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  5. FP197 : Validation of Newly Proposed Expansion of BETTS Ocular Trauma Classification for Eye Injuries

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Dr. Kashyap Patel, P16784, Dr. Siddharth Rajendragiri Gosai, Dr. Juhee Vishnu Agrawal, Dr. Mehul Ashvin Kumar Shah

Chief Author Dr.Kashyap Patel
Presenting Author Dr.Kashyap Patel
Co-author Dr.Mehul Shah
Co-author Dr.Juhee Agrawal
Co-author Dr.Siddharth Gosai

Abstract

Introduction: Criticisms have been levelled at the widely accepted Birmingham Eye Trauma Terminology (BETT) classification of mechanical ocular trauma, as it is not specific enough. Alternative modifications to the BETT havebeen proposed and this study aimed to assess these newer classifications.

Methods: A prospective cohort study of all patients presenting to the outpatient department between January 2005 and December 2014, who were examined and categorised based on the BETT. Cases which did not comply with the BETT system were placed in additional categories, and documented for each type of injury.

Results: A total of 4721 eyes suffered mechanical injuries and 1060 (22.4%) could not be classified with BETT, including 368 globe injuries (7%) associated with orbital/ocular adnexa injury; 692 eyes (14.6%) with ocular surface foreign body(OSFB) or ocular wall foreign body (IWFB). There were 77 eyes (1.6%) with contusion, 9 eyes (0.19%) with lamellar laceration-associated OSFB or OWFB, 29 eyes (0.6%) with globe rupture-associated OSFB, OWFB or intraocular foreignbody (IOFB) and 60 eyes (1.4%) with laceration-associated OSFB or OWFB.

Conclusion: The BETT needs modification to be fully applicable to the wide range of ocular trauma seen across the world.

Keywords

BETTs, mechanical ocular trauma, open globe injuries, closed globe injuries, ocular surface foreign bodies, adnexalinjuries

Introduction

Trauma is a common cause of monocular blindness in the developed world, although few studies have addressed the problem of eye trauma in rural areas,1where the aetiology of ocular injury is likely to differ from that in urban areas and is worthy of investigation. 2,3 Eye trauma represents a large, potentially preventable burden on both victims and society as a whole. 3 It is clear that any strategy for prevention of such injuries, requires knowledge of their cause, which

may enable more appropriate targeting of resources towards preventing such injuries. This is facilitated by having a common terminology that allows direct comparison of like-with-like. The Birmingham Eye Trauma Terminology (BETT) 4 is regarded as an ideal ocular trauma terminology system as it provides a clear definition for each injury type, places each injury type within the framework of a comprehensive system and allows comparison

between datasets. As a consequence, the BETT iswidely accepted amongst ophthalmologists and is extensively used in articles, conferences and books. Our own experiences of using the BETT have, however, revealed some difficulties in classifying some instances of mechanical eye injuries because of a lack of specificity.

Whilst the BETT is widely accepted, it is not universally so and is not free from challenge or controversy,and some authors have proposed modifications andnewer classification systems to complement the existingBETT, especially in the setting of open globe injuries.

5–7 In addition, there are other scoring systemssuch as the Ocular Trauma Score, which are designedto predict visual outcomes, which are not consideredfurther in this study of patho-aetiological classification. This study aimed to examine those cases that would

not be specifically classified by the BETT and to examine whether a modified classification would be more useful.

Methods

This was a prospective cohort study of all mechanical ocular trauma patients presenting to the ophthalmology outpatient department of multiple centres of the same hospital between January 2005 and December 2014. All patients who consented to inclusion were enrolled in the project, with the exception of life threatening polytrauma cases in whom consent could not be obtained. Details of all enrolled patients (new and follow-up) were documented using the US Eye Injury Registry form.8 Patients were thoroughly examined according to a standard protocol for ocular adnexa and anterior/posteriorsegment findings. The information was recorded

electronically, and all eyes were classified according to the BETT, which is the accepted standardised international classification of ocular trauma. The eye injuries which were difficult to classify by BETT were documented for type and number, and classified in supplemented categories. The documented data wereexported to MS Excel spreadsheets and analysedusing SPSS v22.

