important considerations in trauma

IMPORTANT CONSIDERATIONS IN TRAUMA

PRESENTER: Dr. KRATI GUPTA

MODERATOR: Dr. GAYATRI BHARALI

EPIDEMIOLOGY AND PREVENTION

INTRODUCTION

• Damage or trauma inflicted to the eye by external means.

• The concept includes both surface injuries and intraocular injuries.

• During trauma soft tissues and bony structures around the eye maybe involved.

• Ocular trauma is a major cause of preventable monocular blindness and visual impairment in the world, especially in the developing countries.

• Ocular trauma and resultant loss of vision leads to psychological, economical and professional crippling of the patient.

NEED FOR CLASSIFICATION OF OCULAR TRAUMA

• Ophthalmologists are unable to unambiguously communicate with each other if the terms they use to describe an eye injury are not standardized.

• Research cannot be conducted and the results cannot be quantified without the risk of the data being misinterpreted.

Kuhn F, ocular traumatology.2008 :p 3

CHARACTERISTICS OF AN IDEAL EYE TRAUMA TERMINOLOGY SYSTEM

In an ideal eye trauma terminology system, the following criteria must be satisfied:

The tissue of reference must always be obvious.

Each term must have a unique definition.

CLASSIFICATION OF OCULAR TRAUMA

• The Ocular Trauma Classification Group developed a classification system for mechanical injuries to the eye.

• It is based on the initial examination or evaluation at the time of primary surgical intervention.

CLASS OF INJURY

• Open-globe/penetrating: injury with full thickness wound to the cornea and sclera.

• Closed-globe/non penetrating: injury without full thickness defect of the cornea and sclera.

CLASSIFICATION OF OCULAR TRAUMA

• The Birmingham Eye Trauma Terminology System (BETTS) devised a classification for ocular trauma which is accepted worldwide.

• BETT satisfies all criteria for unambiguous standard terminology by:

1. Providing a clear definition for all injury types.

2. Placing each injury type within the framework of a comprehensive system.

Kuhn F, Pieramici DJ. ocular trauma principals and practice: 2002 :p.4

TERMS AND DEFINITIONS IN BETT*

BETT: THE TERMINOLOGY OF OCULAR TRAUMA

OCULAR TRAUMA CLASSIFICATION

• The Ocular Trauma Classification Group has developed a classification system based on BETT and features of globe injury at initial examination.

• Mechanical trauma to the eye is subdivided into open and closed globe injuries because these have different pathophysiological and therapeutic ramifications.

• The system categorizes trauma by four parameters.

1. TYPE

• The type of the injury should be determined based on the history as reported by the patient or witnesses regarding the circumstances of the incident.

• If a patient is unconscious or unreliable typing may be based on clinical examination.

• If media opacity or other clinical factors preclude adequate examination, ultrasonography, x-ray, or CT scanning may assist.

2. GRADE

• Grade, as defined by visual acuity measurement at the initial examination.

• Testing is done with a Snellen acuity chart and should be performed with the patient’s corrective lenses if possible.

• A pinhole vision may be recorded.

3. PRESENCE/ ABSENCE OF RELATIVE AFFERENT PUPILLARY EFECT

• The presence of an APD, as measured by the swinging flashlight test is a gross indicator of aberrant optic nerve and/or retinal function.

• If the affected eye is nonreactive for mechanical or pharmacologic reasons, observing the consensual response in the fellow eye (i.e., looking for a “reverse” APD) is advised.

4. EXTENT (i.e ZONE) OF THE INJURY

• Wound location in open globe injuries or the most posterior extent of damage in closed globe injuries.

• The zone of injury depends on whether the injury is open or closed globe.

OPEN GLOBE INJURY CLASSIFICATION

CLOSED GLOBE INJURY CLASSIFICATION

CALCULATING THE OTS : VARIABLES AND RAW POINTSVariable Raw points

Initial Vision

NLP 60

LP/HM 70

1/200- 19/200 80

20/200-20/50 90

≥20/40 100

Rupture -23

Endophthalmitis -17

Perforating Injury -14

Retinal Detachment -11

Afferent pupillary defect -10

CONVERSION OF THE RAW POINTS INTO THE OTS, AND IDENTIFYING THE LIKELY VISUAL OUTCOME (%) Sum of raw points

OTS No PL PL/HM 1/200-19/200 20/200-20/50 ≥20/40

0-44 1 74% 15% 7% 3% 1%

45-65 2 27% 26% 18% 15% 15%

66-80 3 2% 11% 15% 31% 41%

81-91 4 1% 2% 3% 22% 73%

92-100 5 0% 1% 1% 5% 94%

EPIDEMIOLOGY OF OCULAR TRAUMA

EPIDEMIOLOGY- INTRODUCTION

• Epidemiology involves systematic observation leading to the development and execution of a strategy.

