Incidence
and Types of Eye Injuries in Patients with Major
Trauma
.........................................................................................................................
Issam Albataenah, MD*
Ahmed Khatatbeh, MD*
Fakhry Athamneh, MD*
* From the department of Ophthalmology at King
Hussein Medical Center
Correspondence:
Dr. Issam M. Al-Bataineh,
Ophthalmology Department at King Hussein Medical
Center,
P.O. Box 862, 11947
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ABSTRACT
Objectives:
Finding the relationship and the association
between ocular injuries and major trauma,
and determining the incidence and causes
of ocular injuries when there is an associated
facial fracture.
Methods:
A prospective study in multiple hospitals
in Jordan, from June 2005 to December
2007, analyzing data taken from 190 patients
with major trauma.
Results:
Of the 190 patients with major trauma,
17 (11.2%) patients had associated ocular
injuries and 37 (19.5%) patients had a
facial fracture (zygoma, orbit or maxilla).
The risk of an eye injury for a patient
with a facial fracture is 5 times that
for a patient with no facial fracture
(95%, confidence interval 4.3 to 5.6).
Of the patients with major trauma and
an eye injury, 78.2% were men, and the
median age was 32 years. 64.7% of ocular
injuries were due to road traffic accidents
(RTAs).
Conclusions:
The incidence of ocular injuries in patients
with major trauma is low, but considerable
association was found between eye injuries
and facial fractures. Young adults have
the highest incidence of ocular injury.
RTAs are the leading cause of ocular injuries
in patients with major trauma. It is vital
that all patients with major trauma include
the face to be examined specifically for
an ocular injury.
Keywords:
ocular injuries, trauma, incidence, facial
fracture.
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Worldwide, an estimated 1.6
million people are blind as a result of eye
injuries, and a further 19 million have monocular
blindness or low vision due to eye trauma(1).
Eye injuries in association with major trauma
are particularly important as these injuries
have a high risk of threatening vision(2).
Even minor eye injuries can cause considerable
morbidity and time lost from work(3).
Eye injuries in association
with major trauma can cause diagnostic difficulties,
because patients with a reduced conscious level
may not report visual symptoms, and assessment
of the eye can be difficult in a supine patient.
Eye injuries may be associated with facial injuries:
in patients with periorbital haematomas and
swelling, it may not be possible to see the
eye properly at the initial examination and
treating life-threatening injuries will be a
priority in a patient with multiple injuries,
but the possibility for vision loss due to ocular
trauma should not be forgotten.
Although penetrating eye
injuries from road traffic accidents (RTAs)
have decreased considerably after seatbelt legislation
and the introduction of laminated windscreens(4),
little is known about the current epidemiology
of ocular injuries in patients with major trauma,
especially in Jordan. To investigate this group
of patients, we performed a prospective study
of 190 patients having major trauma, looking
at the incidence of ocular injuries, and their
association with facial fractures.
The study collected data
on patients attending the emergency department
in three hospitals in Jordan (Prince Rashid
Bin Al-Hussien Hospital, Prince Zaid Bin Al-Hussien
Hospital and King Hussein Medical Hospital),
those patients had an injury resulting in an
immediate admission to the hospital for =3 days,
or admission to an intensive care unit. We excluded
patients aged >65 years with an isolated
fracture of the femoral neck or pubic ramus
and those with single uncomplicated limb injuries.
Patient information was recorded at the time
of discharge.
The evaluation method was
by using the Injury Severity Score (ISS). An
ISS of 16 is predictive of a mortality of about
10%, and this defines major trauma based on
anatomical injury(5).
Major trauma was defined as ISS >15. We examined
the data for all patients who had sustained
an eye injury, injury to the second, third,
fourth or sixth cranial nerve, or a facial fracture
(maxilla, zygoma or orbit) between June 2005
and June 2008.
Among the 190 patients with major trauma, 17
(11.2%) patients had associated ocular injuries
and 37 (19.5%) patients had a facial fracture
(zygoma, orbit or maxilla). Of the patients
with major trauma and an eye injury, 78.2% were
men, and the median age was 32 years. The median
ISS was 26.
These 17 patients had 31 eye injuries (Table
1). Blunt trauma was responsible for 13 (76.4%)
injuries and 4 (23.6%) injuries were the result
of penetrating trauma.
