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Comparison of Ocular Trauma Indices in Grading Severity of Injury ...

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704 AIOC 2010 PROCEEDINGS<strong>Comparison</strong> <strong>of</strong> <strong>Ocular</strong> <strong>Trauma</strong> <strong>Indices</strong> <strong>in</strong> Grad<strong>in</strong>g <strong>Severity</strong> <strong>of</strong><strong>Injury</strong> and Predict<strong>in</strong>g Visual Disability after Open Globe Injuries<strong>Ocular</strong> trauma has now ga<strong>in</strong>ed attention as amajor cause <strong>of</strong> visual morbidity.1Assessment <strong>of</strong> severity <strong>of</strong> ocular <strong>in</strong>jury atpresentation us<strong>in</strong>g a standardized scor<strong>in</strong>g systemis helpful for unambiguous <strong>in</strong>terpretation andreport<strong>in</strong>g <strong>of</strong> research results to allow for<strong>in</strong>ternationally valid comparisons.Various ocular trauma scor<strong>in</strong>g systems <strong>in</strong> usetoday <strong>in</strong>clude <strong>Trauma</strong> Index - TI (1983) by Shuklaet al2 <strong>in</strong>stituted before eye trauma wasunambiguously classified by the International<strong>Ocular</strong> <strong>Trauma</strong> Classification Group3 <strong>in</strong> 1997.After the Birm<strong>in</strong>gham Eye <strong>Trauma</strong> Term<strong>in</strong>ology– BETT 4 (1996) was reported by the ISOT –International Society for <strong>Ocular</strong> <strong>Trauma</strong>5 <strong>in</strong> 1997,the <strong>Ocular</strong> <strong>Trauma</strong> Score – OTS (2002) by Kuhn etal6 and the <strong>Ocular</strong> <strong>Trauma</strong> <strong>Severity</strong> Score – OTSS(2001) by Vasu et al7 based on <strong>Trauma</strong> and <strong>Injury</strong><strong>Severity</strong> Score (TRISS) 8 and A <strong>Severity</strong>Characterization <strong>of</strong> <strong>Trauma</strong> (ASCOT) 9, wereformulated.To the best <strong>of</strong> our knowledge the accuracy <strong>of</strong>these scor<strong>in</strong>g systems <strong>in</strong> predict<strong>in</strong>g visualdisability after open globe <strong>in</strong>juries have neitherbeen established nor compared. The subjectiveand objective quantification <strong>of</strong> visual disability <strong>in</strong>open globe <strong>in</strong>juries also lacks standardreferences. Moreover, studies <strong>in</strong>volv<strong>in</strong>g theexist<strong>in</strong>g scores have been retrospective result<strong>in</strong>g<strong>in</strong> lack <strong>of</strong> standardized term<strong>in</strong>ology, assessmentand report<strong>in</strong>g <strong>of</strong> ocular trauma cases. Hence anattempt has been made by us to quantify thevisual disability <strong>in</strong> open globe <strong>in</strong>juries us<strong>in</strong>g thepublished ocular trauma severity scores.To critically evaluate and compare ocular traumascores <strong>in</strong> predict<strong>in</strong>g visual function and disabilityafter open globe <strong>in</strong>juries.Materials and MethodsThis is a prospective study <strong>of</strong> patients with openglobe <strong>in</strong>juries conducted <strong>in</strong> Department <strong>of</strong>Ophthalmology at St. John’s Medical College andHospital, from June 2005 to June 2007. Patientswith previous ocular surgery/trauma/major eyedisease/difficulty <strong>in</strong> measur<strong>in</strong>g the visualfunction/new <strong>in</strong>jury dur<strong>in</strong>g follow-up wereDr. Mayuri Bhargava, Dr. Usha Vasu(Present<strong>in</strong>g Author: Dr. Mayuri Bhargava)excluded. At presentation, all patients underwenta detailed history and ophthalmic evaluation.<strong>Severity</strong> <strong>of</strong> patient’s <strong>in</strong>jury was then gradedaccord<strong>in</strong>g to the follow<strong>in</strong>g <strong>Ocular</strong> <strong>Trauma</strong>Scor<strong>in</strong>g <strong>Indices</strong>, used <strong>in</strong> the study:• <strong>Ocular</strong> <strong>Trauma</strong> Score (OTS) – Kuhn et al 6• <strong>Ocular</strong> <strong>Trauma</strong> <strong>Severity</strong> Score (OTSS) – Vasu etal 7 • <strong>Trauma</strong> Index (TI) – Shukla et al 2• Percentage Disability was calculated for everypatient at the end <strong>of</strong> 6 months follow<strong>in</strong>g the<strong>in</strong>juries (As per Workman’s Compensation Act,1923, 10 which was subsequently revised <strong>in</strong>200111 with similar guidel<strong>in</strong>es).At follow-up <strong>of</strong> six months, after the last surgery,patients were f<strong>in</strong>ally evaluated to assess VisualDisability objectively as well as subjectively torelate the effect <strong>of</strong> his/her visual disability onvarious doma<strong>in</strong>s <strong>of</strong> life like rout<strong>in</strong>e activities,psychological and work performance / study.Objectively:• Best Corrected Visual Acuity, • DiplopiaChart<strong>in</strong>g, 12, • Visual Fields 12 by AutomatedHumphrey Perimeter (central 30-2), • %Efficiency (B<strong>in</strong>ocular Vision) for distance = [%efficiency <strong>of</strong> poorer eye + 3*(% efficiency <strong>of</strong> bettereye)] / 4 12Subjectively: Representative Questionnaire fromscales used to measure various Doma<strong>in</strong>s <strong>of</strong>Quality <strong>of</strong> LifeResultsSixty–four patients were <strong>in</strong>cluded <strong>in</strong> the studywith mean age <strong>of</strong> 28.6 years. Majority <strong>of</strong> patients(n=45; 70.6%) belonged 11 – 40 age group. Malesaccounted for 90.6% (n=58) <strong>of</strong> the studypopulation. Visual acuity <strong>of</strong>