Results

A total of 4200 patients with 4271 mechanical eye injurieswere registered during the nine-year study period.According to the BETT, 2608 (55.4%) and 1047(22.1%) were in the closed globe and open globeinjury categories, respectively, but 368 eyes (7%) withonly orbital or ocular adnexa injuries, and 692 (14.6%)with ocular surface and ocular wall foreign body injuries could not be classified in either of those; overall,1060 (22.33%) eye injuries could not be classified

according to the BETTs (Figure 1). As part of the study, newer categories were created and the unattributed injuries were grouped accordingly (Figure 2).Of the 2608 (55.4%) with closed globe injury, 1333 exhibited closed globe contusion, and 1273 showed lamellar laceration; 548 (12%) eye injuries with ocular surface foreign body (OSFB) and 144 (3.5%) with ocular wall foreign body (OWFB) could not be classified, and accounted for 14.5% of all mechanical eyeinjuries. In addition, 77 eyes with contusion and ninewith lamellar laceration-associated OSFB or OWFB(1.6% and 0.19% of all closed globe injuries) failed to get categorised (Figure 1).Of the 803 eyes with open globe injuries, rupture andlaceration cases numbered 244 (5%) and 803 (16.5%),respectively. There were 29 cases of globe rupture-associated OSFB, OWFB or intraocular foreign body(IOFB) accounting for 0.6% of the whole total, 1.4% of the mechanical eye injury category, 3.6% of the open globe injuries and 11% of all rupture injuries. Figure 1. Patients classified according to the existing BETT: Birmingham Eye Trauma Terminology; IOFB: intraocular foreign body; SUP FB: Superficial Foreign Body.2 Trauma 0(0) Overall, 728/803 (5%) of the eyes were penetrating, 50

(1%) were perforated and 25 (0.5%) were IOFB, and showed perforation. Within the laceration group,60 eyes were associated with OSFB or OWFB,equivalent to 1.27% of the total mechanical eye injurycategory, 7.4% of the total open globe injuries and10.6% of all laceration injuries.

Discussion

Undoubtedly, the BETT is the language of everyday ophthalmic clinical practice, and is endorsed by many ophthalmic organisations, journals and ophthalmologists. In the present study, it helped in eliminating many ambiguities while communicating in the domain

of ocular traumatology.9–11 However, according tosome authors,  BETT is not perfect, and needs to be developed and modified further in order to be the ideal system.4 The BETT provides a standardised terminology for mechanical eye injuries,9 but in practice, this system

considers the entire optic globe as the tissue of reference,and remains concerned only with mechanical eyeball injuries. Consequently, certain injuries resist classification in the BETT system, and in the present investigation, this group constituted 11% of the total mechanical eye injuries. Although some proportion of orbital and ocular adnexa-associated globe injuries canbe classified as globe injury according to the BETT system, this description is incomplete and misses outsome vital information. Furthermore, some mechanical

eye injuries with only orbital and ocular adnexa injuries do not fit into any category; this group constituted nearly 7% of all mechanical eye injuries in the present investigation. In a study of hospitalised ocular injuries among people from a low socioeconomic background,

Chen et al.12 observed that the three foremost types of ocular injuries seeking hospitalisation, included orbital floor fracture, open wounds of the eyeball and open wounds of the ocular adnexa. Another study on paediatric eye injury-related hospitalisations in the United States reveals that open wounds of the adnexa andorbital floor fractures represented almost two-thirds of  hospitalisations for adolescents aged 15–17 years(61.6%), as well as young adults aged 18–20 years(62.9%).13 In his study on the nature, incidence andimpact of eye injuries among US military personnel, Andreotti et al.14 noted that 85% of hospitalisationswere diagnosed as either orbital floor fractures (30%), contusions (28%) or open wounds to ocular adnexaand orbit (27%).