• Subsequent observation determines whether the recommended strategy has been successful.

• Through the development of scientific and public health models, injuries are now defined and measured; and interventions are designed, tested for effectiveness,and implemented if their efficacy is proved.

IMPACT OF OCULAR TRAUMA ON HUMAN LIVES

• The eyes represent only 0.1% of the total body surface and 0.27% of the anterior body surface.

• Their significance to individuals and society is disproportionally higher.

• Most of the information reaches humans through vision.

• Consequently, the socioeconomic impact of ocular trauma can hardly be overestimated.

• Those affected often have to face:

Loss of career opportunities

Major lifestyle changes

Occasionally Permanent physical disfigurement

• In addition to the physical and psychological costs of eye injuries to the individual, financial costs to society are enormous.

• The cost-effectiveness of well-planned preventive measures based on sound epidemiologic data has repeatedly been demonstrated.

• In industrialized nations, trauma has become the most common reason for extended hospitalization of ophthalmologic patients.

• In the United States alone there are almost 2.5 million incident cases of eye injuries each year.

• The number of people with trauma related visual impairment was close to 1 million in 1977 .

• 40,000–60,000 incident cases of trauma related visual impairment annually.

• The WHO Programme for the Prevention of Blindness, suggests that annually.

• 55 million eye injuries restricting activities more than one day.

• 750,000 cases will require hospitalization.

• 200,000 open-globe injuries.

• Approximately 1.6 million blind from injuries.

• 2.3 million people with bilateral low vision.

• 19 million with unilateral blindness or low vision.

Internet

THE UNITED STATES EYE INJURY REGISTRY

• The prerequisite for the scientific study of injury is acquisition of data to design appropriate preventive and therapeutic interventions.

• The same surveillance system is used to monitor the effectiveness of preventive, and rehabilitative interventions.

THE UNITED STATES EYE INJURY REGISTRY

• Established in 1988, the USEIR satisfies the following criteria:

Collects information at hospitals and emergency rooms as well as at physicians’ offices.

Uses single-page initial and 6 months follow-up reporting forms.

Surveys all types of eye injuries—open globe, closed globe, and adnexal.

Limits data collection to injuries resulting in permanent and significant structural or functional change to the eye.

OCULAR TRAUMA EPIDEMIOLOGY:

GENERAL FINDINGS

• Annual Incidence Rate of Hospitalization for Eye Injuries

The annual incidence rate of hospitalization for eye injuries is

• 8.1 in Scotland

• 12.6 in Singapore

• 13.2 in the United States

• 15.2 in Sweden

CUMULATIVE LIFETIME PREVALENCE

• The cumulative lifetime prevalence of eye injuries is 860 to 14,400

• Vats et al in their study ( Epidemiological study of ocular trauma in urban slum population in Delhi) reported a cumulative lifetime prevalence of ocular trauma at>/= 40 years as 4.5%.

• Incidence of ocular trauma reported by them was 2.4%

• Kuhn F, Pieramici DJ. ocular trauma principals and practice: 2002 :p.14• Vats S, Murthy GVS, Chandra M, Gupta K, Vashist, Gogoi M. Epidemiological study of ocular trauma in an urban slum

population in Delhi, India. Indian J Ophthalmol. 2008;56:313- 6.

• The majority of those injured are young adults, with an average agearound 30 years .

• Those sustaining a serious eye injury over the age of 60 years have different etiologies (rate of fall: 23% if over 60 years, 2% if under 60 years, p<0.001).

• injury types (rate of rupture: 31% if over 60 years, 11% if under 60 years, p<.001).

• Sengupta et al in their study reported adults comprised 79% of the study population.

• Vats et al reported the mean age of participants was 28.21 yrs and the mean age at which trauma was sustained was 24.2 yrs.