Among the 190 patients with major trauma, 37
(19.5%) had a facial fracture (zygoma, orbit
or maxilla), and 4 (10.8%) of these patients
also had an eye injury. Of the 190 patients
without a facial fracture, 4 (2.1%) patients
had an eye injury. So the risk of an eye injury
for a patient with a facial fracture is 5 times
more than that for a patient with no facial
fracture (95% confidence interval (CI) 4.3 to
5.6).
|
Table 1: Ocular
injuries in patients with major trauma |
| Ocular
injury |
Number
of injuries |
Percentage |
| Tear
duct |
1 |
3.2% |
| Conjunctiva |
4 |
12.9% |
| Cornea |
9 |
29.0% |
| Iris |
6 |
19.4% |
| Vitreous |
2 |
6.1% |
| Retina |
3 |
9.6% |
| Sclera |
4 |
12.9% |
| Oculomotor
nerve |
1 |
3.2% |
| Abducens
nerve |
1 |
3.2% |
| Total |
31 |
~100% |
|
Table 2: Causes
of ocular injury in patients with major
trauma |
| Cause
of ocular injury |
Number
of patients |
Percentage |
| Road
traffic accident |
11 |
64.7
% |
| Falling
from height |
3 |
17.6
% |
| Assault |
2 |
11.7
% |
| Other |
2 |
11.7
% |
| Total |
17 |
~100
% |
In this study, (11.2%)
of patients with major trauma have associated
ocular injuries; this is close to some results
found in previous studies. A study in Washington,
DC, in 1982-88 found that 13.5% of patients
with major trauma had associated ocular injuries(6). The use of seat belts during the study
period was not recorded, although it is likely
to have been low and this will have contributed
to the higher percentage of eye injuries. A
more recent Australian study (1990-1997) found
the incidence of injuries affecting the eye,
adnexae, orbit and anterior visual pathways
in patients with major trauma was 16%(2). Our
lower incidence of ocular injury may be at least
partly explained by different inclusion criteria.
Both of these studies included adnexal injuries,
whereas we only included tear duct lacerations.
We counted orbital fractures as facial fractures,
unlike the Australian study, which grouped them
with ocular injuries(2).
We can see that this
study may underestimate the incidence of eye
injuries, because relatively minor eye injuries
may be missed in patients with major, life-threatening
trauma. In this study, the most common ocular
injuries involved (in descending order) the
cornea, iris, conjunctiva and sclera. Facial
fractures are commonly associated with ocular
injury, although most patients with an eye injury
do not have a facial fracture. Patients with
a fracture of the maxilla, zygoma or orbit are
five times as likely to have sustained an eye
injury compared to patients without a facial
fracture. Maxilla fractures are most common,
but the proportion of eye injuries associated
with each fracture was similar.
An association between facial fractures and
visual impairment has been well documented(7).
Several papers report
that the highest incidence of severe ocular
injury occurs in patients with mid-facial fractures
caused by RTAs, although some of the populations
studied had low seatbelt usage(8). Another
study found that most patients with mid-facial
fractures had evidence of an eye injury, and
27% sustained a moderate or severe eye injury(9). Impairment in visual acuity was the most
sensitive single predictor of ocular injury.
Other factors associated with an increased risk
of ocular injury in the case of facial injuries
can be remembered by the acronym BAD ACT: Blow-out
fracture, Acuity, Diplopia, Amnesia, Comminuted
Trauma(10).
RTAs still cause a large
proportion of ocular injuries in patients with
major trauma (64.7% in our study). This is similar
to the US study where motor vehicle crashes
accounted for 52.1% of injuries(6).
Major trauma and associated
ocular injuries are three times more common
in men as in women, and young adults are at
greatest risk. Visual impairment in the active
years of life will be particularly devastating,
delaying rehabilitation and having serious vocational
and economic consequences(1,11).
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CONCLUSION
AND RECOMMENDATIONS |
Early recognition of eye injuries in patients
with major trauma is important as urgent treatment
of injuries, such as retinal detachments and
intraocular foreign bodies, may save vision.
All patients with major trauma should be examined
for evidence of eye injury, with particular
attention to patients with facial injuries and
those involved in RTAs.
Visual acuity should be measured where possible,
and the pupils and ocular movements should be
examined.
Computed tomographic scans of the orbit can
be a helpful adjunct to clinical examination.
They are especially useful for diagnosing orbital
fractures and optic nerve injuries, but can
also show ocular soft-tissue injuries.
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