Cesare Forlini, MD,
said trauma specialists must be able to care for all parts of the eye.
Image: Forlini C
Both general and specialist ophthalmologists should be familiar with the
newest, most effective treatments for ocular injuries, experts say.
Ferenc Kuhn, MD, PhD, executive vice president of the International
Society of Ocular Trauma and president of the American Society of Ocular
Trauma, said prevention is vital for reducing ocular injuries from common
household and workplace accidents. General ophthalmologists must educate
patients about eye safety, including the importance of eye protection, he said.
“Hopefully do it before, and not after [an injury],” Dr. Kuhn
said. “This is something that is so important to emphasize. All of these
stores that sell the tools and the equipment and materials have [eye
protection] available. It’s just that people don’t make the
Recent innovations in the field of ocular trauma have helped save more
eyes than in the past. The Birmingham Eye Trauma Terminology System and the
Ocular Trauma Score, two systems providing a common language and scoring method
for ocular trauma for all physicians, have assisted in structuring trauma
treatment, Dr. Kuhn said. He helped devise both systems.
In addition, he helped plan the first symposiums at major U.S. and world
meetings on ocular trauma from terrorist attacks, including the recent World
Ophthalmology Congress in Berlin. He said ophthalmologists are beginning to
realize that readiness for future disasters, whatever the cause, is necessary.
“There is definite interest. I think a lot of people realize this
problem. They are willing to do whatever they personally can, but this is a
problem that is bigger than any single ophthalmologist,” Dr. Kuhn said.
Managing ocular trauma
General ophthalmologists should have a good working knowledge of ocular
injuries, including prevention and treatment of the two most common causes,
mechanical and chemical, Dr. Kuhn said. A 2009 report from the American Academy
of Ophthalmology’s EyeSmart campaign found that 56% of ocular injuries
were treated in ophthalmologists’ offices and 32% were treated in a
hospital emergency department or emergency room.
Emergent eye injuries are often managed by generalists or young doctors
without sufficient experience, which often affects the final outcome, Cesare
Forlini, MD, said.
“Understanding what should and should not be done is an important
first step. Sometimes it’s better to do nothing than take the risk to do
something wrong,” he said.
There are emergency departments in Europe that can guarantee appropriate
management of ocular trauma, but they are becoming the exception rather than
“The thing is, ocular trauma can’t choose. You go to the
nearest hospital, and finding someone who is really able to deal with your
problem appropriately is pure chance,” Dr. Forlini said.
Challenge of eye trauma surgery
A member of the International Society of Ocular Trauma and board member
for the Italian Society of Ocular Trauma, Dr. Forlini expressed concern about
current trends. Not only are governments cutting back on resources, but ocular
traumatology as a subspecialty could become a derelict field of practice, he
said. Fewer ophthalmologists choose to specialize in ocular trauma, and fewer
schools are equipped to offer the appropriate training.
“Trauma care costs far more money than it earns and is extremely
demanding in terms of time, surgical skill and dedication,” Dr. Forlini
said. “As a discipline, it goes against the tide, because medicine is
increasingly fragmented in super-specialized areas of knowledge and
intervention, while ocular trauma requires a wide, global knowledge and
experience of the eye as a whole, beyond the traditional boundaries of anterior
and posterior segment.”
Trauma surgery is pole-to-pole surgery, a term that Dr. Forlini has
popularized. Trauma specialists must be able to care for all parts of the eye
and to coordinate a complex variety of surgical actions. They must “move
in the eye like a dancer, because trauma surgery is not like climbing a ladder
in a linear sequence of preset maneuvers, but performing on a stage where the
hand moves in all directions,” Dr. Forlini said. “Mostly, medical
schools don’t prepare people to do this.”
Dr. Forlini founded the “High School of Ocular Trauma,” a
small group of specialists who volunteer to train younger physicians who are
interested in ocular traumatology.
“We organize symposia but need to broaden our scope and give
[trainees] the opportunity to practice,” Dr. Forlini said. “Some of
us periodically open our operating rooms to young specialists. They see what we
do, can be involved in performing a few surgical maneuvers, but we need, of
course, a more official, better and broader organization.”
