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 Table of Contents  
Year : 2020  |  Volume : 32  |  Issue : 2  |  Page : 110-113

Referral in ocular trauma

Dr. Kalpana Narendran Chief Cataract Services and Department of Pediatric Ophthalmology, Aravind Eye Hospital, Coimbatore, Tamil Nadu, India

Date of Submission06-May-2020
Date of Acceptance07-May-2020
Date of Web Publication25-Aug-2020

Correspondence Address:
Kalpana Narendran
Dr. Kalpana Narendran Chief Cataract Services and Department of Pediatric Ophthalmology, Aravind Eye Hospital, Coimbatore, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/kjo.kjo_50_20

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How to cite this article:
Narendran K. Referral in ocular trauma. Kerala J Ophthalmol 2020;32:110-3

How to cite this URL:
Narendran K. Referral in ocular trauma. Kerala J Ophthalmol [serial online] 2020 [cited 2021 Jun 18];32:110-3. Available from: http://www.kjophthal.com/text.asp?2020/32/2/110/293297

Eye injuries are a major and underrecognized cause of disabling ocular morbidity that especially affects the young. Ocular traumas represent a complex and heterogeneous entity showing high variability both in terms of etiology and clinical expression [Table 1]. The most affected patient categories are children and workers; which has important implications in terms of long-term prognosis, morbidity as well as economic cost.[1],[2] Globally, more than 500,000 blinding injuries occur every year. Approximately 1.6 million people are blind owing to ocular trauma, 2.3 million are bilaterally visually impaired, and 19 million have a unilateral visual loss.[3],[4],[5] Developing countries often lack adequate infrastructure for persons with eye injuries to reach a primary care center, when one exists, and the lack of awareness of preventive measures and/or immediate actions increases the risk for complications and consequent visual disability. In most instances, emergency care units are not able to deal with such events, thus making it necessary to refer the patient to specialized ophthalmic facilities. A multidisciplinary ophthalmic intervention may be required, making management and treatment of these cases complex and difficult.[1],[2],[3],[4],[5]
Table 1: Classification for ocular injuries

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When confronted with ocular trauma, the practitioner should firstly take a comprehensive history [Table 2] of the events leading to, and timeline surrounding, the injury. Second, on examination of the patient, an ocular assessment as outlined should be performed after the general examination.
Table 2: History and examination

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The management of an injured eye requires meticulous history collection, measurement of visual acuity, and detection of relative pupillary defects, a careful inspection of the eyes, using anesthetic if needed. Proper documentation of initial vision is required medicolegally and is also a prognostic indicator. If letters cannot be read, the ability to count fingers, detect hand movements, and to perceive light are recorded in that order as CF (Counting Fingers), HM (Hand Motions), LP (Light Perception) and NLP (No Light Perception). An ultrasound is useful in evaluating posterior structures and the presence of an intraocular foreign body. An assessment of the trauma provides primarily the score calculation and analysis of wounds requiring immediate suturing to avoid any superinfection.

Birmingham Eye Trauma Terminology (BETT) is an internationally standardized terminology allowing a fine description of eye injuries. Following BETT, it is possible to describe clinical features of given eye trauma. BETT allows unambiguous description and helps in the referral of cases with clarity in management requirement between centers. Once the clinical and instrumental evaluation of the ocular damage is completed, an important step is to quantify visual prognosis.[6],[7],[8] The Ocular Trauma Score (OTS) is a set of six factors, which provide a prediction of the patient's visual acuity recovery at 6-month follow-up. OTS score is a reliable predictor of visual prognosis when assessing an open globe injury, but a deeper investigation is required when other serious conditions, such as endophthalmitis and retinal detachment, occur in the trauma patient, OTS provides a practical guideline to referral centers for counseling patients regarding the gravity of injury and expectation of visual prognosis.[6],[9],[10]

  Triaging Ocular Emergencies Top

Triage is the process of determining the priorities for action in an emergency and of establishing the order in which to carry out acts of medical assistance. This process is critical to appropriate care and treatment of patients who experience ocular emergencies and could mean the difference between adequate vision and potential blindness.[11],[12],[13],[14]

  Level of Urgency Top

First, establish the level of urgency. Individual eye physicians also may have a definition of what they perceive the levels of urgency are for specific emergencies which are not an acceptable practice with regard to the specific emergencies. It is important to have the eye physician develop triage guidelines that provide the appropriate time frame for a specific medical emergency. The level of urgency helps to define the time frame for specialized intervention to maximize vision potential [Table 3].
Table 3: Level of urgency

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  Nonpenetrating/contusion Injuries Top

  • Mechanism: Sudden increase in the orbital pressure as a result of a striking object[15],[16]
  • Evaluation: An orbital blow-out fracture and optic neuropathy to be ruled out even if white eyed. Periocular ecchymosis and edema, deterioration in vision, numbness of the cheek, side of the nose and upper lip, and diplopia (double vision)
  • Level of urgency: Urgent/(Suspected with withe eyed blow out): Immediate.