TRAUMA SESSION705Visual acuity recorded at 6 months after the lastsurgery was most commonly between < HM –No PL <strong>in</strong> 27 patients (42.2%). 30 out <strong>of</strong> 64 patients(46.8%) had poor b<strong>in</strong>ocular vision at 6 monthsfollow-up. At the end <strong>of</strong> follow – up period, only14 patients (29.1%) had a severe visual disabilityobjectively, while 44 patients (68.8%) had onlymild objective visual disability. Among the 24patients with good b<strong>in</strong>ocular vision at 6 months,23 patients (95.8%) had mild objective disability.With respect to subjective disability, 40 patients(62.5%) were only mildly restricted <strong>in</strong> theirrout<strong>in</strong>e activities, while 29 patients (45.3%), werefound to be moderately psychologically affectedand were anxious, depressed and emotionallydisturbed at the end <strong>of</strong> 6 months. Well – be<strong>in</strong>gscale with respect to life satisfaction, general well– be<strong>in</strong>g and positive attitude was found to beonly mildly affected <strong>in</strong> most <strong>of</strong> the patients, 37(57.8 %), at the end <strong>of</strong> 6 months. Work / studyperformance was found to have suffered mildloss <strong>in</strong> 23 patients (35.9%), at the end <strong>of</strong> 6 months.19 out <strong>of</strong> 24 patients (79.1%) with good b<strong>in</strong>ocularvision had mild total subjective disability at 6months.OTS correlation with visual rega<strong>in</strong> at 6 monthswas found to be better for mild and moderate<strong>in</strong>juries while that <strong>of</strong> OTSS showed bettercorrelation for severe <strong>in</strong>juries. However, acorrelation between TI and various grades <strong>of</strong>visual rega<strong>in</strong> could not be obta<strong>in</strong>ed.With respect to correlation <strong>of</strong> <strong>in</strong>jury severity at1. Parver L. Eye trauma. The neglected disorder. ArchOphthalmol; 104(10):1452–3.2. B. Shukla and B<strong>in</strong>od Khanna. <strong>Trauma</strong> Index – asystem <strong>of</strong> evaluation <strong>of</strong> ocular damage due totrauma. Indian Journal <strong>of</strong> Ophthalmology, July 1983,31:439–41.3. Pieramici DJ, Sternberg P Jr, Aaberg TM Sr, BridgesWZ Jr, Capone A Jr, Cardillo JA, de Juan E Jr, KuhnF, Meredith TA, Mieler WF, Olsen TW, RubsamenP, Stout T.”A system for classify<strong>in</strong>g mechanical<strong>in</strong>juries <strong>of</strong> the eye (globe). The <strong>Ocular</strong> <strong>Trauma</strong>Classification Group.” American Journal <strong>of</strong>Ophthalmology. 1997 Jun;123(6):820-31.4. Kuhn F, Morris R, Witherspoon CD. Birm<strong>in</strong>ghamEye <strong>Trauma</strong> Term<strong>in</strong>ology (BETT): Term<strong>in</strong>ology andclassification <strong>of</strong> mechanical eye <strong>in</strong>juries.”Ophthalmology Cl<strong>in</strong>ics <strong>of</strong> North America. 2002 Jun;15(2):139–43.5. Kuhn.F, Morris R, Witherspoon CD, Heimann K,Jeffers JB, Treister G. A standardized classification<strong>of</strong> ocular trauma. Ophthalmology. 1996 Feb;103(2):Referencespresentation with objective disability at 6months, <strong>in</strong> OTS it is better for mild and moderate<strong>in</strong>juries while OTSS correlates better formoderate and severe <strong>in</strong>juries. TI does not reallyrelate the severity <strong>of</strong> <strong>in</strong>jury at presentation withvisual disability at 6 months well.On correlat<strong>in</strong>g <strong>in</strong>jury severity at presentationwith subjective disability at 6 months, OTSshowed statistically significant correlation (P


706 AIOC 2010 PROCEEDINGSDisabilities Act, 1965, 1st June 2001.12. Council on Industrial Health, A.M.A.:Estimation <strong>of</strong> loss <strong>of</strong> visual efficiency, Arch. Indust.H. 1955;12:439.13. Schipper J, Landau K, Hornung r. Evaluation <strong>of</strong>visual field defects, motility disorders and diplopiawith<strong>in</strong> the scope <strong>of</strong> accident <strong>in</strong>surance law. Kl<strong>in</strong>Monatsbl Augenheikd. 1993 May; 202(5):382-5.

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