Prevalence, causes, prevention
Common reasons for ocular injury in the U.S. include fireworks, motor
vehicle crashes and lawn maintenance. The majority of injuries in the U.S.
result from accidents, with a lesser number caused by assaults. According to
the 2009 EyeSmart report, an estimated 48% of injuries in the U.S. happened in
the home, and of those, about one-third were due to recreation or sports. No
general ocular trauma statistics are available for Europe, but numerous
hospital-based surveys have been carried out in individual countries or
A large study by Schrader analyzed the prevalence of open-globe injuries
in patients treated at two university eye clinics in Germany over 2 decades.
Occupational injuries decreased from 42% to 32% in that time, according to the
“Generally speaking, work-related eye injuries are on the decline
but still highly prevalent in some countries,” Dr. Forlini said.
“Compliance with safety regulations is related to several factors, such as
appropriate information, awareness, risk perception, working conditions and,
last but not least, supervision. Safety legislation is now quite uniform across
Europe, but these factors may vary considerably.”
The same study reported that since 1984, when seat belt legislation
became effective, the number of eye injuries decreased by 83%.
On the other hand, home injuries, particularly those related to
do-it-yourself projects and gardening, are increasingly common. A study
conducted at the University of Birmingham, U.K., found that 41.2% of
penetrating ocular injuries occurred in the home. Accidents from do-it-yourself
home projects or gardening were the cause of 51.5% of the cases. None of the
patients were wearing eye protection at the time they were injured. The authors
noted that overall, do-it-yourself stores and garden centers were inadequate at
promoting eye safety in stores and on company websites.
A growing phenomenon in Europe is increased eye trauma occurring on
Saturday nights, due to intoxicated driving and riots, Dr. Forlini said.
“We are dealing with an increasing number of such cases. Moreover,
hospitals work with reduced forces at weekends, and this further reduces the
chances of getting appropriate treatment. As a result, many young people
sustain permanent damage, which is often both visual and aesthetic,” he
Fireworks continue to be a major cause of severe eye injury around New
Year’s Day and other celebrations.
The Netherlands Society of Ophthalmology reported a total of 268
patients with 315 eye injuries caused by fireworks during New Year’s 2009.
More than half of the patients were bystanders and 60% were minors between the
ages of 3 years and 17 years. One-third of the eyes sustained permanent damage.
In 47 eyes, the extent of the damage was such that it led to irreversible loss
of vision, with complete loss of vision in 24 eyes. Fifteen of these 24 eyes
were surgically removed.
According to the report, “The [Netherlands Society of
Ophthalmology] believes that the current policy of tolerance regarding
fireworks makes the risk of eye injuries to which the Dutch population is
exposed too high. As long as consumer fireworks are allowed, the [Netherlands
Society of Ophthalmology] advises that protective polycarbonate glasses should
be worn while lighting and watching fireworks.”
A prospective survey promoted by the British Ophthalmological
Surveillance Unit and involving all ophthalmologists in the U.K. registered a
peak of firework injuries (81%) in October and November. A large number of
victims were minors and males. Injuries were mostly severe, leading to visual
acuity of 20/200 or worse in more than 50% of the cases.
Statistics from around the world show that young age and male sex are
risk factors for ocular injuries of all types and in all environments and
Preparedness is necessary to effectively treat ocular injuries sustained
in mass-casualty emergencies, including natural disasters and terrorist
attacks, experts say. These injuries are likely to be treated by general
ophthalmologists and subspecialists because of limited access to care outside
the immediate vicinity. General ophthalmologists should have up-to-date skills
in treating facial injuries, including injuries to the globe and eyelid,
retired U.S. Army Col. Robert Mazzoli, MD, said.
For instance, natural disasters such as the Haitian earthquake and
Hurricane Katrina have presented sudden, serious ocular trauma. Other
incidents, such as the recent oil spill in the Gulf of Mexico, can present
potential for ocular damage. Oculoplastic specialist Philip R. Rizzuto, MD,
FACS, working with Project Medishare in conjunction with University of Miami
Global Health Initiative and Bascom Palmer Eye Institute, was asked to assist
with the relief effort in Haiti. He said that eye and facial injuries that he
encountered related to the earthquake included superficial and complex eyelid
lacerations, trauma to the lacrimal drainage system, and multiple facial
lacerations. Complex injuries included facial and orbital fractures, ruptured
globes, and traumatic visual loss related to blunt trauma.