  Chemical Splashes and Burns Top

  • Mechanism: Usually caused by either alkali (having a pH of 7.1 or greater) or acids (having a pH <7.0). Chemical burns also are caused by thermal or ultraviolet exposure. Alkalines are usually more damaging because they can permeate the eye rapidly. Common alkalines are ammonia (fertilizer, refrigerants, and household cleaners), lye (drain and oven cleaners), lime (plaster and concrete), and fireworks (sparklers and flares)[17],[18],[19]
  • Evaluation: As soon as the patient arrives at the clinic, the eye should be irrigated again (after checking with the physician) and its pH level checked until the reading is 7.0 (neutral)
  • Special instructions: Ask the patient to bring the chemical agent or provide a label identifying the contents of the source of the splash if possible
  • Level of urgency: Semi-urgent, if with limbal ischemia/melt: Urgent

  Corneal Abrasion Top

  • Mechanism: Depends on the time of onset. If pain was noted at the time of waking up, with foreign body sensation and redness, it is possible the patient would have scratched themselves during sleep. Abrasions can also be caused by contact lens over wear or recurrent erosion syndrome. Minor abrasions may heal on their own within two to 4 h; many patients experience significant pain, depending on the severity and location of the abrasion, and will request immediate care[20],[21]
  • Evaluation: Include a slit-lamp evaluation using fluorescein dye to determine if an epithelial defect is present, and if so, to what extent. Make certain that there is no foreign-body visible in the cornea or fornices. Primary concern is to prevent infection and to ease pain while making certain that the abrasion heals appropriately. Patients should be seen within 24 h of their injury
  • Special instructions: Instruct the patient not to remove foreign body or treat the eye with any drops
  • Level of urgency: Semi-urgent to urgent (with infiltration).

  Blunt Trauma Top

  • Mechanism: Sports-related injuries, assault/fights, job-related injuries, automobile accidents, projectiles, and explosions
  • Effect: Blunt trauma often causes simultaneous injuries to multiple parts of the eye
  • Ecchymosis (bruising) of the eyelids, hyphemia, angle recession, retinal tears, a retinal detachment, and ruptured globe.[9],[22]
  • Evaluation: Comprehensive eye examination, including extraocular muscle evaluation, pupil testing, intraocular pressure, and dilation
  • Special instructions: Instruct not to put pressure on the eye, not to patch the eye, and not to manipulate the eye in any way before the ophthalmologist evaluation
  • Referral level of urgency: Urgent (nonopen globe)/immediate (open globe).

  Penetrating Trauma Top

  • Mechanism: Penetrating injuries may include fishhooks, nails, sticks, and pencils[21],[22]
  • Primary level evaluation: Important to stabilize the patient and the object immediately, taking care to avoid putting any pressure on the foreign object. If the eye can be close, a shield can be applied and bandaged. Avoid the use of topical medications with preservative. Only use a preservative-free antibiotic or ointments under patch
  • Special instructions: Make sure to provide clear instructions to leave the object in the eye!
  • Level of urgency: Immediate

In conclusion, triaging trauma for a referral depends on the level of facility at which initial management in sought. The conventional BETT system classification, though robust, does not include a comprehensive spectrum of ophthalmic trauma. It fails to describe nonmechanical globe trauma, which makes up a significant proportion of eye injuries. A tertiary care ophthalmic facility is required in all cases of trauma with adnexal traumas and severe chemical and blunt trauma and is imperative for all open globe injuries. Referrals can me made using predesigned format [Table 4] covering nature/mechanism of injury and level of triage to be given at the higher center avoiding initial delay in the referral centers.
Table 4: Ocular trauma referral form

