- Email: [email protected]
BB Gun–Related Open Globe Injuries
BB GuneRelated Open Globe Injuries Mehak Aziz, MD, Shriji Patel, MD Purpose: To describe the characteristics and outcomes of patients treated for BB and pellet gunerelated open globe injuries. Design: Retrospective case series. Participants: Patients presenting to a tertiary care trauma center with open globes secondary to BB or pellet gun injury from January 2002 to November 2017. Methods: A retrospective chart review was conducted of all patients presenting with open globe injuries from January 2002 to November 2017. Charts were reviewed to isolate the mechanism of injury related to BB or pellet guns. Demographic data, injury type, presenting clinical examination findings, visual acuity (VA), secondary ocular complications, necessary surgical procedures and long-term outcome data were recorded. Additionally, the ocular trauma score (OTS) was calculated for all patients who had documented VA on presentation. Main Outcome Measure: Final VA. Results: During the study period, 681 open globe injuries were identified, 16 of which met inclusion criteria. Fourteen cases were due to injury from a BB gun and 2 were due to a pellet gun. Fourteen of the 16 patients (88%) were males. The average age of patients at time of presentation was 146.4 years (range, 4e28 years). Common presenting complications included hyphema, traumatic cataract, and retinal detachment. Twelve of the 16 patients required at least one additional surgery after open globe repair. Fifteen (94%) patients had hand motioneonly or worse vision at time of final presentation. Eight patients had no light perception vision in the injured eye at final follow-up. Conclusions: Open globe injuries related to BB or pellet guns result in devastating visual outcomes. They are often associated with multiple complications and the need for additional surgeries. Modern surgical techniques can increase the rate of globe salvage although final vision remains poor. The study findings highlight the risks associated with widely available BB and pellet guns and underscore the importance of eye protection in this setting. Ophthalmology Retina 2018;-:1e6 ª 2018 by the American Academy of Ophthalmology
Open globe injuries can result in devastating trauma to the eye.1e4 They are often associated with a need for multiple surgical procedures including enucleation and generally portend an overall poor visual prognosis. A nonpowder gun is a gun that does not need gun powder to fire and instead uses compressed air, springs, or electricity to fire. This includes BB guns, paintball guns, Airsoft guns (Airsoft Station, St. Paul, MN), and pellet guns. BB guns fire ball bearings, small 4.5mm round balls made of lead or steel, and can reach maximum velocities of 380 m/s if powered by a spring.5 Similarly, pellet guns fire 4.5mm metal, nonspherical pellets. Although often marketed as toys, BB guns and other nonpowder guns have been shown to injure as many as 21 840 Americans each year.6 Children and teenagers account for about 80% of all injuries due to nonpowder guns and the majority of these injuries result from unintentional shootings. In the United States, up to 12% of these injuries involve the eye.6 In 2012, 3161 children 2 to 18 years of age were treated in U.S. emergency departments for eye injuries secondary to nonpowder gun use.5 Injuries have shown to be more common among young males.7e9 Nonpowder guns represent a rising public health concern given their ease of acquisition and unsuspecting ability to cause serious harm. 2018 by the American Academy of Ophthalmology Published by Elsevier Inc.
Open globe injuries caused by BB guns are particularly severe and associated with poor visual prognosis.10,11 The largest case series to date covering BB gunerelated open globe injuries in the United States evaluated patient data from the 1970s; in this series a significant number of patients subsequently required enucleation.1 More recent studies analyzing the risks associated with nonpowder guns have been performed abroad.12,13 In this study, we describe the injury type, management, and outcomes of eyes with BB gunerelated open globe injuries in patients presenting to a tertiary care trauma center from 2002 to 2017. To our knowledge, this series represents the largest compilation of recently reported BB gunerelated open globe injuries in the United States and their outcomes in the setting of modern ophthalmic surgical technique.
Methods A retrospective chart review was performed of all patients with open globe injuries secondary to BB and pellet guns who presented to the Vanderbilt University Medical Center adult and pediatric emergency departments between January 2002 and November 2017. All open globe cases were identified using Current Procedural Terminology codes 65280 and 65285 (repair of laceration https://doi.org/10.1016/j.oret.2018.03.006 ISSN 2468-6530/18
1
Ophthalmology Retina Volume -, Number -, Month 2018 Table 1. Demographics Patient
No. (%)
Male Average age (yrs) Right eye Race Caucasian African American Unknown race Laceration location Cornea Sclera Cornea and sclera BB location Orbit Globe Sphenoid sinus Temporal lobe Initial vision 20/200 HM LP NLP Unable to assess Final vision 20/100 HM LP NLP
14/16 (88%) 146.2 7/16 (44%) 9/16 (56%) 5/16 (31%) 2/16 (13%) 5/16 (31%) 8/16 (50%) 3/16 (19%) 9/16 5/16 1/16 1/16
(56%) (31%) (6%) (6%)
1/16 2/16 6/16 5/16 2/16
(6%) (13%) (38%) (31%) (13%)
1/16 3/16 4/16 8/16
(6%) (19%) (25%) (50%)
HM ¼ Hand motion; LP ¼ light perception; NLP ¼ no light perception.
procedures on the eyeball). These charts were reviewed and open globe injuries due to BB guns or pellet guns were selected. Open globe injury was defined as any full-thickness laceration of the sclera, cornea, or both. The retrospective chart review was approved by the Vanderbilt University institutional review board (IRB 171711). We characterized these injuries by age, sex, race, presenting visual acuity (VA), laceration site, laceration size, and location of BB or pellet. All operative reports were reviewed. Exclusion criteria included nonpenetrating injuries, open globe injuries not related to BB or pellet guns, or those due to unidentified trauma. Patients were followed up for the need for enucleation, number of subsequent surgical procedures, and length of follow-up. Only patients with at least 3 months of follow-up were included. Final VA was recorded as vision at the last follow-up visit. We also assessed for the presence of complications, including hyphema, cataract, vitreous hemorrhage, retinal detachment (RD), and intraocular foreign body. Any evidence of endophthalmitis was recorded. The ocular trauma score (OTS)14 was calculated for all patients. The following OTS parameters were analyzed: initial VA, globe rupture, endophthalmitis, perforation of the globe (presence of both an entrance and an exit wound), RD, and the presence of relative afferent pupillary defect (RAPD). Patients were excluded if no initial VA was available. Patients were not excluded if the presence of RD or RAPD was not documented at time of initial evaluation.
