Eye Trauma – An orphan discipline

Open globe injuries present an ophthalmologist with management dilemmas with many unresolved controversies. The visual prognosis at presentation is often difficult to assess in the vast majority of injuries leading to primary repair. Multiple intraocular surgical procedures may be needed on such eyes in an attempt to salvage some useful vision. We have come a long way in the field of ophthalmology from intracapsular cataract surgery to femtosecond refractive surgery and from subjective macular assessment to Fourier domain and adaptive optics imaging of the macula. Likewise, we are in the era of ocular nanotechnology and its application in ocular pathologies. The results of globe injuries have improved with better understanding of complications and improvement in techniques of vitrectomy, however, still many eyes still end up in poor vision. Despite all the work and efforts of key players in the field of ocular trauma, it still searches for recognition and identity as a subspeciality. Not many ophthalmologists are familiar with the terminology of ocular trauma and still reckon Ocular Trauma Score as a research tool and the eye injury registry is most ignored and neglected part in the clinics. With the basic understanding of eyes with open globe injuries and following the concepts of ocular trauma repair, we can prevent significant ocular morbidity due to this devastating entity. Concept of atraumatic repair needs to be ingrained into strategic planning in ocular trauma management to achieve optimal outcome in globe trauma. Multidisciplinary approach is warranted in patients with complex ocular trauma. Empowering the fellow ophthalmologists with specialty training in ocular trauma can be one of the steps forward in optimizing the outcome in patients with ocular trauma and further streamlining the care of traumatized eyes. Medicolegal litigation can  be minimized by good documentation, establishing rapport with the patient and family and following the basic principles in management of ocular trauma.

Five-year view: One of the most neglected parts in ocular trauma management is very weak epidemiological data. Every attempt should be made by the local and national societies to mandate the reporting of eyes with Open Globe Injuries, if not all eyes with ocular trauma under common local registry. Further attempts should be made to link the local registry with the state and national registry, which should be eventually linked to the international registry of ocular trauma. The epidemiologic data hence generated will guide us about the impact and burden of this problem and in terms of health economics research will pave the way for boosting up healthcare policy and resources to prevent this gigantic but preventable cause of blindness. It will also highlight any obvious regional and national causes and safety tools than can be devised accordingly. Training of junior ophthalmologists in management of ocular trauma along with training in cataract should be part of the curriculum and the trainees should be given exposure in theatres or use of wet labs. Unsupervised repair of the traumatized eyes by inexperienced surgeons should be strongly discouraged and every attempt should be made to transfer the surgical skills to the novice surgeon by more experienced surgeon. Likewise, prospective multicenter studies need to be conducted to further investigate the prognostic factors in Open Globe Injuries and to revisit classification of ocular trauma and Ocular Trauma Score and to redefine some of these parameters based on the analysis and outcome of prospective multicenter studies. A strong emphasis on preventative aspects should be the major goal in the next 5 years and this may involve closely working with regulatory authorities in healthcare planning.

Published by Rupesh Agrawal

Dr Rupesh Agrawal MMed, FRCS(Glasg), FAMS, DNB, DO, MD(Res) Senior Consultant Ophthalmologist (Uveitis and General Ophthalmology) National Healthcare Group Eye Institute Tan Tock Seng Hospital, Singapore Co-Head: Ocular Infections and Antimicrobials group ( Singapore Eye Research Institute) Associate Professor: Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore Honorary Consultant – Moorfields Eye Hospital, London, United Kingdom

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