“Hospital facilities, especially those in larger U.S. cities,
should be prepared for mass-casualty situations,” Dr. Mazzoli said.
“A working plan for ocular trauma disaster treatment is key.”
According to the 2009 report of the National Counterterrorism Center,
approximately 11,000 terrorist attacks occurred in 83 countries during 2009,
resulting in over 58,000 victims, including nearly 15,000 fatalities.
The largest number of attacks occurred in South Asia and the Near East,
which also had the highest number of casualties.
Ocular injuries are increasingly being recognized in association with
terrorist acts and may be associated with anatomical and functional morbidity,
Salil Mehta, MD, said.
“Despite the fact that the eye is relatively small, being only 0.1%
of the frontal surface area, ocular injuries are common and may be seen in 3%
[to] 10% of survivors of terrorist blasts,” Dr. Mehta said.
In a retrospective study, Dr. Mehta and colleagues reported on the
ocular injuries of 28 patients who survived the Mumbai, India, train bombings
in July 2006. A series of seven bomb blasts took place over a period of 11
minutes on the Mumbai Suburban Railway. More than 200 people lost their lives
and more than 700 were injured. Of the 28 patients seen at Lilavati Hospital,
16 (57.1%) had ocular injuries.
The most common ocular injuries were periorbital hemorrhages, eyelid
burns and corneal wounds. Open- globe injuries were seen in two eyes of two
patients, and one patient had a traumatic optic neuropathy.
The terrorist bombings in Madrid, Spain, in March 2004 caused the
largest loss of life from a single terrorist attack on European soil in modern
history, killing 191 people. A total of 2,051 people were injured.
A study of the seven hospitals that received most victims following the
Madrid bombings reported that the most frequently injured body regions were the
head, neck and face. Eye injuries were frequent (18%), although most were mild
to moderate in severity.
“Emergency management planners and emergency physicians should be
aware of these patterns of ocular injuries following mass-casualty incidents.
Protocols need to include the screening of large numbers of patients in a short
time, diagnostic tests and early surgery, preferably performed in the
[emergency department] to allow early specific treatment and minimize the risk
of missed ocular injuries,” Dr. Mehta said.
Creating a plan for treating mass casualties has assisted the
ophthalmology department in the Tel Aviv Medical Center in Israel, where Adiel
Barak, MD, is head of the vitreoretinal service.
Dr. Barak said that following a mass-casualty incident in Tel Aviv, all
physicians report to the emergency room at the medical center. Ophthalmologists
examine patients for eye injuries, especially those who have head injuries or
“The main thing you have to do is prepare the hospitals,” Dr.
Barak said. “We speak mostly about terrorist-related injuries because
that’s more that you’ll see in the West, but it can happen if you
have a bus crash. … You have to find your way to work through the system
and prepare for it, because as ophthalmologists, we’re not used to working
with other doctors. We’re used to sitting in our quiet room and working by
[ourselves].” – by Erin L. Boyle and Michela Cimberle
What should be done to ensure that non-ophthalmologist medical personnel are properly trained to recognize and treat ocular traumatic injuries? How much treatment should they administer?
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- Adiel Barak, MD, is head of vitreoretinal service at the Tel Aviv
Medical Center in Israel. He can be reached at +972-3-6973408; e-mail:
- Cesare Forlini, MD, is head of the Ophthalmology Department,
Hospital Santa Maria delle Croci, Viale Randi 43, 48100 Ravenna, Italy. He can
be reached at +39-0544-270385; fax: +39-0544-280049; e-mail:
- Ferenc Kuhn, MD, can be reached at 1201 11th Ave. South, Suite 300,
Birmingham, AL 35202, U.S.A.; +1-205-558-2588; fax: +1-205-933-1341; e-mail:
- Robert Mazzoli, MD, can be reached at
- Salil Mehta, MD, can be reached at Department of Ophthalmology,
Lilavati Hospital and Research Centre, Mumbai, India; e-mail:
- Philip R. Rizzuto, MD, FACS, is clinical assistant professor of
surgery, the Warren Alpert Medical School of Brown University and Ophthalmic
Plastic Surgery. He can be reached at 120 Dudley St., Suite 301, Providence, RI
02905, U.S.A.; +1-401-274-6622; fax: +1-401-490-7051; e-mail: