Clinical and Experimental Ophthalmology (2002) 30, 15–18

Original Article _____________________________________

Original Article

Four-year review of open eye injuries at the Royal Adelaide HospitalRobert J Casson FRANZCO,* James C Walker MB BS and Henry S Newland FRACO MPHOphthalmology Unit, Royal Adelaide Hospital, North Terrace, South Australia, Australia

ABSTRACT

Purpose: To review the epidemiology of penetrating eyeinjuries and ruptured globes presenting to the RoyalAdelaide Hospital, South Australia.

Methods: A retrospective case review over a 4-year period.

Results: There were 109 penetrated or ruptured globes in105 patients. The average age was 41 years and 80.2%were men. Over half were from rural areas. The common-est cause of injury was hammering metal followed bymotor vehicle accidents. Falls in the elderly were thecommenest cause of globe ruptures. A final visual acuity of6/12 or better was found in 40% of eyes and no perceptionof light in 27%.

Conclusions: At the Royal Adelaide Hospital, the predom-inant referral centre for serious ocular injury in SouthAustralia, approximately 25 open globe injuries areencountered a year. Although the epidemiology of theseinjuries was found to be similar to those previouslyreported in Victoria and rural New South Wales, differ-ences were thought to reflect to the ageing population ofSouth Australia. Rupture of an old, healed large-incisioncataract extraction wound was the commonest cause ofruptured globe. An effective preventive strategy to reducethe incidence of severe ocular trauma has yet to beimplemented. The concept of a national population-basedsevere ocular trauma database is considered.

Key words: epidemiology, penetrating eye injuries, rup-tured globe.

INTRODUCTION

Open globe injuries, encompassing penetrated, perforatedand ruptured globes, constitute a major cause of visualmorbidity worldwide.1 South Australia is no exception.2

Limited information is available in Australia concerningthe epidemiology of ocular trauma. Recent data from Vic-toria and rural New South Wales illustrates the magnitudeand cost of serious ocular trauma.3–5 This information isessential for planning preventive strategies and allocatinglimited resources.

METHODS

The study involved all patients diagnosed with a breach ofthe outer tunic of the eye or ruptured globe whether byblunt or sharp force presenting to the Royal Adelaide Hos-pital from July 1994 to June 1998 inclusive. The RoyalAdelaide Hospital is the major adult trauma centre manag-ing the majority of serious ocular injuries in South Australia.

Patient records were retrieved by computer search ofnotes with International Classification of Disease (ICD-9 CM) codes 871.0–9 (open wound of eyeball). The recordsof all patients were studied to determine the age, sex andplace of residence of the patient; initial and final visualacuity; anatomical site, nature, date and cause of injury;association of injury with alcohol; and operations per-formed, complications and follow up. The minimum follow-up information from presentation was 4 months. The finalvisual acuity was taken as the best corrected or pinholevisual acuity on their most recent outpatient visit. The initialvisual acuity was the acuity measured on presentation tohospital.

RESULTS

There were 109 eyes involved in 105 patients over the4-year period. Based on an estimated catchment populationfor the RAH of 700 000 (Dr Paul Basso, RAH MedicalAdministration, 2000, pers. comm.), the annual incidence ofpenetrating eye injuries and ruptured globes in South Aus-tralia is 3.9 per 100 000. The rate of penetrated or rupturedglobes at the RAH was 27.3 per year.

Figure 1 shows the age and sex distribution of thepatients. Of the 105 patients, 88 (83.8%) were men. This

� Correspondence: Dr James C Walker, Royal Adelaide Hospital, North Terrace, SA 5000, Australia. Email: james.walker@adelaide.edu.au

*Present address: Specialist Eye Registrar, Radcliffe Infirmary, Oxford, UK.

16 Casson et al.

represented a statistically significant gender difference (χ2,p < 0.001). The average age was 41 years (men 37.6 years,women 55.4 years). The majority of patients were youngmen in their third to sixth decade.

A disproportionate number of patients (50.5%) werefrom rural South Australia, which comprises only 15% of thetotal population of the State.6 The right and left eyes wereaffected approximately equally and there were four bilateralpenetrating injuries.

