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Prognostic indicators of open globe injuries in children
American Journal of Emergency Medicine (2009) 27, 530–535
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Original Contribution
Prognostic indicators of open globe injuries in children Ching-Hsing Lee MD a , Lan Lee MD b , Ling-Yuh Kao MD b , Ken-Kuo Lin MD b , Meng-Ling Yang MD b,⁎ a
Department of Emergency Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kweishan 333, Taoyuan, Taiwan, ROC b Department of Ophthalmology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Kweishan 333, Taoyuan, Taiwan, ROC Received 12 March 2008; revised 4 April 2008; accepted 8 April 2008
Abstract Purpose: To determine the prognostic indicators of visual outcome in children with open globe injuries. Basic procedures: The charts of 62 patients, 16 years of age or younger, who had been treated for open globe injuries were reviewed. Main findings: The types of injury included penetrating (30 eyes), rupture (20 eyes), intraocular foreign body (10 eyes), and perforation (2 eyes). Sharp objects, such as knives or scissors, were the most common causes of open globe injuries. A visual acuity (VA) of at least 20/40 was achieved in 80.8% (21/26) of eyes with a corneal injury only, in 45.5% (5/11) of eyes with additional lens damage, and in 17.4% (4/23) of eyes with extensive anterior and posterior injuries. Conclusions: Unfavorable outcomes were related to the location of injury, the extent of injury, the initial presentation of hyphema, vitreous hemorrhage, retina detachment, cornea wound across the pupil, and the development of endophthalmitis. © 2009 Elsevier Inc. All rights reserved.
1. Introduction Ocular traumas often cause significant visual loss and are leading causes of noncongenital unilateral blindness in children [1]. In the United States, a population-based study reported the annual incidence of ocular trauma in children to be 15.2 per 100000 [2]. Worldwide, 2% to 14% of the pediatric ocular trauma patients ended in severe visual impairment or blindness [3-5]. Compared to closed globe injuries, open globe injuries yield the worst visual outcomes in ocular trauma [6]. Previous studies have shown that in
adult patients with penetrating ocular injuries, factors such as initial visual acuity, type of injury, location and extent of the wound, type of lens damage, severity of vitreous hemorrhage, and type of intraocular foreign body correlated with the final visual outcome [7,8]. However, there are limited studies regarding the anatomic and functional outcomes after open globe injuries in children [9]. We report herein our experience with treating childhood open globe injuries and determine the prognostic indicators of visual outcome.
2. Methods ⁎ Corresponding author. Tel.: +886 3 3281200x8666; fax: +886 3 3287798. E-mail address: [email protected] (M.-L. Yang). 0735-6757/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.ajem.2008.04.004
This study consisted of a consecutive series of pediatric patients younger than 16 years with open globe injuries who
Open globe injuries in children underwent surgery between May 1996 and August 2005 at Chang Gung Memorial Hospital, a medical center and referral center serving the northern area of Taiwan. An open globe injury was defined as a full thickness wound of the eyewall involving the cornea, the sclera, or both [10]. The patient's age, sex, cause of injury, type of injury, location of injury, severity of injury, surgical intervention, and final visual acuity (VA) were recorded and analyzed. Data were obtained from the findings of the initial examination in the ED or at the time of surgery. The type of injury was classified according to the Ocular Trauma Classification Group guidelines [10] and the Birmingham Eye Trauma Terminology [11] as penetration, perforation, intraocular foreign body, or rupture. Penetrating injury was defined as single laceration of the eyewall, usually caused by a sharp object. Perforating injury was defined as 2 fullthickness lacerations (entrance and exit) of the eyewall by the same agent, usually caused by a sharp object or missile. Rupture referred to full thickness wound of the eyewall, caused by a blunt object. The impact results in a momentary increase in intraocular pressure and an inside-out injury mechanism. The location of the injury was classified according to Ocular Trauma Classification Group as follows: zone 1, wound involvement limited to the cornea; zone 2, full thickness wound involving the sclera and no more posterior than 5 mm from the corneoscleral limbus; and zone 3, wound involvement posterior to the anterior 5 mm of the sclera. The severity of injury was classified according to Eagling [12] as follows: grade 1, cornea/anterior sclera with or without prolapse of the iris; grade 2, wound to the anterior segment plus lens damage; grade 3, posterior segment injury with vitreous loss; and grade 4, extensive anterior and posterior injuries. Surgical intervention was performed under general anesthesia and using an operating microscope in all cases. All corneal wounds were sutured with 10/0 nylon and scleral wounds were sutured with 8/0 vicryl. Additional procedures at the time of initial repair included lens aspiration in eyes
531 Table 1
Causes of ocular injury
Scissors, knife Stick Nail Projectile Glass Pencil Fall Toy Sport Traffic accident Tool Miscellaneous Unknown
n
%
15 7 6 5 4 4 4 3 2 2 2 4 4
24.2 11.3 9.7 8.1 6.5 6.5 6.5 4.8 3.2 3.2 3.2 6.5 6.5
with lens capsule rupture and vitrectomy in eyes with vitreous loss. Subconjunctival gentamicin injection was given at the end of every surgery. Postoperative treatment consisted of local antibiotics twice per day in all cases and additional systemic antibiotics were given for 3 to 5 days in some cases. Follow-up was scheduled at 1, 2, and 4 weeks after discharge and then at 3- to 6-month intervals. Prescription of spectacles and occlusion therapy were suggested for patients younger than 9 years. Visual acuity was assessed with the Landolt C test at a distance of 6 m. Good visual outcome was defined as a VA better than 20/40 and poor visual outcome was defined as a VA less than 20/ 200, according to a previous study [9]. Ocular status and VA at final follow-up visit were obtained from the records. All analyses were performed using the SPSS program package (version 10.0, SPSS, Inc, Chicago, Ill). For univariant analyses, we used the Student t test for continuous variables, χ2 analysis test for categorical variables, and odds ratios for each variable. A P value of less than .05 was considered statistically significant. Those variables with odds ratios greater than 2 were considered to be prognostic indicators.