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  References Top

Katz J, Tielsch JM. Lifetime prevalence of ocular injuries from the Baltimore Eye Survey. Arch Ophthalmol 1993;111:1564-8.  Back to cited text no. 1
Schein OD, Hibberd PL, Shingleton BJ, Kunzweiler T, Frambach DA, Seddon JM, et al. The spectrum and burden of ocular injury. Ophthalmology 1988;95:300-5.  Back to cited text no. 2
Vats S, Murthy GV, Chandra M, Gupta SK, Vashist P, Gogoi M. Epidemiological study of ocular trauma in an urban slum population in Delhi, India. Indian J Ophthalmol 2008;56:313-6.  Back to cited text no. 3
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Wong TY, Klein BE, Klein R. The prevalence and 5-Year incidence of ocular trauma. The Beaver dam eye study. Ophthalmology 2000;107:2196-202.  Back to cited text no. 4
Nirmalan PK, Katz J, Tielsch JM, Robin AL, Thulasiraj RD, Krishnadas R, et al. Ocular trauma in a rural south Indian population: The aravind comprehensive eye survey. Ophthalmology 2004;111:1778-81.  Back to cited text no. 5
Shukla B, Agrawal R, Shukla D, Seen S. Systematic analysis of ocular trauma by a new proposed ocular trauma classification. Indian J Ophthalmol 2017;65:719-22.  Back to cited text no. 6
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Kuhn F, Morris R, Witherspoon CD, Mester V. The birmingham eye trauma terminology system (BETT). J Fr Ophtalmol 2004;27:206-10.  Back to cited text no. 7
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Serdarevic R. The ocular trauma score as a method for the prognostic assessment of visual acuity in patients with close eye injuries. Acta Inform Med 2015;23:81-5.  Back to cited text no. 9
Kuhn F, Pieramici DJ. Ocula Trauma, Principles and Practice. New York, Stuttgart: Thieme; 2002.  Back to cited text no. 10
AlSamnan MS, Mousa A, Al-Kuwaileet S, AlSuhaibani AH. Triaging self-referred patients attending ophthalmic emergency room. Saudi Med J 2015;36:678-84.  Back to cited text no. 11
Rossi T, Boccassini B, Iossa M, Mutolo MG, Lesnoni G, Mutolo PA. Triaging and coding ophthalmic emergency: The rome eye scoring system for urgency and emergency (RESCUE): A pilot study of 1,000 eye-dedicated emergency room patients. Eur J Ophthalmol 2007;17:413-7.  Back to cited text no. 12
Australian College of Emergency Medicine. The Australian Triage Scale. Carlton Vic. Publisher; 2000.  Back to cited text no. 13
Cheng H. Emergency ophthalmology. London: BMJ Publishing Group; 1997.  Back to cited text no. 14
Folberg R, Parrish RK. Glaucoma following trauma. In: Duke-Elder S, editor. System of Ophthalmology Vol XIV Part 1. Mechanical Injuries. London: Henry Kimpton; 1972. P 1-7.  Back to cited text no. 15
Slade MP. Ocular trauma. Aust N Z J Surg 1999;69:582-3.  Back to cited text no. 16
Singh P, Tyagi M, Kumar Y, Gupta KK, Sharma PD. Ocular chemical injuries and their management. Oman J Ophthalmol 2013;6:83-6.  Back to cited text no. 17
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Jinagal J, Gupta PC, Gupta G, Sahu KK, Ram J. Ocular chemical burns from accidental exposure to topical dermatological medicinal agent. Indian J Ophthalmol 2018;66:1476-7.  Back to cited text no. 18
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Kam KW, Patel CN, Nikpoor N, Yu M, Basu S. Limbal ischemia: Reliability of clinical assessment and implications in the management of ocular burns. Indian J Ophthalmol 2019;67:32-6.  Back to cited text no. 19
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External Disease and Cornea. Basic and Clinical Science Course, Section 8. San Francisco: American Academy of Ophthalmology; 2017-2018.  Back to cited text no. 20
Krachmer J, Mannis M, Holland E. Cornea. St. Louis, MO: Mosby/Elsevier; 2011.  Back to cited text no. 21
Badrinath SS. Ocular trauma. Indian J Ophthalmol 1987;35:110-1.  Back to cited text no. 22
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  [Table 1], [Table 2], [Table 3], [Table 4]


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  In this article
Triaging Ocular ...
Level of Urgency
Chemical Splashe...
Corneal Abrasion
Blunt Trauma
Penetrating Trauma
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