennai, India followed by a residency and advanced subspecialty training in Ophthalmic Plastic & Reconstructive Surgery & Ocular Oncology from the Henry Ford Hospital, Detroit, USA. He specializes in the diseases and surgery of the Eyelids, Lacrimal system, Orbit & Oculofacial diseases with special interest in Ophthalmic Oncology including Retinoblastoma, Orbitofacial Trauma, Thyroid Eye Disease & Dacryology. Committed to clinical and surgical excellence, he is a regional and international expert in his field, travels extensively with invited named lectureships and keynote addresses at various international subspecialty meetings. He has trained Fellows from Singapore, Malaysia, Myanmar, Philippines, India, Thailand, Iran, Syria, the United Kingdom, Nepal, Jordan and Palestine. He has authored numerous scientific papers in his field, including editing a books on Common Medical Emergencies, Orbital Fractures – Principles, Concepts & Techniques and co-edited a book on Ocular Adnexal Lesions. He has and continues to serve in leadership capacities in various national, regional and international professional societies including as the President of the Singapore Society of Ophthalmic Plastic & Reconstructive Surgery (SSOPRS), President, Asia Pacific Ophthalmic Trauma Society (APOTS) and Vice President, International Society of Dacryology & Dry Eyes (ISD-DE).