Results Sixteen eyes from 16 patients with open globe injuries from BB or pellet guns were identified between January 2002 and November
2
2017. The average patient age at time of presentation was 146.2 years (range, 4e28 years), with the majority (81%) younger than 20 years of age. Fourteen cases (88%) were due to BB gun injury and 2 cases (12%) were due to pellet gun injury. All were monocular injuries. Five patients (31%) were African Americans, 9 (56%) were Caucasians, and 2 (13%) had no race or ethnicity recorded during their hospital or clinic visits (Table 1). Presenting VA ranged from 20/200 to no light perception (NLP). Only one patient presented with 20/200 vision. Two (13%) patients presented with hand motions vision. Six (38%) patients presented with light perceptioneonly vision and 5 of 16 (31%) patients had NLP vision at time of presentation. The presenting VA results for 2 patients were unable to be recorded due to poor cooperation. Most patients (94%) had documented vitreous hemorrhage, hyphema, or both. Eight eyes (50%) had scleral laceration, 5 eyes (31%) had corneal laceration, and 3 eyes (19%) had combined corneoscleral laceration. The laceration size for those eyes for which this was recorded ranged from 2mm to 7mm. All patients underwent computed tomographic scanning of the orbits to evaluate for retained foreign bodies. For 9 patients (56%) the projectile landed in the orbit. For one patient, the projectile landed in the temporal lobe of the brain, and for another (6%) patient it landed in the sphenoid sinus. Five patients (31%) had confirmed intraocular foreign bodies. RD developed in all patients, either at the time of diagnosis or at subsequent follow-up. A traumatic cataract developed in 11 (69%) eyes. Our series had no cases of endophthalmitis. A total of 22 subsequent ocular surgeries were performed in this cohort of 16 patients. Twelve patients (75%) required at least one additional ocular surgery after their initial open globe repair. One patient eventually underwent an enucleation, and another patient underwent an evisceration due to blind painful eyes (Table 2). At the time of final follow-up (before any globe removal surgery), 15 (94%) patients had hand motions vision or worse. Eight of these patients subsequently had NLP vision. One patient in this cohort had final vision better than hand motions (20/100). The length of follow-up ranged from 5 to 68 months. The ocular trauma score (OTS) was calculated for all patients for whom adequate data points were available. Two patients were excluded because their presenting VA was not recorded. Of the 14 patients for whom the OTS was calculated, 12 patients had an OTS of 1 and 2 patients had an OTS of 2. The 2 patients with an OTS of 2 both had NLP vision at the time of final visual assessment. It is important to note that only patients who had a documented RD at time of presentation received points in this category when calculating the OTS. Although a RD eventually developed in all patients in our study, only 3 patients had a documented RD at time of diagnosis (Table 3).
Discussion Our cases series of BB and pellet gunerelated ocular injuries reaffirms the devastating visual consequences of trauma in this context. The majority of patients in our study had final best-corrected visual acuity of hand motions or worse vision (94%), and exactly half of our patients had final vision of NLP at final assessment. Two patients eventually required globe removal surgery due to NLP
Aziz and Patel
BB GuneRelated Open Globe Injuries
Table 2. Secondary Ocular Complications After Open Globe Repair Patient No.
No. of Subsequent Surgeries
1 2
1 4
3
5
4 5
0 1
6
1
7
4
8 9
1 1
10
1
11
1
12 13 14 15 16
0 0 0* 0 2
Indication for Surgery
Operation Performed
VH and RD VH and tractional RD Tractional RD, cataract Recurrent tractional RD Recurrent tractional RD RD and cataract Recurrent tractional RD Recurrent tractional RD Recurrent tractional RD and band keratopathy Recurrent tractional RD
PPV/MP/SB PPV/MP/RR/EL PPV/MP/SO/lensectomy/anterior chamber washout PPV/MP/RR/EL/1000 centistoke SO PPV/MP/RR/5000 centistoke SO PPV/lensectomy PPV/MP/RR/EL/1000 centistoke SO PPV/MP/RR/EL/1000 centistoke SO Chelation of calcium, epithelial debridement PPV/MP/RR/EL/5000 centistoke SO
Leaking corneal wound with uveal prolapse Complete traumatic RD and traumatic cataract VH, retained FB Blind painful eye Conjunctival thinning Extrusion, exposure, chronic socket drainage RD, traumatic cataract IOFB
Corneal laceration repair with excision of prolapsed uveal tissue PPV/lensectomy/5000 centistokes of SO
VH, total tractional RD, pupillary synechia NLP vision with posterior scleral rupture
Giant retinal tear, VH Recurrent tractional RD
PPV/Removal of magnetic FB Enucleation with implant Conjunctivoplasty with tutoplast placement Replacement of orbital implant PPV/lensectomy/MP/EL/5000 centistoke SO PPV/lensectomy/closure of scleral wound/excision of prolapsed uveal tissue PPV/synechiolysis/lensectomy/MP/5000 centistoke SO Evisceration
PPV/SB/EL/5000 centistokes SO PPV/SO removal/MP/EL/SO placement
EL ¼ endolaser; FAX ¼ fluid air exchange; FB ¼ foreign body; IOFB ¼ intraocular foreign body; MP ¼ membrane peel; NLP ¼ no light perception; PPV ¼ pars plana vitrectomy; RD ¼ retinal detachment, rheg ¼ rhegmatogenous; RR ¼ relaxing retinectomy; SB ¼ scleral buckle; SO ¼ silicone oil; VH ¼ vitreous hemorrhage. *Retinal detachment repair planned but patient refused.
vision and intractable ocular pain. The implications of this severe vision loss are only compounded by the young age of nonpowder gun users. Sternberg et al. described 22 patients with penetrating eye injuries from Airsoft gun pellets who presented to the Wilmer Eye Institute from 1970 to 1981.1 In this case series, 19 eyes were eventually enucleated. In our study of 16 patients from the past 15 years (2002e2017), only one eye underwent enucleation and one eye underwent evisceration. The authors hypothesize the diminished rate of eye removal relates to the evolution of operative technique, especially in the setting of posterior segment trauma. However, despite surgical advances allowing for a higher rate of globe salvage, final visual outcomes continue to remain poor with only one patient in our cohort achieving functional final vision (20/100). Notably, endophthalmitis did not develop in any of our study patients. It is theorized that the heated high-speed projectile renders the laceration site microbiologically sterile. Ahmadabadi et al. recently reported a series of 13 patients who had BB gunerelated open globe injuries and
presented to Farabi Eye Hospital in Tehran, Iran, from 2004 to 2008.12 Before our study, this was the largest recent case series to date on BB gunerelated penetrating ocular injuries. Their study showed that more than half of the patients (7 [54%]) were older than 18 years of age and were not children playing with guns. However, in our study the majority of patients (81%) were younger than age 20. This suggests that in the United States, BB gun injuries are a greater public health issue for the younger population. Their study also showed that only 2 of 13 patients (15.4%) required final enucleation, and the best final VA in their study was counting fingerseonly vision. This supports our hypothesis demonstrating that advances in ophthalmic surgery have increased the chances of preserving the eye after devastating trauma in this setting. Again, both series reported overwhelmingly poor final VA. The OTS is a well-established tool to predict visual outcomes after eye trauma.14 It is based on the data from 2500 patients (both children and adults) recorded in the United States Eye Injury Registry. A higher OTS predicts a better visual prognosis. Previous studies have shown the
3
NLP HM HM NLP LP NLP NLP* HM LP LP NLPy NLP LP NLP NLP 20/100 Yes 23 Yes 23 Yes 23 Yes 23 NA Yes 23 Yes 23 Yes 23 Yes 23 Yes 23 Yes 23 NA Yes 23 Yes 23 Yes 23 Yes 23 þ70 (LP) þ70 (LP) þ70 (LP) þ60 (NLP) UTA þ90 (20/200) þ70 (HM) þ70 (HM) þ70 (LP) þ60 (NLP) þ60 (NLP) UTA þ70 (LP) þ60 (NLP) þ60 (NLP) þ70 (LP) Globe Sphenoid sinus Orbit Orbit Temporal lobe Orbit Globe Orbit Globe Orbit Orbit Orbit Orbit Globe Globe Orbit Sclera Sclera Sclera Sclera Cornea Cornea/Sclera Cornea/Sclera Cornea Sclera Cornea Cornea Cornea/Sclera Sclera Cornea Sclera Sclera M F M M M M F M M M M M M M M M 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
14 16 17 11 12 10 21 16 15 9 8 4 27 8 28 13
Sex
F ¼ female; HM ¼ hand motions; LP ¼ light perception; M ¼ male; NLP ¼ no light perception; RAPD ¼ relative afferent pupillary defect; RD ¼ retinal detachment; UTA ¼ unable to assess; VA, visual acuity. *Enucleated. y Eviscerated.