• Study conducted in our hospital ( Open globe injuries : A prospective study of patient profile and prognostic factors for visual outcome following surgical treatment at a tertiary eye institution) reported the mean age as 24.28 yrs

• Sengupta P, Mazumdar M, Gyatsho J,. Epidemiology of ocular trauma cases presenting to a tertiary care hospital in a rural area in West Bengal, India over a period of 2 years. IOSR Journal of Dental and Medical Sciences.2016;15(3):92-97.

• Vats S, Murthy GVS, Chandra M, Gupta K, Vashist, Gogoi M. Epidemiological study of ocular trauma in an urban slum population in Delhi, India. Indian J Ophthalmol. 2008;56:313- 6.

GENDER

• The typical male:female ratio is 4:1

• In the USEIR, 79% of injured persons are males.

• Sengupta et al reported 83.7% of injured were male.

• Our hospital study reported 74% of the ocular trauma patients were males.

• Kuhn F, ocular traumatology.2008 :p 54-55• Sengupta P, Mazumdar M, Gyatsho J,. Epidemiology of ocular trauma cases presenting to a tertiary care hospital in a rural

area in West Bengal, India over a period of 2 years. IOSR Journal of Dental and Medical Sciences.2016;15(3):92-97.

SOCIOECONOMIC STATUS

• The lower on the societal “ladder” a person is, the higher his risk of suffering an eye injury is.

• The breaking of rules/laws (e.g., traffic violations, alcohol, or drug use) or unsettled social status (e.g., unemployment) also signifies an elevated risk.

LITERACY

• Vats et al reported 23.4% of the patients were illiterate.

• Sengupta et al reported 90.6% of patients were literate.

• The study conducted in our hospital reported 26% of the patients were illiterate.

• Among those aged 25-65 years in the U.S., blacks and Hispanics have a 40-60% higher risk than whites

• In the U.S., blacks have a risk twice as high as whites and a more than twice as high risk of having visual impairment from injury.

• Per mile traveled, 13 to 19 year-old black and Hispanic male teenagers have a nearly twice as high risk of dying in an MVC than white teenagers of the sameage.

• Race and socioeconomics have a combined effect.

• The significant shift from the workplace to the home, identified first by USEIR researchers

• In some rural areas in developing countries the workplace remains the most important site .

Kuhn F, ocular traumatology.2008 :p 56-57

• Sengupta et al reported 41.1% of patients suffered injuries at the workplace including agricultural activities .

• Vats et al reported 33.1% of injuries were sustained at workplace.

• Our hospital study reported most common place of injury was home followed by workplace

Sengupta P, Mazumdar M, Gyatsho J,. Epidemiology of ocular trauma cases presenting to a tertiary care hospital in a rural area in West Bengal, India over a period of 2 years. IOSR Journal of Dental and Medical Sciences.2016;15(3):92-97

SOURCE

• What the most common object causing a serious eye injury is largely depends on the location of the study.

• The significance of the study site is also shown by the very different national scenes (U.S., Hungary, Mexico) when comparing injuries caused by pressurized bottles or by the proportion of injuries inflicted by champagne bottle corks.

SOURCE

• Vats et al reported blunt trauma in 41% of patients.

INTENT

• Assault was the cause in 15% of injuries in the USEIR .

• 1% was self-inflicted.

• Firearms were responsible for 71% of all self-inflicted ocular trauma.

Kuhn F, ocular traumatology.2008 :p 59-60

INTENT

• As per Vats et al

Assault was the cause in 10.4% of cases

Accidents -81.1%

Self inflicted- 2.5%

• As per Sengupta et al

Assault was the cause in 9% of cases

Road Accidents -11.2%

OPEN GLOBE V/S CLOSED GLOBE

• Sengupta et al reported

• Closed globe injuries were the commonest 72.2% type of injury.

• Among open globe injuries (27.8%), rupture of the globes was the most common.

Sengupta P, Mazumdar M, Gyatsho J,. Epidemiology of ocular trauma cases presenting to a tertiary care hospital in a rural area in West Bengal, India over a period of 2 years. IOSR Journal of Dental and Medical Sciences.2016;15(3):92-97

SPORTS RELATED

PREVENTION OF OCULAR TRAUMA

PREVENTION

• It is human nature to presume that although “eye injuries happen, they happen to somebody else.”

• To be effective, it is this mindset that prevention must change.

• All ophthalmologists have a responsibility to contribute to the fight for preventing eye injuries by identifying risk factors in general and risky behaviors in particular.

PREVENTION

• The contribution can range from warning a single individual of the dangers in a given situation to initiating legislation against a more general threat.