3. Results There were 66 patients, 2 to 16 years of age, with open globe injuries who were treated during the abovementioned Table 2
Visual outcome and type of injury (n=62)
Injury type
n
%
Visual acuity ≥20/40
≥20/200
b20/200
Penetration 30 48.4 11 (55.0%) 23 (76.7%) 7 (23.3%) Rupture 20 32.3 12 (40.0%) 13 (65.0%) 7 (35.0%) Intraocular 10 16.1 7 (70.0%) 7 (70.0%) 3 (30.0%) foreign body Perforating 2 3.2 1 (50%) 2 (100%) 0 (0%) Fig. 1 Age and sex distribution of children with open globe injuries.
χ2 Analysis was used to determine statistical significance regarding VA ≥20/200 between types of injury (P = .655).
532
C.-H. Lee et al.
Table 3
Visual outcome and location of injury (n=62)
Zone
n
%
Visual acuity ≥20/40
≥20/200
b20/200
1 2 3
49 9 4
79.0 14.5 6.5
26 (53.1%) 5 (55.6%) 0 (0%)
39 (79.6%) 5 (55.6%) 1 (25.0%)
10 (20.4%) 4 (44.4%) 3 (75.0%)
period. Four patients were excluded owing to incomplete records. Follow-up varied from 5 days to 6 years, with a mean of 17.9 months. Of the 62 patients enrolled, 45 patients (72.6%) were males and 17 patients (27.4%) were females. Boys were more likely to have open globe injuries than girls (P = .004). The average age at the time of injury was 8.9 ± 4.6 years. The distribution of age and sex of the patients with open globe injuries is summarized in Fig. 1. No patient in this series had bilateral injuries. Twenty-seven patients (43.5%) had a right eye injury and 35 patients (56.5%) had a left eye injury. There was no difference between the laterality of trauma (P = .31). The causes of injuries are summarized in Table 1. Scissors and knives were the most common causes, followed by sticks and nails. The causes of injury in 4 patients were unknown. The number of patients with each type of injury, location of injury, and severity of injury is summarized in Tables 2-4. Ninety-two surgeries were performed on these children. The operative techniques used are listed in Table 5. Fifty-two children presented to hospital on the day of injury and the remaining 10 children went to the hospital 1 to 3 days after the injury. All patients received primary repair of the ocular wound on the day of presentation to the hospital. Intraocular foreign bodies were removed from all eyes with retained intraocular foreign bodies. Additional procedures at the time of initial repair included lentectomies in 22 eyes with lens capsule ruptures, vitrectomies in 16 eyes with vitreous loss, intraocular lens implantation in one eye, and cryotherapy in one eye with a scleral perforation. Twenty-two children (35.5%) had more than 1 surgery. The sequential procedures were necessary for treating traumatic cataracts, aphakic correction, endophthalmitis, retinal detachment, disruption of the wound, and corneal scars. No eyes were enucleated. The VA at the final visit ranged between 20/20 and no light perception. Thirty-one children (50%) had a VA of 20/40 or
%
Primary surgery 62 100 Primary closure only 39 62.9 Primary closure + lentectomy + vitrectomy 16 25.8 Primary closure + lentectomy 5 8.0 Primary closure + lentectomy + IOL a implantation 1 1.6 Primary closure + cryotherapy 1 1.6 Secondary surgery Secondary IOL implantation ± vitrectomy Vitrectomy Lentectomy ± vitrectomy Lentectomy + IOL implantation Resuture of wound Vitrectomy + pars plana lentectomy + scleral buckle + endolaser + silicone oil Penetrating keratoplasty
22 10 4 2 2 2 1
35.4 16.1 6.5 3.2 3.2 3.2 1.6
1
1.6
Tertiary surgery Lensectomy + IOL implantation Secondary IOL implantation Revitrectomy Vitrectomy + endolaser + SF6 b Revitrectomy + laser + silicone oil Revitrectomy + scleral buckle + silicone oil
6 1 1 1 1 1 1
9.6 1.6 1.6 1.6 1.6 1.6 1.6
Quaternary surgery Resuture of disrupted corneal wound + revitrectomy + silicone oil Vitrectomy + silicone oil
2 1
3.2 1.6
1
1.6
a b
Intraocular lens. Sulfur hexafluoride.
better. Forty-five children (72.6%) had a VA of 20/200 or better. In the group with a VA less than 20/200 (17 eyes, 27.4%), 9 children (14.5%) met the criteria for blindness (VA b20/400 to no light perception). Within the group that became blind, 6 eyes deteriorated from extensive corneal/scleral wounds and 3 eyes deteriorated from endophthalmitis. The relationships between type of injury and final VA are shown in Table 2. Penetrating injuries were the most common type of injury (30 eyes, 48.4%). Of the penetrating injuries, 76.7% (23/30 eyes) achieved a VA of 20/200 or better. Eyeball rupture was the second most common type of injury (20 eyes, 32.3%). Sixty-five percent (13/20) of eyes
Visual outcome and severity of injury (n=62)
Extent of injury
Grade Grade Grade Grade
Operative techniques n
χ2 Analysis was used to determine statistical significance regarding VA ≥20/200 between locations of injury (P = .029).