OTS
1 1 1 1 UTA 2 2 1 1 1 1 UTA 1 1 1 1 33 12 33 12 NA 53 47 33 26 13 23 NA 33 13 26 33 Not documented Yes 10 Absent Present 10 NA Not documented Not documented Not documented Present 10 Present 10 Not documented NA Not documented Present 10 Not documented Not documented No Yes 11 No No NA No No No Yes 11 No No NA No No Yes 11 No Yes 14 Yes 14 Yes 14 Yes 14 NA Yes 14 No Yes 14 No Yes 14 Yes 14 NA Yes 14 Yes 14 No Yes 14
Final Raw Score RAPD RD at Presentation Perforating Injury
Ocular Trauma Score Calculation
Endophthalmitis Globe Rupture
Table 3. Ocular Trauma Score
Initial Raw Score (VA) BB Location Laceration Location Patient No.
Age (yrs)
4
No No No No NA No No No No No No NA No No No No
Final VA
Ophthalmology Retina Volume -, Number -, Month 2018 limitations of using the OTS in the pediatric population and have also noted that the parameter RAPD cannot be evaluated in many cases.15e17 These studies often removed this parameter entirely from their OTS calculation for this reason. The presence or absence of RAPD was not documented for 6 of 14 patients in our study. Despite this, removing the RAPD parameter did not change the final calculated OTS for any of our patients. Similarly, although all of our patients eventually had RDs, only 3 patients had documented detachments at time of initial presentation. This was because the presence of vitreous hemorrhage and/or hyphema precluded an adequate view of the fundus for most cases. Ultrasonography to evaluate for RD was typically avoided preoperatively to avoid additional pressure on an open globe. Our study highlights the difficulty of assessing for these 2 parameters when calculating the OTS for patients with penetrating eye injuries. However, despite these limitations the OTS accurately predicted poor visual prognosis. In our study, 12 patients had an OTS of 1 and 2 patients had an OTS of 2. Only one patient with an OTS of 1 had better final vision than hand motions. Despite current surgical advances, not all eyes can be salvaged after severe penetrating injuries. The globe could not be preserved in 2 patients in our study. One patient (patient 7) requested enucleation for the management of a blind painful eye. Another patient (patient 11) had presenting vision of NLP in the setting of a posterior scleral rupture; proceeding to enucleation was a mutual decision between both the surgeon and patient. The final pathology for both cases was consistent with the clinical examination findings. These 2 cases illustrate the reasons patients and surgeons continue to choose to surgically remove a globe after severe injury. High-velocity open globe injuries have the potential to severely damage multiple ocular structures. This heterogeneity of presentations makes it difficult to pinpoint the exact reason underlying the poor outcomes in these patients. However, we have learned from previous studies that open globe injuries involving the posterior segment have significantly higher rates of poor visual outcomes than injuries that are more anteriorly located.18,19 De Juan et al. studied 453 patients who underwent primary surgical repair of penetrating ocular injuries from 1970 to 1981.20 Their article showed that the prognosis after a penetrating injury is influenced by the nature of the injury and the extent of initial damage. Factors associated with poor visual outcomes included poor VA at presentation, posteriorly located wounds, the presence of dense vitreous hemorrhage, and injuries associated with an intraocular BB pellet. In fact, the presence of an intraocular foreign body did not affect visual prognosis in their study except for cases with an intraocular BB pellet, which was associated with a much worse prognosis. Although the OTS is a helpful predictor, poor outcomes are frequently related to subsequent complications, including proliferative vitreoretinopathy formation that can exert traction on the ciliary body21 and retina.22 Ciliary body dysfunction can lead to hypotony and eventual phthisis, increasing the risk that an eye would ultimately be removed. Traction on the retina increases the risk of RDs,
Aziz and Patel
BB GuneRelated Open Globe Injuries
which leads to poor visual outcomes.23 RD developed in all patients in our study at some point during follow-up, indicating that patients with penetrating ocular BB gun injuries are at high risk for this complication. The majority of the patients in this case series had similar outcomes. All but 2 globes were able to be salvaged, although all patients ultimately had poor vision in the injured eye. It is difficult to make any conclusions regarding ideal surgical management in this setting. However, the benefits of pars plana vitrectomy in open globe injuries has been extensively discussed in the literature.22,24,25 As mentioned in these articles, vitrectomy clears the visual axis, helps in identification and management of retinal breaks, and prevents the formation of late tractional RDs. The timing of the surgery continues to be controversial,25 although studies have shown that intervention performed within 5 weeks is associated with better visual prognosis.26 Intervention after this time increases the risks of proliferative vitreoretinopathy formation. It is also well known that silicone oil can prevent hypotony and subsequent phthisis bulbi27; thus this method of tamponade may play a significant role in globe salvage. Primary scleral buckling has also been shown to improve outcomes and lower rates of proliferative vitreoretinopathy.28 Nine patients in our study had at least one subsequent pars plana vitrectomy, reaffirming its importance after penetrating open globe injuries today. Based on our case series and a review of the literature, we believe urgent surgical intervention to preserve the integrity of the globe remains vital for its preservation. This should soon be followed by retinal consultation and close observation for potential surgical intervention, such as pars plana vitrectomy and silicone oil placement. Further study would be ideal to elucidate the optimal timing and choice of surgery for these patients after initial open globe repair. Lee and Fredrick studied recent epidemiologic trends in nonpowder gun use among children and reported these firearms were a leading cause of pediatric eye injury requiring hospital admission.5 They noted that between 2006 and 2010 the rate of admissions and observations related to these guns among children decreased by 722%, likely due to increased public awareness and legislation during that time. However, the injury rates rebounded and increased by 511% from 2010 to 2012. They hypothesized that this recent rise was related to an increase in the sales of air guns since 2004 that has not been accompanied by an increase in awareness or regulation. Their study cautions that nonpowder air guns continue to be an increasingly prevalent health concern, especially in the pediatric population. Unfortunately, there are currently no federal laws regulating nonpowder guns, and the majority of states allow minors to purchase them.5,29 Appropriately sized polycarbonate lenses have been shown to be resistant to shatter even when hit by BBs at maximum gun velocities. However, only 1 of 71 children have some form of eye protection at the time of injury with these guns.5 Safe storage laws aimed at restricting access to guns among children have been shown to reduce unintentional shootings by 23% in this population. This lends credence to the role of
