The prospective study of visual outcome in patients with isolated open-globe injuries

INTRODUCTION

Among the myriad of ocular afflictions, ocular trauma stands out as a significant cause of visual impairment and blindness, particularly among the younger population. Unlike age-related ocular diseases such as cataracts or macular degeneration, which predominantly affect older individuals, ocular trauma can strike an individual of any age, often with devastating consequences. In the realm of ocular trauma, corneoscleral lacerations emerge as a particularly concerning entity, capable of causing extensive damage to the delicate structures of the eye.^[1] The cornea, with its transparent and avascular nature, is the primary refractive surface of the eye, responsible for focusing incoming light onto the retina. The sclera, on the other hand, forms the tough outer shell of the eye, providing structural support and protection to the delicate intraocular contents.

When these structures are compromised by lacerations or perforations, the risk of vision loss and ocular complications escalates dramatically, underscoring the urgent need for intervention. Two types of errors occur in the evaluation of such injuries: Errors of commission and errors of omission. Errors of commission (performing surgery or prescribing medication that is contraindicated) are rare. More common are errors of omission, most frequently a failure to appreciate the true extent of the injury at the time of evaluation. The globe must be closed so that it is watertight with the original anatomy restored and the original function can be as closely approximated as possible.

The Ocular Trauma Classification Group^[2] classified eye injuries based on four characteristics: Mechanism of injury, initial visual acuity, pupillary involvement, and most posterior location of the wound. This classification could be easily performed at the time of initial evaluation and primary injury repair.

Furthermore, the Birmingham eye trauma terminology^[3] represents a significant advancement in the field of ocular trauma classification, offering clear definitions and standardised terminology for describing several types of ocular injuries.

The repair of corneoscleral perforations requires a systematic approach involving detailed history taking, thorough evaluation, and appropriate surgical techniques. Evaluation includes slit-lamp examination and imaging studies to assess the extent of injury and rule out complications. Pre-operative management involves antibiotic therapy and careful consideration of surgical principles to achieve watertight globe closure. Suturing techniques should target wound apposition while avoiding any induced astigmatism. For small perforations, non-surgical methods such as bandage contact lenses or glue application can be effective. Management of complications such as iris incarceration involves careful suturing techniques. Post-operative care includes antibiotics and corticosteroid therapy. Overall, adherence to these principles facilitates successful wound healing and visual recovery.

Hence, repairing corneoscleral perforations requires meticulous attention, precise surgical technique, and consideration of several factors to achieve optimal outcomes and preserve visual function. Hence, this study was undertaken to study and predict factors affecting visual acuity in open-globe injuries and to determine the final visual outcome after intervention.

MATERIALS AND METHODS

The study conducted in a tertiary hospital in central Gujarat between 1 January 2021 and 31 October 2021 aimed to comprehensively evaluate patients with open-globe injuries. Thirty patients with such injuries, involving the cornea, sclera, lens, and iris, were included in the study after obtaining ethical clearance from the Institutional Committee and informed consent from the patients. Patients with closed globe injuries, endophthalmitis, or previous eye surgeries were excluded from the study. Detailed demographic data, including age, sex, occupation, and type of trauma, were recorded for each patient, along with the duration between injury and hospital consultation. History of any primary treatment taken elsewhere after the trauma in the form of topical eye drops or systemic medication was inquired. A history of visual status before injury or a history of wearing glasses or ocular surgery was also asked for. History of other associated systemic illnesses such as diabetes and hypertension was recorded. Inquiry about the exact object causing the injury was done, and injuries were categorised into Zones I, II, and III; with the type of open-globe injuries such as penetrating, perforating, and rupture classified.

Patients underwent a thorough clinical examination, including an assessment of visual acuity, ocular structures, and intraocular pressure. The examination involved torchlight and slit-lamp examinations, dilated fundoscopy (wherever possible), and assessment of eyeball movements. Uncorrected visual acuity and best-corrected pre-operative visual acuity were recorded using Snellen’s chart. Those who had a visual acuity <6/60 were then tested for finger counting. If this too was defective, then the hand movements, perception of light, and projection of rays were assessed. X-ray orbit was performed to detect associated foreign bodies or fractures. Systemic evaluations included basic tests such as blood sugar and blood pressure measurements.