• Using common sense in daily life is also crucial.

• Several published reports have identified areas amenable for the introduction of preventive measures and showed the benefits of such measures.

MVC-RELATED DEATHS AND INJURIES

• Although the number of drivers increased sixfold between 1925 and 1997 in the U.S., the annual death rate has declined from 18 to 1.7 per 100 million vehicle miles traveled (a 90% decrease) in the same period.

• Several factors (e.g., better road design, improved driver education, energy absorbing vehicle systems, the use of laminated, not heat-toughened, windshields) contributed to the improvement.

• It was primarily the introduction of seat belts and air bags that must be credited.

• Seat belt laws reduced the number of eye injuries by 47-65% and facial fractures by 9 percentage points in the U.S. where 82% of drivers buckle up.

• Air bags reduce the risk of sustaining an eye injury during a crash by 2.5 times.

• Although air bags may themselves be a source of ocular trauma, this risk is minimal, especially when compared with the risk of death in the crash.

• In the USEIR, the rate of MVC-related serious eye injuries decreased from 12% in 1995 to 8% in 2005.

MVC-RELATED DEATHS AND INJURIES

SPORTS-RELATED OCULAR TRAUMA

• Ice hockey is a prototype success story.

• Among Canadian youth players, 283 eye injuries were seen in the 1974-1975 season.

• After face visors were mandated, the number of eye injuries dropped by 68%, and not a single eye was injured if the player wore full-face protection.

• Baseball is a major source in the U.S.

• In one study, a 28% reduction was achieved with a protective device.

SPORTS-RELATED OCULAR TRAUMA • Racquetball and squash.

• The proportion of these games among all sport-related injury cases was reduced from 73% in 1982 to 38% in 1987 as proper protective devices were introduced.

• Paintball, an increasingly popular sport, represents a very significant risk of causing permanent visual loss.

• Proper eye protection is very efficient in preventing it-if the device is actually worn.

• Golf is not a common cause of eye injury, but if either the club or, more often, the ball does cause injury, it is very serious, resulting in a 40% enucleation rate.

WAR-RELATED TRAUMA

• The rate of eye injuries among all war-related trauma has steadily increased since the mid-19th century .

• 1.76% in the Crimean War [1854-1856]

• 6.8% in the Lebanon War [1982]

• 16% in Iraq [2004]

• Not a single eye injury occurred among Israeli Defense Forces soldiers wearing proper goggles.

FIREWORKS-RELATED OCULAR TRAUMA

• In the USEIR database, 4% of cases are caused by fireworks, and 80% of these result from bottle rockets.

• States that prohibit private fireworks have a 50-fold reduction in the rate of injuries as compared to states without such regulation.

• Fireworks can result in very severe injury.

HAMMERING

• In the USEIR database, 4% of all serious trauma are sustained while hammering.

• This statistically significant difference is most probably due to increased public awareness in the U.S., emphasizing the danger of this activity and the benefits of protective devices.

PROTECTIVE EYEWEAR

The ideal device is:

Tailored to a specific purpose (i.e., different designs are necessary forsoccer and for racquetball).

Resistant against major impact (made of 3- or even 4-mm polycarbonate) as well as against scratching.

Held by a proper frame that does not break or let go.

PROTECTIVE EYEWEAR

Offering frontal as well as side protection without interfering with the field of view.

Designed to prevent fogging.

Readily available (e.g., prominently displayed at the checkout counter in home-improvement stores).

Affordable.

REHABILITATION

• If complete restoration of the injured eye’s visual functions cannot be achieved, rehabilitation becomes necessary so that the person can utilize his remaining vision to the fullest extent possible.

• If vision cannot be improved, the person needs rehabilitation.

• e.g. vocational training, psychological support.

SUMMARY

• Collecting epidemiological data on the occurrence of eye injuries allows identification of trends and societal risk factors and injuries.

• Can help the ophthalmologist play a key role in successfully preventing ocular trauma.

• The USEIR model has proved to be an efficient epidemiological tool.

• Use of this model in other countries has allowed research involving between regions and even countries.

• Such comparisons have highlighted injury patterns in different geographical areas, pinpointing areas where prophylaxis (e.g., legislation, public campaigns) was effective.

• If the eye’s functional capability remains seriously depressed despite all reasonable treatment efforts, rehabilitation must planned.

THANK YOU

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