legislation and awareness in limiting the harmful effects of firearms among children. In conclusion, our series demonstrates the unfortunate consequences associated with ocular injuries from nonpowder guns. Modern ophthalmic surgical techniques significantly improve the possibility of globe salvage. However, visual outcomes remain almost uniformly poor in this setting. Increased awareness about the dangers of nonpowder guns along with an emphasis on eye protection is crucial in preventing devastating vision loss. References 1. Sternberg Jr P, de Juan Jr E, Green WR, Hirst LW, Sommer A. Ocular BB injuries. Ophthalmology. 1984;91:1269e1277. 2. Li X, Zarbin MA, Bhagat N. Pediatric open globe injury: a review of the literature. J Emerg Trauma Shock. 2015;8: 216e223. 3. Liu X, Liu Z, Liu Y, et al. Determination of visual prognosis in children with open globe injuries. Eye (Lond). 2014;28: 852e856. 4. Gupta A, Rahman I, Leatherbarrow B. Open globe injuries in children: factors predictive of a poor final visual acuity. Eye (Lond). 2009;23:621e625. 5. Lee R, Fredrick D. Pediatric eye injuries due to nonpowder guns in the United States, 2002-2012. J AAPOS. 2015;19: 163e168.e1. 6. Laraque D. Injury risk of nonpowder guns. Pediatrics. 2004;114:1357e1361. 7. Schein OD, Enger C, Tielsch JM. The context and consequences of ocular injuries from air guns. Am J Ophthalmol. 1994;117:501e506. 8. LaRoche GR, McIntyre L, Schertzer RM. Epidemiology of severe eye injuries in childhood. Ophthalmology. 1988;95: 1603e1607. 9. Ramstead C, Ng M, Rudnisky CJ. Ocular injuries associated with Airsoft guns: a case series. Can J Ophthalmol. 2008;43: 584e587. 10. Sridhar J, Chang JS, Liao S, Cavuoto KM, Rachitskaya AV. The spectrum of pediatric orbital BB gun injuries: a case series. J Pediatr Ophthalmol Strabismus. 2015;52:e59ee62. 11. Marshall DH, Brownstein S, Addison DJ, Mackenzie SG, Jordan DR, Clarke WN. Air guns: the main cause of enucleation secondary to trauma in children and young adults in the greater Ottawa area in 1974-93. Can J Ophthalmol. 1995;30: 187e192. 12. Ahmadabadi MN, Karkhaneh R, Valeshabad AK, Tabatabai A, Jager MJ, Ahmadabadi EN. Clinical presentation and outcome of perforating ocular injuries due to BB guns: a case series. Injury. 2011;42:492e495. 13. Shuttleworth GN, Galloway P, Sparrow JM, Lane C. Ocular air gun injuries: a one-year surveillance study in the UK and Eire (BOSU). 2001-2002. Eye (Lond). 2009;23:1370e1376. 14. Kuhn F, Maisiak R, Mann L, Mester V, Morris R, Witherspoon CD. The Ocular Trauma Score (OTS). Ophthalmology Clin North Am. 2002;15:163e165. vi. 15. Acar U, Tok OY, Acar DE, Burcu A, Ornek F. A new ocular trauma score in pediatric penetrating eye injuries. Eye. 2011;25:370e374. 16. Unver YB, Acar N, Kapran Z, Altan T. Visual predictive value of the ocular trauma score in children. Br J Ophthalmol. 2008;92:1122e1124. 17. Schorkhuber MM, Wackernagel W, Riedl R, Schneider MR, Wedrich A. Ocular trauma scores in paediatric open globe injuries. Br J Ophthalmol. 2014;98:664e668.
5
Ophthalmology Retina Volume -, Number -, Month 2018 18. Hutton WL, Fuller DG. Factors influencing final visual results in severely injured eyes. Am J Ophthalmol. 1984;97:715e722. 19. Madhusudhan AP, Evelyn-Tai LM, Zamri N, Adil H, WanHazabbah WH. Open globe injury in Hospital Universiti Sains Malaysiada 10-year review. Int J Ophthalmol. 2014;7: 486e490. 20. De Juan Jr E, Sternberg Jr P, Michels RG. Penetrating ocular injuries. Types of injuries and visual results. Ophthalmology. 1983;90:1318e1322. 21. Lopez PF, Grossniklaus HE, Aaberg TM, Sternberg Jr P, Capone Jr A, Lambert HM. Pathogenetic mechanisms in anterior proliferative vitreoretinopathy. Am J Ophthalmol. 1992;114:257e279. 22. Spalding SC, Sternberg Jr P. Controversies in the management of posterior segment ocular trauma. Retina. 1990;10(suppl 1): S76eS82. 23. Jin Y, Chen H, Xu X, Hu Y, Wang C, Ma Z. Traumatic proliferative vitreoretinopathy: clinical and histopathological observations. Retina. 2017;37:1236e1245.
24. Mittra RA, Mieler WF. Controversies in the management of open-globe injuries involving the posterior segment. Surv Ophthalmol. 1999;44:215e225. 25. Agrawal R, Shah M, Mireskandari K, Yong GK. Controversies in ocular trauma classification and management: review. Int Ophthalmol. 2013;33:435e445. 26. Salehi-Had H, Andreoli CM, Andreoli MT, Kloek CE, Mukai S. Visual outcomes of vitreoretinal surgery in eyes with severe open-globe injury presenting with no-light-perception vision. Graefes Arch Clin Exp Ophthalmol. 2009;247: 477e483. 27. Morse LS, McCuen 2nd BW. The use of silicone oil in uveitis and hypotony. Retina. 1991;11:399e404. 28. Cohen D, Levy J, Lifshitz T, et al. The outcomes of primary scleral buckling during repair of posterior segment open-globe injuries. Biomed Res Int. 2014;2014:613434. 29. Nguyen MH, Annest JL, Mercy JA, Ryan GW, Fingerhut LA. Trends in BB/pellet gun injuries in children and teenagers in the United States, 1985-99. Inj Prev. 2002;8:185e191.
Footnotes and Financial Disclosures Originally received: December 23, 2017. Final revision: March 5, 2018. Accepted: March 14, 2018. Available online: ---. Manuscript no. ORET_2017_532. Vanderbilt Eye Institute, Nashville, Tennessee. Financial Disclosures: The authors have no conflicts of interest to disclose. Financial Support: Supported in part by an unrestricted departmental award from Research to Prevent Blindness. Author Contributions: Conception and design: Aziz, Patel. Analysis and interpretation: Aziz, Patel. Data collection: Aziz, Patel.
6
Overall responsibility: Patel. Human Subjects: This study includes human subject/tissues. No animal subjects were used in this study. Study protocol was approved by the Vanderbilt University institutional review board. This retrospective chart review was exempt from obtaining written informed consent, determined to pose minimal risk by the institutional review board. All tenets of the Declaration of Helsinki were followed. Abbreviations and Acronyms: NLP ¼ no light perception; OTS ¼ ocular trauma score; RAPD ¼ relative afferent pupillary defect; RD ¼ retinal detachment; VA ¼ visual acuity. Correspondence: Shriji Patel, MD, Vanderbilt Eye Institute, 2311 Pierce Avenue, Nashville, TN 37232. E-mail: [email protected].
Open globe injuries can result in devastating trauma to the eye.1e4 They are often associated with a need for multiple surgical procedures including enucleation and generally portend an overall poor visual prognosis. A nonpowder gun is a gun that does not need gun powder to fire and instead uses compressed air, springs, or electricity to fire. This includes BB guns, paintball guns, Airsoft guns (Airsoft Station, St. Paul, MN), and pellet guns. BB guns fire ball bearings, small 4.5mm round balls made of lead or steel, and can reach maximum velocities of 380 m/s if powered by a spring.5 Similarly, pellet guns fire 4.5mm metal, nonspherical pellets. Although often marketed as toys, BB guns and other nonpowder guns have been shown to injure as many as 21 840 Americans each year.6 Children and teenagers account for about 80% of all injuries due to nonpowder guns and the majority of these injuries result from unintentional shootings. In the United States, up to 12% of these injuries involve the eye.6 In 2012, 3161 children 2 to 18 years of age were treated in U.S. emergency departments for eye injuries secondary to nonpowder gun use.5 Injuries have shown to be more common among young males.7e9 Nonpowder guns represent a rising public health concern given their ease of acquisition and unsuspecting ability to cause serious harm. 2018 by the American Academy of Ophthalmology Published by Elsevier Inc.
Open globe injuries caused by BB guns are particularly severe and associated with poor visual prognosis.10,11 The largest case series to date covering BB gunerelated open globe injuries in the United States evaluated patient data from the 1970s; in this series a significant number of patients subsequently required enucleation.1 More recent studies analyzing the risks associated with nonpowder guns have been performed abroad.12,13 In this study, we describe the injury type, management, and outcomes of eyes with BB gunerelated open globe injuries in patients presenting to a tertiary care trauma center from 2002 to 2017. To our knowledge, this series represents the largest compilation of recently reported BB gunerelated open globe injuries in the United States and their outcomes in the setting of modern ophthalmic surgical technique.
Methods A retrospective chart review was performed of all patients with open globe injuries secondary to BB and pellet guns who presented to the Vanderbilt University Medical Center adult and pediatric emergency departments between January 2002 and November 2017. All open globe cases were identified using Current Procedural Terminology codes 65280 and 65285 (repair of laceration https://doi.org/10.1016/j.oret.2018.03.006 ISSN 2468-6530/18
1
Ophthalmology Retina Volume -, Number -, Month 2018 Table 1. Demographics Patient
No. (%)
Male Average age (yrs) Right eye Race Caucasian African American Unknown race Laceration location Cornea Sclera Cornea and sclera BB location Orbit Globe Sphenoid sinus Temporal lobe Initial vision 20/200 HM LP NLP Unable to assess Final vision 20/100 HM LP NLP
14/16 (88%) 146.2 7/16 (44%) 9/16 (56%) 5/16 (31%) 2/16 (13%) 5/16 (31%) 8/16 (50%) 3/16 (19%) 9/16 5/16 1/16 1/16
(56%) (31%) (6%) (6%)
1/16 2/16 6/16 5/16 2/16
(6%) (13%) (38%) (31%) (13%)
1/16 3/16 4/16 8/16
(6%) (19%) (25%) (50%)
HM ¼ Hand motion; LP ¼ light perception; NLP ¼ no light perception.
procedures on the eyeball). These charts were reviewed and open globe injuries due to BB guns or pellet guns were selected. Open globe injury was defined as any full-thickness laceration of the sclera, cornea, or both. The retrospective chart review was approved by the Vanderbilt University institutional review board (IRB 171711). We characterized these injuries by age, sex, race, presenting visual acuity (VA), laceration site, laceration size, and location of BB or pellet. All operative reports were reviewed. Exclusion criteria included nonpenetrating injuries, open globe injuries not related to BB or pellet guns, or those due to unidentified trauma. Patients were followed up for the need for enucleation, number of subsequent surgical procedures, and length of follow-up. Only patients with at least 3 months of follow-up were included. Final VA was recorded as vision at the last follow-up visit. We also assessed for the presence of complications, including hyphema, cataract, vitreous hemorrhage, retinal detachment (RD), and intraocular foreign body. Any evidence of endophthalmitis was recorded. The ocular trauma score (OTS)14 was calculated for all patients. The following OTS parameters were analyzed: initial VA, globe rupture, endophthalmitis, perforation of the globe (presence of both an entrance and an exit wound), RD, and the presence of relative afferent pupillary defect (RAPD). Patients were excluded if no initial VA was available. Patients were not excluded if the presence of RD or RAPD was not documented at time of initial evaluation.
Results Sixteen eyes from 16 patients with open globe injuries from BB or pellet guns were identified between January 2002 and November
2
2017. The average patient age at time of presentation was 146.2 years (range, 4e28 years), with the majority (81%) younger than 20 years of age. Fourteen cases (88%) were due to BB gun injury and 2 cases (12%) were due to pellet gun injury. All were monocular injuries. Five patients (31%) were African Americans, 9 (56%) were Caucasians, and 2 (13%) had no race or ethnicity recorded during their hospital or clinic visits (Table 1). Presenting VA ranged from 20/200 to no light perception (NLP). Only one patient presented with 20/200 vision. Two (13%) patients presented with hand motions vision. Six (38%) patients presented with light perceptioneonly vision and 5 of 16 (31%) patients had NLP vision at time of presentation. The presenting VA results for 2 patients were unable to be recorded due to poor cooperation. Most patients (94%) had documented vitreous hemorrhage, hyphema, or both. Eight eyes (50%) had scleral laceration, 5 eyes (31%) had corneal laceration, and 3 eyes (19%) had combined corneoscleral laceration. The laceration size for those eyes for which this was recorded ranged from 2mm to 7mm. All patients underwent computed tomographic scanning of the orbits to evaluate for retained foreign bodies. For 9 patients (56%) the projectile landed in the orbit. For one patient, the projectile landed in the temporal lobe of the brain, and for another (6%) patient it landed in the sphenoid sinus. Five patients (31%) had confirmed intraocular foreign bodies. RD developed in all patients, either at the time of diagnosis or at subsequent follow-up. A traumatic cataract developed in 11 (69%) eyes. Our series had no cases of endophthalmitis. A total of 22 subsequent ocular surgeries were performed in this cohort of 16 patients. Twelve patients (75%) required at least one additional ocular surgery after their initial open globe repair. One patient eventually underwent an enucleation, and another patient underwent an evisceration due to blind painful eyes (Table 2). At the time of final follow-up (before any globe removal surgery), 15 (94%) patients had hand motions vision or worse. Eight of these patients subsequently had NLP vision. One patient in this cohort had final vision better than hand motions (20/100). The length of follow-up ranged from 5 to 68 months. The ocular trauma score (OTS) was calculated for all patients for whom adequate data points were available. Two patients were excluded because their presenting VA was not recorded. Of the 14 patients for whom the OTS was calculated, 12 patients had an OTS of 1 and 2 patients had an OTS of 2. The 2 patients with an OTS of 2 both had NLP vision at the time of final visual assessment. It is important to note that only patients who had a documented RD at time of presentation received points in this category when calculating the OTS. Although a RD eventually developed in all patients in our study, only 3 patients had a documented RD at time of diagnosis (Table 3).