Medical treatment comprised local and systemic antibiotics, anti-inflammatory drugs, topical and systemic antifungals (wherever indicated), topical lubricants, and cycloplegics, while surgical intervention involved primary repair in the form of suturing of corneoscleral and conjunctival lacerations. Post-operative care included antibiotic and steroid therapy, intra ocular pressure (IOP)-lowering drugs, topical and systemic antifungals (wherever indicated), topical lubricants, cycloplegics, and measures to reduce corneal haze and oedema. Subconjunctival injections of dexamethasone and amikacin were administered in a few of the cases, along with topical medications.

Patients were closely monitored postoperatively, with daily examinations and dressing changes. Visual acuity, slit-lamp examination, and fundus evaluation were performed regularly until discharge. Follow-up appointments were scheduled at 1 week, 2 weeks, and 6 weeks, with additional assessments for patients with complications. Ultrasonography B-scan was conducted in cases of suspected vitreous haemorrhage or retinal detachment.

RESULTS

• The majority of the patients were male (80%). The male-to-female ratio was 4:1 in our study.

• The right eye (56.67%) was more commonly involved than the left eye (43.33%)

• The majority of patients had penetrating open-globe injury (53.33%) followed by rupture and perforating open-globe injuries which were 33.34% and 13.33% each, respectively.

• The youngest patient reported was 6 years and the eldest patient was 65 years old. Of the total male patients (24), the majority were in their 2^nd decade (37.5%) of life, followed by 3^rd decade (25%) and 1^st decade (16.7%). Of the total female patients (6), the majority were in the 1^st decade (33.33%) of their life [Figure 1].

• In the majority of the patients, agricultural injuries and industrial injuries were the major mode of injuries followed by others [Figure 2].

• The majority of injuries were caused by wood (26.67%), followed by iron material injury (20%) and others [Figure 3].

• The majority of patients were having zone I injury (43.33%). Patients with Zone II and Zone III injuries were 36.67% and 20% each, respectively.

• Pre-operative best-corrected visual acuity (BCVA) was markedly reduced (<6/60) in 25 patients (83.3%) [Table 1].

• Post-operative BCVA after 6 weeks was found to be <6/60 in 60% of patients and >6/60 in 40% of patients [Table 2].

• Post-operative complications: 33% of patients had no complications, traumatic cataract (16.67%), vitreous haemorrhage (16.67%), retinal detachment (13.33%), corneal opacity (6.67%) and phthisis bulbi (13.33%) were significant post-operative complications after 6 weeks.

• Visual acuity as 6-week follow-up: 60% of patients had improvement in visual acuity as compared to pre-operative visual acuity, 23% of patients had no improvement and 17% of patients had decreased visual acuity than that at the time of presentation.

• Logistic regression of factors affecting the final visual acuity is as follows:

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Figure 1:

Age distribution of patients in the present study.

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Figure 2:

Etiological mode of injury in our study.

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Figure 3:

Distribution of objects causing injury.

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To understand the factors that were associated with a beneficial outcome at the end of 6 weeks, we dichotomised the outcomes into two groups – improvement versus no improvement or deterioration. Subsequently, we carried out logistic regression with all other pertinent factors (i.e. age, sex, occupation, mode of injury, and type of open-globe injury) as the independent variables. While conducting logistic regression, we took improvement in visual acuity as the reference and assessed independent variables against the probability of obtaining improved visual acuity at 6 weeks versus non-improvement/deterioration at 6 weeks. We found that the type of open-globe injury was the only independent variable that was found to be significantly associated with visual outcome at 6 weeks. We observed that participants with ruptured open-globe injuries had an aOR of –0.91 (95% Confidence interval: –1.7, –0.14, P = 0.023) of improvement in visual acuity at 6 weeks. In other words, rupture open-globe injury is significantly predictive of non-improvement/ deterioration of visual acuity at 6 weeks. On assessing model fit, we found that the R2 for the model was 0.58, while the adjusted R2 was 0.24. However, the overall significance (P-value) of the model was found to be 0.1534, indicating that the model is non-significant [Table 3].

DISCUSSION

Our study on open-globe injuries conducted at a tertiary hospital in central Gujarat provides valuable insights into the epidemiology, clinical characteristics, and outcomes of patients with these injuries, comparing the findings with those of other relevant studies.

