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Massachusetts Eye and Ear
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Ophthalmology Outcomes

Eye Trauma Surgery

The Eye Trauma Service at Mass Eye and Ear provides high-quality and successful surgical care for patients with open globe injuries from throughout New England.

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Time to Surgical Repair for Open Globe Injuries

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During calendar year 2020, 110 open globe injuries requiring repair presented to the Eye Trauma Service. There were an additional five cases where an exploration was performed and no repair was needed. Of the 110 repaired injuries, four cases involving intraocular foreign bodies in the posterior segment were repaired by the Retina Service and eight dehisced penetrating keratoplasties were repaired by the Cornea Service; these were not included in the analysis but are also repaired within 24 hours of injury when possible. Ninety-eight eyes of 97 patients had open globe injuries that required urgent surgical repair by the Eye Trauma Service. Of these 97 patients, 95 (97.9%) were taken to the operating room (OR) within 24 hours of arrival at Mass Eye and Ear. Sixty-two of the 97 patients (63.9%) were taken to the operating room in less than 12 hours. Two patients were taken to the operating room more than 24 hours after admission. The first of these cases was due to a delayed presentation of the open globe injury, while the second was due to an initially self-sealing wound that, after admission and observation, eventually required surgical intervention.

The mean time from presentation at the Emergency Department to arrival in the operating room was 9.8 hours (range: 2.33 to 42.88 hours).

Multiple studies suggest the benefit of repairing open globe injuries within 12-24 hours after injury, in particular for the prevention of endophthalmitis.1-2

In calendar year 2020, the Trauma Service repaired 97.9% of presenting open globe injuries within 24 hours after presentation to Mass Eye and Ear. This rate is similar to prior years.

Final Visual Acuity and Ocular Trauma Score

Ocular trauma score (OTS), a commonly used predictor in ocular trauma management, categorizes patients by the severity of open globe injury. This score accounts for the patient’s visual acuity at presentation and other preoperative findings, such as the mechanism of the open globe injury and the presence or absence of relative afferent pupillary defect. To calculate a patient’s score, all the raw points corresponding to the presenting variables are added; the final sum corresponds to the OTS. A higher ocular trauma score predicts a better visual outcome.1

Patients who undergo open globe repair in the Mass Eye and Ear Trauma Service often do not return for follow-up within the four- to six-month postoperative period in which we historically collected data on median visual acuity outcomes; this can be due to factors such as distant home location and patient’s perceived satisfactory recovery. Therefore, starting with 2018 outcomes, we changed our methodology for outcomes of trauma surgery. This analysis now consists of final visual acuity for all patients with a minimum of one week of follow-up as a function of their respective OTS.

During the 2020 calendar year, 98 eyes of 97 patients had an open globe injury repaired by the Mass Eye and Ear Trauma Service. Of these, 91 eyes had a recorded visual acuity at presentation and at least one week of follow-up at Mass Eye and Ear. The most recent visual acuity in the one week to six months window following surgery was recorded for each patient. Of the 45 eyes that presented with extensive injuries to the globe (OTS 1 or 2), 8.89% (4/45) had a final visual acuity of 20/400 or better. Of the remaining 46 patients that presented with ocular trauma scores 3 to 5, 76.1% (35/46) had final visual acuities ranging from 20/50 to 20/15.

*The tables below have been adapted from their original publication.1

Variables 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

 

Sum of Raw Points OTS
0-44 1
45-65     2
66-80 3
81-91 4
92-100 5

Distribution of Final Visual Acuity in 2020

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Median Postoperative Vision

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The numbers in white represent the number of patients for that OTS for their respective years

Rates of Endophthalmitis After Open Globe Repair

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During calendar year 2020, 98 eyes of 97 patients underwent open globe repair by the Eye Trauma Service. Of these 97 patients, 0 (0.0%) developed endophthalmitis postoperatively. Similar results were reported since 2009.

The standard Mass Eye and Ear protocol for eye trauma (i.e. surgical repair by a dedicated trauma team and 48 hours of intravenous antibiotics) is associated with post-traumatic endophthalmitis rates far below international benchmarks. A review of the literature suggests that endophthalmitis rates associated with open globe injuries range worldwide from 2.6% to 17%. The United States National Eye Trauma Registry has reported an endophthalmitis rate of 6.9% after open-globe repair.1

A published study of our antibiotic protocol for open globe injuries included 675 open globe injuries treated at Mass Eye and Ear from January 2000 to July 2007. Intravenous vancomycin and ceftazidime were started on admission and stopped after 48 hours for all patients. Patients were discharged on topical antibiotics, corticosteroids, and cycloplegics. Of these 675 eyes, 558 had at least 30 days of follow-up (mean, 11 months). The overall rate of endophthalmitis was 0.9% (5/558 cases).1 Based on the Mass Eye and Ear experience and the low percentage of cases with endophthalmitis, we recommend that institutions adopt a standardized protocol for treating open globe injuries and consider the use of prophylactic systemic antibiotics.1

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