Discussion Our cases series of BB and pellet gunerelated ocular injuries reaffirms the devastating visual consequences of trauma in this context. The majority of patients in our study had final best-corrected visual acuity of hand motions or worse vision (94%), and exactly half of our patients had final vision of NLP at final assessment. Two patients eventually required globe removal surgery due to NLP
Aziz and Patel
BB GuneRelated Open Globe Injuries
Table 2. Secondary Ocular Complications After Open Globe Repair Patient No.
No. of Subsequent Surgeries
1 2
1 4
3
5
4 5
0 1
6
1
7
4
8 9
1 1
10
1
11
1
12 13 14 15 16
0 0 0* 0 2
Indication for Surgery
Operation Performed
VH and RD VH and tractional RD Tractional RD, cataract Recurrent tractional RD Recurrent tractional RD RD and cataract Recurrent tractional RD Recurrent tractional RD Recurrent tractional RD and band keratopathy Recurrent tractional RD
PPV/MP/SB PPV/MP/RR/EL PPV/MP/SO/lensectomy/anterior chamber washout PPV/MP/RR/EL/1000 centistoke SO PPV/MP/RR/5000 centistoke SO PPV/lensectomy PPV/MP/RR/EL/1000 centistoke SO PPV/MP/RR/EL/1000 centistoke SO Chelation of calcium, epithelial debridement PPV/MP/RR/EL/5000 centistoke SO
Leaking corneal wound with uveal prolapse Complete traumatic RD and traumatic cataract VH, retained FB Blind painful eye Conjunctival thinning Extrusion, exposure, chronic socket drainage RD, traumatic cataract IOFB
Corneal laceration repair with excision of prolapsed uveal tissue PPV/lensectomy/5000 centistokes of SO
VH, total tractional RD, pupillary synechia NLP vision with posterior scleral rupture
Giant retinal tear, VH Recurrent tractional RD
PPV/Removal of magnetic FB Enucleation with implant Conjunctivoplasty with tutoplast placement Replacement of orbital implant PPV/lensectomy/MP/EL/5000 centistoke SO PPV/lensectomy/closure of scleral wound/excision of prolapsed uveal tissue PPV/synechiolysis/lensectomy/MP/5000 centistoke SO Evisceration
PPV/SB/EL/5000 centistokes SO PPV/SO removal/MP/EL/SO placement
EL ¼ endolaser; FAX ¼ fluid air exchange; FB ¼ foreign body; IOFB ¼ intraocular foreign body; MP ¼ membrane peel; NLP ¼ no light perception; PPV ¼ pars plana vitrectomy; RD ¼ retinal detachment, rheg ¼ rhegmatogenous; RR ¼ relaxing retinectomy; SB ¼ scleral buckle; SO ¼ silicone oil; VH ¼ vitreous hemorrhage. *Retinal detachment repair planned but patient refused.
vision and intractable ocular pain. The implications of this severe vision loss are only compounded by the young age of nonpowder gun users. Sternberg et al. described 22 patients with penetrating eye injuries from Airsoft gun pellets who presented to the Wilmer Eye Institute from 1970 to 1981.1 In this case series, 19 eyes were eventually enucleated. In our study of 16 patients from the past 15 years (2002e2017), only one eye underwent enucleation and one eye underwent evisceration. The authors hypothesize the diminished rate of eye removal relates to the evolution of operative technique, especially in the setting of posterior segment trauma. However, despite surgical advances allowing for a higher rate of globe salvage, final visual outcomes continue to remain poor with only one patient in our cohort achieving functional final vision (20/100). Notably, endophthalmitis did not develop in any of our study patients. It is theorized that the heated high-speed projectile renders the laceration site microbiologically sterile. Ahmadabadi et al. recently reported a series of 13 patients who had BB gunerelated open globe injuries and
presented to Farabi Eye Hospital in Tehran, Iran, from 2004 to 2008.12 Before our study, this was the largest recent case series to date on BB gunerelated penetrating ocular injuries. Their study showed that more than half of the patients (7 [54%]) were older than 18 years of age and were not children playing with guns. However, in our study the majority of patients (81%) were younger than age 20. This suggests that in the United States, BB gun injuries are a greater public health issue for the younger population. Their study also showed that only 2 of 13 patients (15.4%) required final enucleation, and the best final VA in their study was counting fingerseonly vision. This supports our hypothesis demonstrating that advances in ophthalmic surgery have increased the chances of preserving the eye after devastating trauma in this setting. Again, both series reported overwhelmingly poor final VA. The OTS is a well-established tool to predict visual outcomes after eye trauma.14 It is based on the data from 2500 patients (both children and adults) recorded in the United States Eye Injury Registry. A higher OTS predicts a better visual prognosis. Previous studies have shown the
3
NLP HM HM NLP LP NLP NLP* HM LP LP NLPy NLP LP NLP NLP 20/100 Yes 23 Yes 23 Yes 23 Yes 23 NA Yes 23 Yes 23 Yes 23 Yes 23 Yes 23 Yes 23 NA Yes 23 Yes 23 Yes 23 Yes 23 þ70 (LP) þ70 (LP) þ70 (LP) þ60 (NLP) UTA þ90 (20/200) þ70 (HM) þ70 (HM) þ70 (LP) þ60 (NLP) þ60 (NLP) UTA þ70 (LP) þ60 (NLP) þ60 (NLP) þ70 (LP) Globe Sphenoid sinus Orbit Orbit Temporal lobe Orbit Globe Orbit Globe Orbit Orbit Orbit Orbit Globe Globe Orbit Sclera Sclera Sclera Sclera Cornea Cornea/Sclera Cornea/Sclera Cornea Sclera Cornea Cornea Cornea/Sclera Sclera Cornea Sclera Sclera M F M M M M F M M M M M M M M M 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
14 16 17 11 12 10 21 16 15 9 8 4 27 8 28 13
Sex
F ¼ female; HM ¼ hand motions; LP ¼ light perception; M ¼ male; NLP ¼ no light perception; RAPD ¼ relative afferent pupillary defect; RD ¼ retinal detachment; UTA ¼ unable to assess; VA, visual acuity. *Enucleated. y Eviscerated.