The causes of the injuries are presented in Table 1. Fiveof the 12 patients who suffered falls ruptured an old extra-capsular cataract extraction (ECCE) wound. One patientruptured a penetrating keratoplasty wound. These sixpatients all had prolapse of ocular contents and uniformlypoor visual outcome, with a final vision of less than 6/60.

Injuries were significantly more common on Saturday(P < 0.01; Fig. 2) and an association with alcohol was docu-mented in six cases (five men, one woman). There was nosignificant seasonal variation. Of the four bilateral cases,three were a result of motor vehicle accidents.

The anatomical site of the wound was corneal in 41%,scleral in 26%, corneoscleral in 26% and limbal in 14%.Figure 3 shows graphically the distribution of final best

corrected visual acuity for isolated corneal wounds versuswounds involving sclera. The lens was involved in 14.7% ofcases, uveal prolapse in 61% and vitreous prolapse in 40%.Fourteen eyes had an intraocular foreign body (IOFB), nine(65%) with final vision 6/12 or better.

In the majority of cases (54.3%), the initial visual acuitywas less than 6/60. One patient, who sustained bilateralinjuries from a motor vehicle accident, was unconsciouspreoperatively and did not have an initial visual acuityrecorded.

The commonest primary surgery involved reconstitutionof the globe with reposition or excision of ocular contents.All surgery occurred within 8 h of presentation to hospital.All patients received intravenous antibiotics, usually cepha-lothin and gentamicin, in addition to topical antibiotics andtopical steroids. The lens was removed in the primary pro-cedure in seven cases. Four totally disrupted globes wereeviscerated as a primary procedure. Four eyes were enucle-ated as a primary procedure. Subsequent operationsincluded 18 enucleations and 15 vitreoretinal procedures.

Complications included one case of probable, but histo-logically unconfirmed, sympathetic ophthalmitis in a youngman with extensive iris damage. He required a vitrectomy as

Figure 1. Age of patients with open globe injuries by sex. □,women; �, men.

Table 1. Causes of open globe injuries

Cause No. cases

Hammering metal 22Motor vehicle accident 15Fall 12Assault 10Cutting wire 7Chopping wood 5Exploding bottle 4Cutting tiles 3Sports 3Drilling metal 2Gardening 2Grinding metal 2Loading rubbish 2Octopus strap 2Miscellaneous 14Total 105

Figure 2. The day of the week when open globe injuries occurred.

Figure 3. Plot of final best visual acuity by wound type. ‘Corneaonly’ means wounds confined to the cornea while those ‘involvingsclera’ include limbal injuries. NPL, no perception of light; PL, per-ception of light; HM, hand movements; CF, count fingers.

Four-year review of open eye injuries 17

a secondary procedure and 5 months later presented withuveitis in the fellow eye. He was managed with intensivesystemic and topical steroid with good outcome. The exci-ting eye had good vision and was not removed. One elderly,systemically unwell, patient died several days after repair ofwound rupture. There were no cases of endophthalmitis.

The final visual outcome compared with the initial visualacuity is shown in Fig. 4. The final visual acuity was 6/12 orbetter in 44 eyes (40%). Twenty-eight eyes had a finalacuity of no perception of light. Of those eyes that pre-sented with hand movements vision or better, 96.8% had afinal vision of better than 6/60. Only those patients present-ing with no perception of light had a uniformly dismalprognosis.

DISCUSSION

The epidemiology of severe ocular trauma has only recentlyemerged in the Australian literature and is confined to theeastern States of Australia.3–5 To our knowledge, this is thefirst study examining the epidemiology of severe oculartrauma in South Australia. An overview of all ocular traumain South Australia published in 1991 showed a comparableincidence of severe ocular trauma.7

It is possible that some cases were missed due to incorrectcoding of cases. In our opinion this was likely to have beena very rare occurrence. Based on the population serviced,the incidence in the population is estimated to be 3.9 per100 000 per year. This compares with 3.6 per 100 000 inVictoria4 and 4.72 per 100 000 in rural New South Wales.5

Very similar rates have been found in other industrializedcountries.8,9

A male preponderance is a universal characteristic andthought to be related to: occupational exposure, participa-tion in dangerous sports or hobbies, judgement impaired byalcohol or risk taking behaviour.3–5,8–13 Injuries were signifi-cantly more common on Saturdays.

The average age of the patients was higher than thatreported in other Australian studies.4,5 A contributing factorto the older average age is the relatively large number ofelderly patients who presented after a fall. The majority ofthem were over 70 years of age and 50% ruptured an oldwound site. The demographics and causation of rupturedglobes differ from penetrating eye injuries and deservefurther investigation.

In a study by Landen et al. individuals who had recentocular surgery accounted for 4.6% of ruptures and 31.6% ofcases in people 60 years and over.8 While we acknowledgethat the risk of wound rupture is highest in the initialmonths after surgery and declines with time, there is alifelong risk. Our elderly subgroup with ruptured globesgenerally did poorly in terms of visual outcome.

There are limited data regarding the epidemiology ofruptured globes. It has been reported as an injury of youngmales suffering an assault.13 Many of the patients who haveundergone ECCE are now elderly and at risk of suffering aserious fall.14 With the advent of small incision phacoemul-sification surgery, presumably the incidence of rupture fol-lowing a fall will diminish.

A large proportion of the patients were from rural areasand probably reflects a greater occupational exposure topotentially dangerous situations such as cutting wire. Thegreater probability of someone from a rural area sustainingserious ocular injury has recently been reported in a largepopulation-based study conducted in Victoria.3

In the vast majority of cases, whether or not the patientwas wearing protective spectacles was not recorded. It islikely that most of the high velocity fragment injuries couldhave been prevented by the use of polycarbonate protectivespectacles.12 Wounds confined to the cornea had the bestvisual outcome. This has been noted in previous studies5,15

and reflects both the ability of the anterior segment to healand the severity of the initial injury.

Generally eyes with an IOFB did well in terms of visualoutcome, reflecting the relatively sterile nature of theforeign material and minimal tissue disruption.

Sternberg et al. in a multivariate analysis of prognosticfactors in penetrating eye injury, noted that a good initialvision correlated highly with a good final vision.15 Wefound a similar pattern.

Most cases were uncomplicated and we found no cases ofendophthalmitis. Thompson et al. reported one case of post-traumatic endophthalmitis in 77 cases of penetrating injuryin rural New South Wales.5 The literature indicates thatpost-traumatic endophthalmitis is not common, complica-ting approximately 5% of cases.16–18 Risk factors for post-traumatic endophthalmitis include greater than 24 h delaybefore surgical repair, initiation of intravenous antibioticsgreater than 24 h after injury and presence of an IOFB.17,18

A major limitation of a retrospective study of this natureis that it is static. The epidemiology of ocular trauma isdynamic. The National Eye Trauma System (NETS) Regis-try in the United States provides valuable ongoing epidemi-ological feedback. The Registry, however, is limited by the

Figure 4. Initial versus final best recorded visual acuity at last fol-low up. NPL, no perception of light; PL, perception of light; HM,hand movements; CF, count fingers.

18 Casson et al.

fact that it is not population based.10 Data in the NETSRegistry is based on voluntary reporting by ophthalmolo-gists in 48 collaborating centres and is not independentlyconfirmed.10 Given the relatively small population of Aus-tralia, relatively small number of centralised tertiary referralcentres and advances in information technology, a nationalcollaborative registry of severe ocular trauma could beestablished in Australia to provide population-based longi-tudinal data for preventative strategies.

In conclusion, serious ocular trauma occurs in SouthAustralia with a similar estimated incidence to other areas ofAustralia and elsewhere.3–6,8,9 Open eye injuries were mostcommonly due to metal striking the eyes of young men.Properly fitted safety spectacles could probably have pre-vented all of these injuries. Education programmes on theimportance of eye protection have failed to eliminate theproblem. Young men in particular should be targeted.

Falls in the elderly are a cause of a significant number ofsevere ocular injuries. Many of these elderly patients hadruptured an ECCE wound, usually accompanied by severetissue damage and poor visual outcome. This type of injuryis expected to become rare with the advent of small incisionsurgery.

Overall, the visual outcome for open eye injuries is rea-sonably favourable, particularly for those with wounds con-fined to the cornea.

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