Table 4
Table 5
1: Cornea/anterior sclera with or without prolapse of the iris 2: Wound to the anterior segment plus lens damage 3: Posterior segment injury with vitreous loss 4: Extensive anterior and posterior injury
n
26 11 2 23
%
42.0 17.7 3.2 37.1
Visual acuity ≥20/40
≥20/200
b20/200
21 (80.8%) 5 (45.5%) 1 (50.0%) 4 (17.4%)
25 (96.2%) 9 (81.8%) 2 (100%) 9 (39.1%)
1 (3.8%) 2 (18.2%) 0 (0%) 14 (60.9%)
χ2 Analysis was used to determine statistical significance regarding VA ≥20/200 between grades of injury (P b .001).
Open globe injuries in children
533
with a rupture achieved a VA of 20/200 or better. Seven of the 10 eyes with intraocular foreign bodies achieved a final VA of 20/200 or better. Only 2 eyes had a perforating injury. Both of the children with perforating injuries had a final VA 20/200 or better. There was no statistically significant difference between poor visual outcome and different types of injuries by χ2 analysis (P = .655). Visual outcomes in relation to the location of the injury are shown in Table 3. In 49 eyes with zone 1 injuries, 39 eyes (79.6%) had a final VA of 20/200 or better. In 9 eyes with zone 2 injuries, 5 (55.6%) achieved a final VA of 20/40. The other 4 eyes had a VA of less than 20/200. Four eyes had zone 3 injuries and only 1 eye had a final VA better than 20/ 200. There was a statistically significant difference in poor visual outcome between different locations of injury by χ2 analysis (P = .029). Visual outcome in relation to the grade of injury is shown in Table 4. In 26 eyes with grade 1 injuries, 25 eyes (96.2%) had a final VA of 20/200 or better. In 11 eyes with grade 2 injuries, 9 (81.8%) achieved a final VA of 20/200 or better. Two eyes had grade 3 injuries and all achieved a final VA better than 20/200. In 23 eyes with grade 4 injuries, 9 eyes (39.1%) had a final VA of 20/200 or better. There was a statistically significant difference regarding poor visual outcome between different grades of injury by χ2 analysis (P b .001). The number of grade 3 injuries was too small for Table 6
Laterality Iris prolapse Lens damage Foreign body retention Hyphema Vitreous hemorrhage Retinal detachment Cornea wound across pupil Posterior segment foreign body Multiple surgery (2 or more) Endophthalmitis
b
4. Discussion Ocular trauma is a common, but preventable cause of significant visual impairment and visual loss. Demographic data analysis and identification of prognostic indicators may be helpful in primary prevention and further management. In this study, the boy-to-girl ratio was 2.6:1, which is similar to previous studies [9,13]. Age at the time of injury was evenly distributed in this study. The causes of all injuries are common tools at home which should be placed out of
Odds ratio analysis of variables in open globe injuries
Age, y Sex
a
meaningful statistical analysis. The major differences were between grades 1 and 4 (P b .001) and grades 2 and 4 (P = .02). With odds ratio analysis (Table 6), those variables with a P value of less than .05 and an odds ratio greater than 2 were identified and considered as prognostic indicators. Factors such as age at trauma, sex, laterality, iris prolapse, lens damage, foreign body retention, posterior segment foreign body, and multiple surgeries were not significantly related to the visual outcome. Variables such as hyphema, vitreous hemorrhage, retina detachment, cornea wound across the pupil, and the development of endophthalmitis were found to be highly associated with poor visual outcome.
Confidence interval. Significant.
Male Female OD OS Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
VA ≥20/200 (n = 45)
VA b20/200 (n = 17)
9.0 ± 4.6 (3-16.9) 31 14 21 24 24 21 18 27 7 38 4 41 0 45 0 45 15 30 1 44 13 32 1 44
8.9 ± 4.7 (2-16.3) 14 3 6 11 8 9 12 5 3 14 10 7 8 9 4 13 11 6 3 14 9 8 5 12
P
Odds ratio (95% CI a)
.94 .289
2.11 (0.52-8.53)
.42
1.60 (0.51-5.09)
.659
0.78 (0.25-2.38)
.032
3 (0.91-9.94)
.841
1.16 (0.26-5.14)
b.000
14.64 (3.58-59.95) b
b.000
N999 (N/A) b
b.001
N999 (N/A) b
.026
3.667 (1.14-11.84) b
.027
9.429 (0.91-98.05)
.007
2.769 (0.88-8.75)
b.001
18.33 (1.95-172.20) b
534 children's reach. Children must learn how to use these tools under a caregiver's supervision. Penetrating injuries were the major type of injury in this study, accounting for 48.4% of cases. The second most common type of injury was rupture, accounting for 32.3% of cases. The prevalence was similar in another investigation [9]. There was no statistical differences between the 4 types of injury and final VA by χ2 analysis (P = .655). The Ocular Trauma Classification Group suggests 4 variables at the initial examination as prognostic indicators: (1) type of injury, (2) initial VA, (3) the presence or absence of a relative afferent papillary defect, and (4) location of injury to describe the nature and extent of the injury [10,14]. However, preoperative evaluation of children is often hindered by inadequate history and poor patient cooperation during the physical examination. In our study, only 5 eyes (8%) had a record of a VA at the initial presentation. Most of the time, details of the injuries were only obtained when the children were under general anesthesia in the operating room. Thus, the initial VA and the papillary response are less valuable as prognostic indicators in children than in adults [15]. Practical prognostic indicators were necessary for open globe injuries in children. Our study identified 7 prognostic indicators: location of injury, extent of injury, initial presentation of hyphema, vitreous hemorrhage, retina detachment, cornea wound across the pupil, and development of endophthalmitis. All these indicators can be accessed objectively in children with or without cooperation to predict the final visual outcome. Our result suggests the prognosis of open globe injuries in children is strongly influenced by the extent of initial damage. Ninety-six percent of patients with grade 1 injuries in our study had a final VA of 20/200 or better, but only 39% of patients with grade 4 injuries had the same outcome (P b .001). In contrast, 17% of eyes with grade 4 injuries in our study had a final VA of 0.5 or higher; 36% of grade 4 eye injuries in the Jandeck et al [9] series achieved this. The result suggests that early vitrectomy may allow salvage of the severely injured eyes of children. In this study, hyphema was a significant prognostic indicator, as it was in the series of Rostomian et al [16]. In contrast, in the Rahman et al [17] series, hyphema was not related with final visual outcome. The difference might be because 32% (34/105 cases) of the cases in the Rahman et al series were not known whether they had hyphema or not. As Elder [18] concluded in his study, our study also found the presence of vitreous hemorrhage and retinal detachment were poor prognostic features. Alfaro et al [19] reported good visual outcome in those patients requiring only primary repair for cornea-scleral wounds. In the Baxter et al [13] series, injury involving just the cornea was associated with a good visual prognosis unless it involved the visual axis or greater than one quarter of the corneal diameter. In our study, cornea wound across the pupil was a poor prognostic factor. We think that the central location and irregularity of the corneal wound,
C.-H. Lee et al. instead of the length, would result in scarring and significant astigmatism and correlate with unfavorable outcome. The frequency of endophthalmitis after open globe injury varies from 6.8%, according to Essex et al [20], to 54.2%, according to Narang et al [21], in different geographic areas and populations. Both series concluded that the final VA tended to be worse in eyes with endophthalmitis. In this study, the frequency of endophthalmitis was 9.7% (6/62 cases). Patients with endophthalmitis had a poor prognosis. The 95% confidence interval of the odds ratio of 3 variables in Table 6 (lens damage, posterior segment foreign body, and multiple surgery) did not correlate with the P value significance. All of their lower limits of 95% confidence interval were close to 1. It might be because of the study group not being large enough to show the difference. These variables were possible prognostic indicators. Further study with larger population is needed to prove this. Children with additional lens involvement had a worse prognosis owing to the problems of correcting aphakia and compliance. Contact lenses were found to have a very low acceptance rate in younger children and early intraocular lens implantation was advised [22]. Intraocular lens implantation was performed in most of our aphakic young patients. Amblyopia was the most frequent cause of low visual acuity after intraocular lens implantation as the compliance of patching was poor. Good visual outcome can be established in the majority of children with open globe injuries. Unfavorable outcome was related to location of injury, extent of injury, hyphema, vitreous hemorrhage, retina detachment, cornea wound across the pupil, and the development of endophthalmitis. These were also considered as practical prognostic indicators despite the poor cooperation of the injured child. Vitrectomy and intraocular lens implantation should be performed early if it is necessary. Treatment of subsequent amblyopia should be emphasized for children younger than 9 years.
References [1] Mulvihill A, Bowell R, Lanigan B, et al. Uniocular childhood blindness: a prospective study. J Pediatr Ophthalmol Strabismus 1997; 34:111-4. [2] Strahlman E, Elman M, Daub E, et al. Cause of pediatric eye injuries: a population-based study. Arch Ophthalmol 1990;108:603-6. [3] MacEwen CJ, Baines PS, Desai P. Eye injuries in children: the current picture. Br J Ophthalmol 1999;83:933-6. [4] Poon AS, Ng JS, Lam DS, et al. Epidemiology of severe childhood eye injuries that required hospitalisation. Hong Kong Med J 1998;4:371-4. [5] Moreira Jr CA, Debert-Ribeiro M, Belfort Jr R. Epidemiological study of eye injuries in Brazilian children. Arch Ophthalmol 1988;106: 781-4. [6] Serrano JC, Chalela P, Arias JD. Epidemiology of childhood ocular trauma in a northeastern Colombian region. Arch Ophthalmol 2003; 121:1439-45. [7] Juan ED, Sternberg P, Michels RD. Penetrating ocular injuries. Ophthalmology 1983;90:1318-22.
Open globe injuries in children [8] Esmaeli B, Elner SG, Schork MA, et al. Visual outcome and ocular survival after penetrating trauma. Ophthalmology 1995;102: 393-400. [9] Jandeck C, Kellner U, Bornfeld N, et al. Open globe injuries in children. Graefe's Arch Clin Exp Ophthalmol 2000;238:420-6. [10] Pieramici DJ, Sternberg Jr P, Aaberg Sr TM, et al. Perspective: a system for classifying mechanical injuries of the eye. Am J Ophthalmol 1997;123:820-31. [11] Kuhn F, Morris R, Witherspoon CD, et al. A standardized classification of ocular trauma. Ophthalmology 1996;103:240-3. [12] Eagling EM. Perforating injuries of the eye. Br J Ophthalmol 1976;60: 732-6. [13] Baxter RJ, Hodgkins PR, Calder I, et al. Visual outcome of childhood anterior perforating eye injuries: prognostic indicators. Eye 1994;8: 349-52. [14] Pieramici DJ, Eong KG, Sternberg Jr P, et al. The prognostic significance of a system for classifying mechanical injuries of the eye (globe) in open-globe injuries. J Trauma 2003;54:750-4.
535 [15] Rudd JC, Jaeger EA, Freitag SK, et al. Traumatically ruptured globes in children. J Pediatr Ophthalmol Strabismus 1994;31:307-11. [16] Rostomian K, Thach AB, Isfahani A, et al. Open globe injuries in children. J AAPOS 1998;2:234-8. [17] Rahman I, Maino A, Devadason D, et al. Open globe injuries: factors predictive of poor visual outcome. Eye 2006;20:1336-41. [18] Elder MJ. Penetrating eye injuries in children of the West Bank and Gaza Strip. Eye 1993;7:429-32. [19] Alfaro DV, Chaudhry NA, Walonker AF, et al. Penetrating eye injuries in young children. Retina 1994;14:201-5. [20] Essex RW, Yi Q, Charles PG, et al. Post-traumatic endophthalmitis. Ophthalmology 2004;111:2015-22. [21] Narang S, Gupta V, Simalandhi P, et al. Paediatric open globe injuries. Visual outcome and risk factors for endophthalmitis. Indian J Ophthalmol 2004;52:29-34. [22] Churchill AJ, Noble BA, Etchells DE, et al. Factors affecting visual outcome in children following uniocular traumatic cataract. Eye 1995; 9:285-91.
www.elsevier.com/locate/ajem
Original Contribution
Prognostic indicators of open globe injuries in children Ching-Hsing Lee MD a , Lan Lee MD b , Ling-Yuh Kao MD b , Ken-Kuo Lin MD b , Meng-Ling Yang MD b,⁎ a
Department of Emergency Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kweishan 333, Taoyuan, Taiwan, ROC b Department of Ophthalmology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Kweishan 333, Taoyuan, Taiwan, ROC Received 12 March 2008; revised 4 April 2008; accepted 8 April 2008
Abstract Purpose: To determine the prognostic indicators of visual outcome in children with open globe injuries. Basic procedures: The charts of 62 patients, 16 years of age or younger, who had been treated for open globe injuries were reviewed. Main findings: The types of injury included penetrating (30 eyes), rupture (20 eyes), intraocular foreign body (10 eyes), and perforation (2 eyes). Sharp objects, such as knives or scissors, were the most common causes of open globe injuries. A visual acuity (VA) of at least 20/40 was achieved in 80.8% (21/26) of eyes with a corneal injury only, in 45.5% (5/11) of eyes with additional lens damage, and in 17.4% (4/23) of eyes with extensive anterior and posterior injuries. Conclusions: Unfavorable outcomes were related to the location of injury, the extent of injury, the initial presentation of hyphema, vitreous hemorrhage, retina detachment, cornea wound across the pupil, and the development of endophthalmitis. © 2009 Elsevier Inc. All rights reserved.
1. Introduction Ocular traumas often cause significant visual loss and are leading causes of noncongenital unilateral blindness in children [1]. In the United States, a population-based study reported the annual incidence of ocular trauma in children to be 15.2 per 100000 [2]. Worldwide, 2% to 14% of the pediatric ocular trauma patients ended in severe visual impairment or blindness [3-5]. Compared to closed globe injuries, open globe injuries yield the worst visual outcomes in ocular trauma [6]. Previous studies have shown that in
adult patients with penetrating ocular injuries, factors such as initial visual acuity, type of injury, location and extent of the wound, type of lens damage, severity of vitreous hemorrhage, and type of intraocular foreign body correlated with the final visual outcome [7,8]. However, there are limited studies regarding the anatomic and functional outcomes after open globe injuries in children [9]. We report herein our experience with treating childhood open globe injuries and determine the prognostic indicators of visual outcome.
2. Methods ⁎ Corresponding author. Tel.: +886 3 3281200x8666; fax: +886 3 3287798. E-mail address: [email protected] (M.-L. Yang). 0735-6757/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.ajem.2008.04.004
This study consisted of a consecutive series of pediatric patients younger than 16 years with open globe injuries who
Open globe injuries in children underwent surgery between May 1996 and August 2005 at Chang Gung Memorial Hospital, a medical center and referral center serving the northern area of Taiwan. An open globe injury was defined as a full thickness wound of the eyewall involving the cornea, the sclera, or both [10]. The patient's age, sex, cause of injury, type of injury, location of injury, severity of injury, surgical intervention, and final visual acuity (VA) were recorded and analyzed. Data were obtained from the findings of the initial examination in the ED or at the time of surgery. The type of injury was classified according to the Ocular Trauma Classification Group guidelines [10] and the Birmingham Eye Trauma Terminology [11] as penetration, perforation, intraocular foreign body, or rupture. Penetrating injury was defined as single laceration of the eyewall, usually caused by a sharp object. Perforating injury was defined as 2 fullthickness lacerations (entrance and exit) of the eyewall by the same agent, usually caused by a sharp object or missile. Rupture referred to full thickness wound of the eyewall, caused by a blunt object. The impact results in a momentary increase in intraocular pressure and an inside-out injury mechanism. The location of the injury was classified according to Ocular Trauma Classification Group as follows: zone 1, wound involvement limited to the cornea; zone 2, full thickness wound involving the sclera and no more posterior than 5 mm from the corneoscleral limbus; and zone 3, wound involvement posterior to the anterior 5 mm of the sclera. The severity of injury was classified according to Eagling [12] as follows: grade 1, cornea/anterior sclera with or without prolapse of the iris; grade 2, wound to the anterior segment plus lens damage; grade 3, posterior segment injury with vitreous loss; and grade 4, extensive anterior and posterior injuries. Surgical intervention was performed under general anesthesia and using an operating microscope in all cases. All corneal wounds were sutured with 10/0 nylon and scleral wounds were sutured with 8/0 vicryl. Additional procedures at the time of initial repair included lens aspiration in eyes
531 Table 1
Causes of ocular injury
Scissors, knife Stick Nail Projectile Glass Pencil Fall Toy Sport Traffic accident Tool Miscellaneous Unknown
n
%
15 7 6 5 4 4 4 3 2 2 2 4 4
24.2 11.3 9.7 8.1 6.5 6.5 6.5 4.8 3.2 3.2 3.2 6.5 6.5
with lens capsule rupture and vitrectomy in eyes with vitreous loss. Subconjunctival gentamicin injection was given at the end of every surgery. Postoperative treatment consisted of local antibiotics twice per day in all cases and additional systemic antibiotics were given for 3 to 5 days in some cases. Follow-up was scheduled at 1, 2, and 4 weeks after discharge and then at 3- to 6-month intervals. Prescription of spectacles and occlusion therapy were suggested for patients younger than 9 years. Visual acuity was assessed with the Landolt C test at a distance of 6 m. Good visual outcome was defined as a VA better than 20/40 and poor visual outcome was defined as a VA less than 20/ 200, according to a previous study [9]. Ocular status and VA at final follow-up visit were obtained from the records. All analyses were performed using the SPSS program package (version 10.0, SPSS, Inc, Chicago, Ill). For univariant analyses, we used the Student t test for continuous variables, χ2 analysis test for categorical variables, and odds ratios for each variable. A P value of less than .05 was considered statistically significant. Those variables with odds ratios greater than 2 were considered to be prognostic indicators.
3. Results There were 66 patients, 2 to 16 years of age, with open globe injuries who were treated during the abovementioned Table 2
Visual outcome and type of injury (n=62)
Injury type
n
%
Visual acuity ≥20/40
≥20/200
b20/200
Penetration 30 48.4 11 (55.0%) 23 (76.7%) 7 (23.3%) Rupture 20 32.3 12 (40.0%) 13 (65.0%) 7 (35.0%) Intraocular 10 16.1 7 (70.0%) 7 (70.0%) 3 (30.0%) foreign body Perforating 2 3.2 1 (50%) 2 (100%) 0 (0%) Fig. 1 Age and sex distribution of children with open globe injuries.
χ2 Analysis was used to determine statistical significance regarding VA ≥20/200 between types of injury (P = .655).
532
C.-H. Lee et al.
Table 3
Visual outcome and location of injury (n=62)
Zone
n
%
Visual acuity ≥20/40
≥20/200
b20/200
1 2 3
49 9 4
79.0 14.5 6.5
26 (53.1%) 5 (55.6%) 0 (0%)
39 (79.6%) 5 (55.6%) 1 (25.0%)
10 (20.4%) 4 (44.4%) 3 (75.0%)
period. Four patients were excluded owing to incomplete records. Follow-up varied from 5 days to 6 years, with a mean of 17.9 months. Of the 62 patients enrolled, 45 patients (72.6%) were males and 17 patients (27.4%) were females. Boys were more likely to have open globe injuries than girls (P = .004). The average age at the time of injury was 8.9 ± 4.6 years. The distribution of age and sex of the patients with open globe injuries is summarized in Fig. 1. No patient in this series had bilateral injuries. Twenty-seven patients (43.5%) had a right eye injury and 35 patients (56.5%) had a left eye injury. There was no difference between the laterality of trauma (P = .31). The causes of injuries are summarized in Table 1. Scissors and knives were the most common causes, followed by sticks and nails. The causes of injury in 4 patients were unknown. The number of patients with each type of injury, location of injury, and severity of injury is summarized in Tables 2-4. Ninety-two surgeries were performed on these children. The operative techniques used are listed in Table 5. Fifty-two children presented to hospital on the day of injury and the remaining 10 children went to the hospital 1 to 3 days after the injury. All patients received primary repair of the ocular wound on the day of presentation to the hospital. Intraocular foreign bodies were removed from all eyes with retained intraocular foreign bodies. Additional procedures at the time of initial repair included lentectomies in 22 eyes with lens capsule ruptures, vitrectomies in 16 eyes with vitreous loss, intraocular lens implantation in one eye, and cryotherapy in one eye with a scleral perforation. Twenty-two children (35.5%) had more than 1 surgery. The sequential procedures were necessary for treating traumatic cataracts, aphakic correction, endophthalmitis, retinal detachment, disruption of the wound, and corneal scars. No eyes were enucleated. The VA at the final visit ranged between 20/20 and no light perception. Thirty-one children (50%) had a VA of 20/40 or
%
Primary surgery 62 100 Primary closure only 39 62.9 Primary closure + lentectomy + vitrectomy 16 25.8 Primary closure + lentectomy 5 8.0 Primary closure + lentectomy + IOL a implantation 1 1.6 Primary closure + cryotherapy 1 1.6 Secondary surgery Secondary IOL implantation ± vitrectomy Vitrectomy Lentectomy ± vitrectomy Lentectomy + IOL implantation Resuture of wound Vitrectomy + pars plana lentectomy + scleral buckle + endolaser + silicone oil Penetrating keratoplasty
22 10 4 2 2 2 1
35.4 16.1 6.5 3.2 3.2 3.2 1.6
1
1.6
Tertiary surgery Lensectomy + IOL implantation Secondary IOL implantation Revitrectomy Vitrectomy + endolaser + SF6 b Revitrectomy + laser + silicone oil Revitrectomy + scleral buckle + silicone oil
6 1 1 1 1 1 1
9.6 1.6 1.6 1.6 1.6 1.6 1.6
Quaternary surgery Resuture of disrupted corneal wound + revitrectomy + silicone oil Vitrectomy + silicone oil
2 1
3.2 1.6
1
1.6
a b
Intraocular lens. Sulfur hexafluoride.
better. Forty-five children (72.6%) had a VA of 20/200 or better. In the group with a VA less than 20/200 (17 eyes, 27.4%), 9 children (14.5%) met the criteria for blindness (VA b20/400 to no light perception). Within the group that became blind, 6 eyes deteriorated from extensive corneal/scleral wounds and 3 eyes deteriorated from endophthalmitis. The relationships between type of injury and final VA are shown in Table 2. Penetrating injuries were the most common type of injury (30 eyes, 48.4%). Of the penetrating injuries, 76.7% (23/30 eyes) achieved a VA of 20/200 or better. Eyeball rupture was the second most common type of injury (20 eyes, 32.3%). Sixty-five percent (13/20) of eyes
Visual outcome and severity of injury (n=62)
Extent of injury
Grade Grade Grade Grade
Operative techniques n
χ2 Analysis was used to determine statistical significance regarding VA ≥20/200 between locations of injury (P = .029).
Table 4
Table 5
1: Cornea/anterior sclera with or without prolapse of the iris 2: Wound to the anterior segment plus lens damage 3: Posterior segment injury with vitreous loss 4: Extensive anterior and posterior injury
n
26 11 2 23
%
42.0 17.7 3.2 37.1
Visual acuity ≥20/40
≥20/200
b20/200
21 (80.8%) 5 (45.5%) 1 (50.0%) 4 (17.4%)
25 (96.2%) 9 (81.8%) 2 (100%) 9 (39.1%)
1 (3.8%) 2 (18.2%) 0 (0%) 14 (60.9%)
χ2 Analysis was used to determine statistical significance regarding VA ≥20/200 between grades of injury (P b .001).
Open globe injuries in children
533
with a rupture achieved a VA of 20/200 or better. Seven of the 10 eyes with intraocular foreign bodies achieved a final VA of 20/200 or better. Only 2 eyes had a perforating injury. Both of the children with perforating injuries had a final VA 20/200 or better. There was no statistically significant difference between poor visual outcome and different types of injuries by χ2 analysis (P = .655). Visual outcomes in relation to the location of the injury are shown in Table 3. In 49 eyes with zone 1 injuries, 39 eyes (79.6%) had a final VA of 20/200 or better. In 9 eyes with zone 2 injuries, 5 (55.6%) achieved a final VA of 20/40. The other 4 eyes had a VA of less than 20/200. Four eyes had zone 3 injuries and only 1 eye had a final VA better than 20/ 200. There was a statistically significant difference in poor visual outcome between different locations of injury by χ2 analysis (P = .029). Visual outcome in relation to the grade of injury is shown in Table 4. In 26 eyes with grade 1 injuries, 25 eyes (96.2%) had a final VA of 20/200 or better. In 11 eyes with grade 2 injuries, 9 (81.8%) achieved a final VA of 20/200 or better. Two eyes had grade 3 injuries and all achieved a final VA better than 20/200. In 23 eyes with grade 4 injuries, 9 eyes (39.1%) had a final VA of 20/200 or better. There was a statistically significant difference regarding poor visual outcome between different grades of injury by χ2 analysis (P b .001). The number of grade 3 injuries was too small for Table 6
Laterality Iris prolapse Lens damage Foreign body retention Hyphema Vitreous hemorrhage Retinal detachment Cornea wound across pupil Posterior segment foreign body Multiple surgery (2 or more) Endophthalmitis
b
4. Discussion Ocular trauma is a common, but preventable cause of significant visual impairment and visual loss. Demographic data analysis and identification of prognostic indicators may be helpful in primary prevention and further management. In this study, the boy-to-girl ratio was 2.6:1, which is similar to previous studies [9,13]. Age at the time of injury was evenly distributed in this study. The causes of all injuries are common tools at home which should be placed out of
Odds ratio analysis of variables in open globe injuries
Age, y Sex
a
meaningful statistical analysis. The major differences were between grades 1 and 4 (P b .001) and grades 2 and 4 (P = .02). With odds ratio analysis (Table 6), those variables with a P value of less than .05 and an odds ratio greater than 2 were identified and considered as prognostic indicators. Factors such as age at trauma, sex, laterality, iris prolapse, lens damage, foreign body retention, posterior segment foreign body, and multiple surgeries were not significantly related to the visual outcome. Variables such as hyphema, vitreous hemorrhage, retina detachment, cornea wound across the pupil, and the development of endophthalmitis were found to be highly associated with poor visual outcome.