In clinical practice, although the eyeball is more important than orbital or ocular adnexa, mechanical injuries in these regions could well be described if classified by listing the injured region by a definition of the anatomy of that region. Foreign body injury, especially IOFB, is an important type of eye injury commonly seen in clinical practice. In the present study, following the BETT guidelines, IOFB cases were grouped separately, because of their special management and prognostic implications, although technically, IOFB is a penetrating injury.1 OSFB and OWFB injuries are equally important components of globe injury, forming nearly 12% of all globe injuries.Figure 2. Newly created categories and the unattributed injuries, grouped accordingly.IOFB: intraocular foreign body.

Shah et al. 3 An examination of the clinical and epidemiological profiles of ocular emergencies in a reference emergency centre indicated that OSFB was the most frequent occurrence, responsible for 58% of cases.15 Another investigation reported that corneal foreign bodies(usually iron) are the most common hazard faced by

workers involved in welding, grinding and hammering activities in factories.16 Such professions also pre-dispose workers to ocular adnexa-associated foreign body injuries, such as eyelid foreign body, orbital foreign body and so on.17 The implication is that foreign body injury should be grouped separately, giving more details with the help of anatomical definitions.Finally, it is proposed that, as a complement to the BETT, injuries that are difficult to categorise may bedescribed as ‘mixed’.1 In fact, many mechanical eye injuries overlap, and can be described accordingly,such as rupture with an IOFB, penetrating with eyelid injury or contusion with OSFB and OWFB.18,19 It is

hoped that other ophthalmic experts can contributebetter alternatives and suggestions, in order to lend perfectionto the BETT system.

Conclusion

Addition of certain categories to the classification of mechanical eye injuries would succeed in improving the present system of terminology, and could encompass all those cases of eye injury that are hitherto, not being accommodated by the existing standard BETT. 

References

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  2. Abraham DI, Vitale SI, West SI, et al. Epidemiology ofeye injuries in rural Tanzania. Ophthalmic Epidemiol 1999;6: 85–94.
  3. Alfaro DV, Jablon EP, Rodriguez Fontal M, et al.Fishing-related ocular trauma. Am J Ophthalmol 2005;139: 488–492.
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  11. Chen G, Sinclair SA, Smith GA, et al. Hospitalizedocular injuries among persons with low socioeconomic status: a medicaid enrolees based study. OphthalmicEpidemiol 2006; 13: 199–207.
  12. Brophy M, Sinclair SA, Hostetler SG, et al. Pediatric eyeinjury-related hospitalizations in the United States.Paediatrics 2006; 117: e1263–e1271.
  13. Andreotti G, Lange JL and Brundage JF. The nature,incidence, and impact of eye injuries among US militarypersonnel: implications for prevention. Arch Ophthalmol2001; 119: 1693–1697.
  14. Cecchetti DF, Cecchetti SA, Nardy AC, et al. A clinicaland epidemiological profile of ocular emergencies in areference emergency centre.Arq Bras Oftalmol 2008; 71:635–638.
  15. Aziz MA and Rahman MA. Corneal foreign body – anoccupational hazard.Mymensingh Med J 2004; 13:174–176.
  16. Santos TS, Melo AR, Moraes HH, et al. Impacted foreignbodies in orbital region: review of nine cases. ArqBras Oftalmol 2010; 73: 438–442.
  17. 18.Larque-Daza AB, Peralta-Calvo J and Lopez-Andrade J.Epidemiology of open-globe trauma in the southeast ofSpain. Eur J Ophthalmol 2010; 20: 578–583.
  18. Chen KJ, Sun MH, Hou CH, et al. Retained large nailwith perforating injury of the eye. Graefes Arch ClinExpOphthalmol 2008; 246: 213–215.

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