OTS
1 1 1 1 UTA 2 2 1 1 1 1 UTA 1 1 1 1 33 12 33 12 NA 53 47 33 26 13 23 NA 33 13 26 33 Not documented Yes 10 Absent Present 10 NA Not documented Not documented Not documented Present 10 Present 10 Not documented NA Not documented Present 10 Not documented Not documented No Yes 11 No No NA No No No Yes 11 No No NA No No Yes 11 No Yes 14 Yes 14 Yes 14 Yes 14 NA Yes 14 No Yes 14 No Yes 14 Yes 14 NA Yes 14 Yes 14 No Yes 14
Final Raw Score RAPD RD at Presentation Perforating Injury
Ocular Trauma Score Calculation
Endophthalmitis Globe Rupture
Table 3. Ocular Trauma Score
Initial Raw Score (VA) BB Location Laceration Location Patient No.
Age (yrs)
4
No No No No NA No No No No No No NA No No No No
Final VA
Ophthalmology Retina Volume -, Number -, Month 2018 limitations of using the OTS in the pediatric population and have also noted that the parameter RAPD cannot be evaluated in many cases.15e17 These studies often removed this parameter entirely from their OTS calculation for this reason. The presence or absence of RAPD was not documented for 6 of 14 patients in our study. Despite this, removing the RAPD parameter did not change the final calculated OTS for any of our patients. Similarly, although all of our patients eventually had RDs, only 3 patients had documented detachments at time of initial presentation. This was because the presence of vitreous hemorrhage and/or hyphema precluded an adequate view of the fundus for most cases. Ultrasonography to evaluate for RD was typically avoided preoperatively to avoid additional pressure on an open globe. Our study highlights the difficulty of assessing for these 2 parameters when calculating the OTS for patients with penetrating eye injuries. However, despite these limitations the OTS accurately predicted poor visual prognosis. In our study, 12 patients had an OTS of 1 and 2 patients had an OTS of 2. Only one patient with an OTS of 1 had better final vision than hand motions. Despite current surgical advances, not all eyes can be salvaged after severe penetrating injuries. The globe could not be preserved in 2 patients in our study. One patient (patient 7) requested enucleation for the management of a blind painful eye. Another patient (patient 11) had presenting vision of NLP in the setting of a posterior scleral rupture; proceeding to enucleation was a mutual decision between both the surgeon and patient. The final pathology for both cases was consistent with the clinical examination findings. These 2 cases illustrate the reasons patients and surgeons continue to choose to surgically remove a globe after severe injury. High-velocity open globe injuries have the potential to severely damage multiple ocular structures. This heterogeneity of presentations makes it difficult to pinpoint the exact reason underlying the poor outcomes in these patients. However, we have learned from previous studies that open globe injuries involving the posterior segment have significantly higher rates of poor visual outcomes than injuries that are more anteriorly located.18,19 De Juan et al. studied 453 patients who underwent primary surgical repair of penetrating ocular injuries from 1970 to 1981.20 Their article showed that the prognosis after a penetrating injury is influenced by the nature of the injury and the extent of initial damage. Factors associated with poor visual outcomes included poor VA at presentation, posteriorly located wounds, the presence of dense vitreous hemorrhage, and injuries associated with an intraocular BB pellet. In fact, the presence of an intraocular foreign body did not affect visual prognosis in their study except for cases with an intraocular BB pellet, which was associated with a much worse prognosis. Although the OTS is a helpful predictor, poor outcomes are frequently related to subsequent complications, including proliferative vitreoretinopathy formation that can exert traction on the ciliary body21 and retina.22 Ciliary body dysfunction can lead to hypotony and eventual phthisis, increasing the risk that an eye would ultimately be removed. Traction on the retina increases the risk of RDs,
Aziz and Patel
BB GuneRelated Open Globe Injuries
which leads to poor visual outcomes.23 RD developed in all patients in our study at some point during follow-up, indicating that patients with penetrating ocular BB gun injuries are at high risk for this complication. The majority of the patients in this case series had similar outcomes. All but 2 globes were able to be salvaged, although all patients ultimately had poor vision in the injured eye. It is difficult to make any conclusions regarding ideal surgical management in this setting. However, the benefits of pars plana vitrectomy in open globe injuries has been extensively discussed in the literature.22,24,25 As mentioned in these articles, vitrectomy clears the visual axis, helps in identification and management of retinal breaks, and prevents the formation of late tractional RDs. The timing of the surgery continues to be controversial,25 although studies have shown that intervention performed within 5 weeks is associated with better visual prognosis.26 Intervention after this time increases the risks of proliferative vitreoretinopathy formation. It is also well known that silicone oil can prevent hypotony and subsequent phthisis bulbi27; thus this method of tamponade may play a significant role in globe salvage. Primary scleral buckling has also been shown to improve outcomes and lower rates of proliferative vitreoretinopathy.28 Nine patients in our study had at least one subsequent pars plana vitrectomy, reaffirming its importance after penetrating open globe injuries today. Based on our case series and a review of the literature, we believe urgent surgical intervention to preserve the integrity of the globe remains vital for its preservation. This should soon be followed by retinal consultation and close observation for potential surgical intervention, such as pars plana vitrectomy and silicone oil placement. Further study would be ideal to elucidate the optimal timing and choice of surgery for these patients after initial open globe repair. Lee and Fredrick studied recent epidemiologic trends in nonpowder gun use among children and reported these firearms were a leading cause of pediatric eye injury requiring hospital admission.5 They noted that between 2006 and 2010 the rate of admissions and observations related to these guns among children decreased by 722%, likely due to increased public awareness and legislation during that time. However, the injury rates rebounded and increased by 511% from 2010 to 2012. They hypothesized that this recent rise was related to an increase in the sales of air guns since 2004 that has not been accompanied by an increase in awareness or regulation. Their study cautions that nonpowder air guns continue to be an increasingly prevalent health concern, especially in the pediatric population. Unfortunately, there are currently no federal laws regulating nonpowder guns, and the majority of states allow minors to purchase them.5,29 Appropriately sized polycarbonate lenses have been shown to be resistant to shatter even when hit by BBs at maximum gun velocities. However, only 1 of 71 children have some form of eye protection at the time of injury with these guns.5 Safe storage laws aimed at restricting access to guns among children have been shown to reduce unintentional shootings by 23% in this population. This lends credence to the role of