Confidence interval. Significant.
Male Female OD OS Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
VA ≥20/200 (n = 45)
VA b20/200 (n = 17)
9.0 ± 4.6 (3-16.9) 31 14 21 24 24 21 18 27 7 38 4 41 0 45 0 45 15 30 1 44 13 32 1 44
8.9 ± 4.7 (2-16.3) 14 3 6 11 8 9 12 5 3 14 10 7 8 9 4 13 11 6 3 14 9 8 5 12
P
Odds ratio (95% CI a)
.94 .289
2.11 (0.52-8.53)
.42
1.60 (0.51-5.09)
.659
0.78 (0.25-2.38)
.032
3 (0.91-9.94)
.841
1.16 (0.26-5.14)
b.000
14.64 (3.58-59.95) b
b.000
N999 (N/A) b
b.001
N999 (N/A) b
.026
3.667 (1.14-11.84) b
.027
9.429 (0.91-98.05)
.007
2.769 (0.88-8.75)
b.001
18.33 (1.95-172.20) b
534 children's reach. Children must learn how to use these tools under a caregiver's supervision. Penetrating injuries were the major type of injury in this study, accounting for 48.4% of cases. The second most common type of injury was rupture, accounting for 32.3% of cases. The prevalence was similar in another investigation [9]. There was no statistical differences between the 4 types of injury and final VA by χ2 analysis (P = .655). The Ocular Trauma Classification Group suggests 4 variables at the initial examination as prognostic indicators: (1) type of injury, (2) initial VA, (3) the presence or absence of a relative afferent papillary defect, and (4) location of injury to describe the nature and extent of the injury [10,14]. However, preoperative evaluation of children is often hindered by inadequate history and poor patient cooperation during the physical examination. In our study, only 5 eyes (8%) had a record of a VA at the initial presentation. Most of the time, details of the injuries were only obtained when the children were under general anesthesia in the operating room. Thus, the initial VA and the papillary response are less valuable as prognostic indicators in children than in adults [15]. Practical prognostic indicators were necessary for open globe injuries in children. Our study identified 7 prognostic indicators: location of injury, extent of injury, initial presentation of hyphema, vitreous hemorrhage, retina detachment, cornea wound across the pupil, and development of endophthalmitis. All these indicators can be accessed objectively in children with or without cooperation to predict the final visual outcome. Our result suggests the prognosis of open globe injuries in children is strongly influenced by the extent of initial damage. Ninety-six percent of patients with grade 1 injuries in our study had a final VA of 20/200 or better, but only 39% of patients with grade 4 injuries had the same outcome (P b .001). In contrast, 17% of eyes with grade 4 injuries in our study had a final VA of 0.5 or higher; 36% of grade 4 eye injuries in the Jandeck et al [9] series achieved this. The result suggests that early vitrectomy may allow salvage of the severely injured eyes of children. In this study, hyphema was a significant prognostic indicator, as it was in the series of Rostomian et al [16]. In contrast, in the Rahman et al [17] series, hyphema was not related with final visual outcome. The difference might be because 32% (34/105 cases) of the cases in the Rahman et al series were not known whether they had hyphema or not. As Elder [18] concluded in his study, our study also found the presence of vitreous hemorrhage and retinal detachment were poor prognostic features. Alfaro et al [19] reported good visual outcome in those patients requiring only primary repair for cornea-scleral wounds. In the Baxter et al [13] series, injury involving just the cornea was associated with a good visual prognosis unless it involved the visual axis or greater than one quarter of the corneal diameter. In our study, cornea wound across the pupil was a poor prognostic factor. We think that the central location and irregularity of the corneal wound,
C.-H. Lee et al. instead of the length, would result in scarring and significant astigmatism and correlate with unfavorable outcome. The frequency of endophthalmitis after open globe injury varies from 6.8%, according to Essex et al [20], to 54.2%, according to Narang et al [21], in different geographic areas and populations. Both series concluded that the final VA tended to be worse in eyes with endophthalmitis. In this study, the frequency of endophthalmitis was 9.7% (6/62 cases). Patients with endophthalmitis had a poor prognosis. The 95% confidence interval of the odds ratio of 3 variables in Table 6 (lens damage, posterior segment foreign body, and multiple surgery) did not correlate with the P value significance. All of their lower limits of 95% confidence interval were close to 1. It might be because of the study group not being large enough to show the difference. These variables were possible prognostic indicators. Further study with larger population is needed to prove this. Children with additional lens involvement had a worse prognosis owing to the problems of correcting aphakia and compliance. Contact lenses were found to have a very low acceptance rate in younger children and early intraocular lens implantation was advised [22]. Intraocular lens implantation was performed in most of our aphakic young patients. Amblyopia was the most frequent cause of low visual acuity after intraocular lens implantation as the compliance of patching was poor. Good visual outcome can be established in the majority of children with open globe injuries. Unfavorable outcome was related to location of injury, extent of injury, hyphema, vitreous hemorrhage, retina detachment, cornea wound across the pupil, and the development of endophthalmitis. These were also considered as practical prognostic indicators despite the poor cooperation of the injured child. Vitrectomy and intraocular lens implantation should be performed early if it is necessary. Treatment of subsequent amblyopia should be emphasized for children younger than 9 years.
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