Eye Trauma Surgery

Time to Surgical Repair for Open Globe Injuries

During calendar year 2022, 105 open globe injuries requiring urgent surgical repair presented to the Eye Trauma Service. There were an additional four cases where an exploration was performed, and no repair was needed. Of the 105 repaired injuries, two cases involving intraocular foreign bodies in the posterior segment were repaired by the Retina Service and three dehisced penetrating keratoplasties were repaired by the Cornea Service; these were not included in the analysis but were also repaired within 24 hours of injury when possible.

Of the 105 repaired injuries, 99 (94.3%) were taken to the operating room (OR) within 24 hours of arrival at Mass Eye and Ear. Fifty-four of the 105 patients (51.4%) were taken to the operating room in under 12 hours. Six patients were taken to the operating room more than 24 hours after admission. Two were due to a delayed presentation, two were due to a need for urgent monitoring with traumatic brain injury, and two were due to an initial minor presentation 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 12.30 hours (range: 0.28 to 88.92 hours). Multiple studies suggest the benefit of repairing open globe injuries within 12-24 hours after injury, particularly for the prevention of endophthalmitis.^1-2

Final Visual Acuity and Ocular Trauma Score

Patients who undergo open globe repair in the 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, in 2018, we changed our outcomes methodology for eye 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 ocular trauma score (OTS).

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

During the 2022 calendar year, 105 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-month window following surgery was recorded for each patient. Of the 33 eyes that presented with extensive injuries to the globe (OTS 1 or 2), 12.1% (4/33) had a final visual acuity of 20/400 or better. Of the remaining 58 patients that were presented with ocular trauma scores 3 to 5, 46.6% (27/58) had final visual acuities ranging from 20/50 to 20/15.

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

Distribution of Final Visual Acuity in 2022

Median Postoperative Vision

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

Rates of Endophthalmitis After Open Globe Repair

During calendar year 2022, 105 patients underwent open globe repair by the Eye Trauma Service. Of these 105 patients, 1 (0.9%) developed endophthalmitis postoperatively. Similar results have been 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