The study conducted by Toh et al.^[4] found that 76.2% of male patients experienced ocular trauma of the open-globe type. Similarly, Ustaoglu et al.^[5] and Rao et al.^[6] observed that 79% and 90% of patients with open-globe injuries, respectively, were male. Our study confirms a male predominance in open-globe injuries, with 80% of the patients being male. This finding is in agreement with previous research indicating that males are more susceptible to ocular trauma due to increased exposure in occupational and outdoor settings.

The study reveals that patients below 40 years of age accounted for the majority (83%) of open-globe injuries. This aligns with findings from other studies, highlighting the higher risk of ocular trauma in younger individuals, possibly due to greater involvement in activities associated with trauma.

Agricultural and industrial injuries were the most common causes of open-globe injuries in the present study, which too has been reported in the findings of previous research. This underscores the importance of implementing preventive measures and safety protocols in these high-risk environments to reduce the incidence of ocular trauma. Misra et al.^[7] showing that agricultural injuries (43.3%) are the most common cause of ocular trauma. Thevi et al.^[8] found that the majority of injuries occurred at the workplace (36.5%).

Gogate et al.^[9] found that 28% of cases of injuries were due to wooden sticks and Misra et al.^[7] studied that in 21.05% of cases, injuries were caused by a wooden stick. In our study too, wooden sticks were the major causative object. A probable reason for this could be that most of our patients were from rural areas where patients acquired wooden stick injuries during work.

Penetrating injuries accounted for the majority (53.33%) of open-globe injuries in the study, consistent with previous research indicating that penetrating injuries are the most common type of ocular trauma. Court et al.^[10] found that 56.4% of open-globe injuries were of penetrating type followed by globe rupture (35.6%). Ustaoglu et al.^[5] found that 75% of open-globe injuries were penetrating type. In our study too, 53.33% of open-globe injuries were of penetrating type.

Zone I injuries were the most common in the present study, similar to the results of other studies like Rao et al.^[6] where 53% of open-globe injuries were in zone I and Ustaoglu et al.^[5] found that patients with penetrating injury and zone I injury among all injury zones had the highest visual acuity. This emphasizes the importance of precise localisation of the injury for optimal management and prognostication.

The study indicates that a considerable proportion of patients presented with poor pre-operative visual acuity, with 63.3% having vision ranging from hand movement to perception of light. Toh et al.,^[4] studied 42 patients with open-globe injuries and 61.9% patients of them had pre-operative vision hand movement to perception of light. In the present study, 63.3% of patients had pre-operative vision hand movement to perception of light.

However, postoperatively, there was an improvement in visual acuity, with 40% of patients achieving final visual acuity ranging from hand movements to perception of light. These findings underscore the importance of timely intervention and appropriate management in optimising visual outcomes in patients with open-globe injuries.

The present study corroborates the study conducted by Toh et al.^[4] in which they studied 42 patients with open-globe injuries and 40.5% patients of who had final vision hand movement to the perception of light. In the present study, 40% of patients had final visual acuity of hand movement to perception of light. Court et al.^[10] found that 46% of patients achieved a final BCVA of >6/12. Guven et al.^[11] observed that final visual acuity >6/60 in 49.3% of their patients.

Our study reports post-operative complications such as retinal detachment and phthisis bulbi in 13.33% of cases, highlighting the challenges associated with managing open-globe injuries and the importance of close monitoring for complications. This could also be a contributing factor to poor visual outcomes in our patients.

Overall, the discussion emphasizes the study findings of previous research, highlighting key epidemiological trends, causative factors, injury patterns, and visual outcomes in patients with open-globe injuries. By comparing the study findings with those of other relevant studies, the discussion provides valuable insights into the broader context of ocular trauma research and contributes to our understanding of the management and outcomes of open-globe injuries. Further, the delay in the presentation of such serious injuries can also be attributed to the attitude of the rural population which increases the complication rate many fold.

CONCLUSION

Ocular trauma represents a significant public health concern, with the potential to cause profound and lifelong disabilities and to highlight the key points in a nutshell:

• Addressing ocular injuries requires a coordinated effort among healthcare professionals, encompassing accurate classification, precise prognostication, and meticulous surgical management.

• The primary aim of surgical management is rapid closure, attainment of a water-tight compartment, and restoration of normal anatomy as closely as possible.

• The final visual acuity largely depends on the mechanism of the trauma, the location of the wound, and the damaged ocular structures.

Thus, by leveraging advanced classification systems, prognostic tools, and surgical techniques, clinicians can mitigate the impact of ocular trauma and preserve visual function, thereby enhancing the quality of life for affected individuals.