legislation and awareness in limiting the harmful effects of firearms among children. In conclusion, our series demonstrates the unfortunate consequences associated with ocular injuries from nonpowder guns. Modern ophthalmic surgical techniques significantly improve the possibility of globe salvage. However, visual outcomes remain almost uniformly poor in this setting. Increased awareness about the dangers of nonpowder guns along with an emphasis on eye protection is crucial in preventing devastating vision loss. References 1. Sternberg Jr P, de Juan Jr E, Green WR, Hirst LW, Sommer A. Ocular BB injuries. Ophthalmology. 1984;91:1269e1277. 2. Li X, Zarbin MA, Bhagat N. Pediatric open globe injury: a review of the literature. J Emerg Trauma Shock. 2015;8: 216e223. 3. Liu X, Liu Z, Liu Y, et al. Determination of visual prognosis in children with open globe injuries. Eye (Lond). 2014;28: 852e856. 4. Gupta A, Rahman I, Leatherbarrow B. Open globe injuries in children: factors predictive of a poor final visual acuity. Eye (Lond). 2009;23:621e625. 5. Lee R, Fredrick D. Pediatric eye injuries due to nonpowder guns in the United States, 2002-2012. J AAPOS. 2015;19: 163e168.e1. 6. Laraque D. Injury risk of nonpowder guns. Pediatrics. 2004;114:1357e1361. 7. Schein OD, Enger C, Tielsch JM. The context and consequences of ocular injuries from air guns. Am J Ophthalmol. 1994;117:501e506. 8. LaRoche GR, McIntyre L, Schertzer RM. Epidemiology of severe eye injuries in childhood. Ophthalmology. 1988;95: 1603e1607. 9. Ramstead C, Ng M, Rudnisky CJ. Ocular injuries associated with Airsoft guns: a case series. Can J Ophthalmol. 2008;43: 584e587. 10. Sridhar J, Chang JS, Liao S, Cavuoto KM, Rachitskaya AV. The spectrum of pediatric orbital BB gun injuries: a case series. J Pediatr Ophthalmol Strabismus. 2015;52:e59ee62. 11. Marshall DH, Brownstein S, Addison DJ, Mackenzie SG, Jordan DR, Clarke WN. Air guns: the main cause of enucleation secondary to trauma in children and young adults in the greater Ottawa area in 1974-93. Can J Ophthalmol. 1995;30: 187e192. 12. Ahmadabadi MN, Karkhaneh R, Valeshabad AK, Tabatabai A, Jager MJ, Ahmadabadi EN. Clinical presentation and outcome of perforating ocular injuries due to BB guns: a case series. Injury. 2011;42:492e495. 13. Shuttleworth GN, Galloway P, Sparrow JM, Lane C. Ocular air gun injuries: a one-year surveillance study in the UK and Eire (BOSU). 2001-2002. Eye (Lond). 2009;23:1370e1376. 14. Kuhn F, Maisiak R, Mann L, Mester V, Morris R, Witherspoon CD. The Ocular Trauma Score (OTS). Ophthalmology Clin North Am. 2002;15:163e165. vi. 15. Acar U, Tok OY, Acar DE, Burcu A, Ornek F. A new ocular trauma score in pediatric penetrating eye injuries. Eye. 2011;25:370e374. 16. Unver YB, Acar N, Kapran Z, Altan T. Visual predictive value of the ocular trauma score in children. Br J Ophthalmol. 2008;92:1122e1124. 17. Schorkhuber MM, Wackernagel W, Riedl R, Schneider MR, Wedrich A. Ocular trauma scores in paediatric open globe injuries. Br J Ophthalmol. 2014;98:664e668.
5
Ophthalmology Retina Volume -, Number -, Month 2018 18. Hutton WL, Fuller DG. Factors influencing final visual results in severely injured eyes. Am J Ophthalmol. 1984;97:715e722. 19. Madhusudhan AP, Evelyn-Tai LM, Zamri N, Adil H, WanHazabbah WH. Open globe injury in Hospital Universiti Sains Malaysiada 10-year review. Int J Ophthalmol. 2014;7: 486e490. 20. De Juan Jr E, Sternberg Jr P, Michels RG. Penetrating ocular injuries. Types of injuries and visual results. Ophthalmology. 1983;90:1318e1322. 21. Lopez PF, Grossniklaus HE, Aaberg TM, Sternberg Jr P, Capone Jr A, Lambert HM. Pathogenetic mechanisms in anterior proliferative vitreoretinopathy. Am J Ophthalmol. 1992;114:257e279. 22. Spalding SC, Sternberg Jr P. Controversies in the management of posterior segment ocular trauma. Retina. 1990;10(suppl 1): S76eS82. 23. Jin Y, Chen H, Xu X, Hu Y, Wang C, Ma Z. Traumatic proliferative vitreoretinopathy: clinical and histopathological observations. Retina. 2017;37:1236e1245.
24. Mittra RA, Mieler WF. Controversies in the management of open-globe injuries involving the posterior segment. Surv Ophthalmol. 1999;44:215e225. 25. Agrawal R, Shah M, Mireskandari K, Yong GK. Controversies in ocular trauma classification and management: review. Int Ophthalmol. 2013;33:435e445. 26. Salehi-Had H, Andreoli CM, Andreoli MT, Kloek CE, Mukai S. Visual outcomes of vitreoretinal surgery in eyes with severe open-globe injury presenting with no-light-perception vision. Graefes Arch Clin Exp Ophthalmol. 2009;247: 477e483. 27. Morse LS, McCuen 2nd BW. The use of silicone oil in uveitis and hypotony. Retina. 1991;11:399e404. 28. Cohen D, Levy J, Lifshitz T, et al. The outcomes of primary scleral buckling during repair of posterior segment open-globe injuries. Biomed Res Int. 2014;2014:613434. 29. Nguyen MH, Annest JL, Mercy JA, Ryan GW, Fingerhut LA. Trends in BB/pellet gun injuries in children and teenagers in the United States, 1985-99. Inj Prev. 2002;8:185e191.
Footnotes and Financial Disclosures Originally received: December 23, 2017. Final revision: March 5, 2018. Accepted: March 14, 2018. Available online: ---. Manuscript no. ORET_2017_532. Vanderbilt Eye Institute, Nashville, Tennessee. Financial Disclosures: The authors have no conflicts of interest to disclose. Financial Support: Supported in part by an unrestricted departmental award from Research to Prevent Blindness. Author Contributions: Conception and design: Aziz, Patel. Analysis and interpretation: Aziz, Patel. Data collection: Aziz, Patel.
6
Overall responsibility: Patel. Human Subjects: This study includes human subject/tissues. No animal subjects were used in this study. Study protocol was approved by the Vanderbilt University institutional review board. This retrospective chart review was exempt from obtaining written informed consent, determined to pose minimal risk by the institutional review board. All tenets of the Declaration of Helsinki were followed. Abbreviations and Acronyms: NLP ¼ no light perception; OTS ¼ ocular trauma score; RAPD ¼ relative afferent pupillary defect; RD ¼ retinal detachment; VA ¼ visual acuity. Correspondence: Shriji Patel, MD, Vanderbilt Eye Institute, 2311 Pierce Avenue, Nashville, TN 37232. E-mail: [email protected].