European Journal of Cardiovascular Medicine

Ocular trauma in children is one of the most common avoidable causes of vision loss in children.[1] According to estimates, 1.6 million children worldwide are blind as a result of ocular trauma, with 2.3 million having bilateral and 19 million having unilateral poor vision.[2] The occurrence of ocular trauma varies greatly by nation, sex, age, and economic status.[3] Various studies have reported that eye injuries in childhood account for 12.5–33.7% of all admissions for eye injuries.[4] According to the American Academy of Pediatrics, 66% of all ocular traumas occur in those aged 16 and less, with the largest prevalence happening between the ages of 9 and 11.[5] Compared to adults, these traumas can cause amblyopia, which may lead to limitations in psychosocial development and social interaction, decreased awareness, loss of self-perception, and poor academic performance.[6]

The standardized classification of eye trauma is useful for ophthalmologists to categorize trauma, predict visual outcomes and develop prognostic, management, and prevention strategies.[7] Ocular trauma score (OTS) was developed as a set of standard language that is a worldwide, exact communication system as well as a system for identifying, quantifying, and predicting mechanical injuries.[8]

The OTS method predicts the final visual acuity (VA) based on the baseline VA, relative afferent pupillary defect (RAPD), globe rupture, endophthalmitis, a perforating injury, and retinal detachment (Table 1). Despite its widespread use and validation in several studies and across age groups, it might be challenging to assess VA and RAPD, two major OTS criteria, in children, especially in post-traumatic situations. Acar et al. created a pediatric OTS (POTS) in 2011 after evaluating 28 cases of pediatric ocular injuries.[9] This score limited the impact of VA as a predictive factor and proposed an alternate technique to estimate the visual result if initial VA was unavailable.

Imaging plays a key role in evaluating the severity of ocular and orbital trauma, making decisions, and planning treatment for ocular trauma.[10] Computed tomography (CT) scans are effective in detecting orbital and intraocular foreign bodies (IOFB), showing their locations, and providing intracranial and facial injury information.[10] CT scanning is easier to use in pediatric trauma patients and does not require patient cooperation.[11] Therefore, the majority of health-care services, including our own, perform a CT scan of orbit before the first repair of the injury. CT findings in traumatized eyes usually match clinical findings.[12] The accurate interpretation of CT scans in children can improve the early assessment of the final visual results for OTS and POTS.

The objective of this research was to assess the correlation between CT findings and pediatric ocular POTS and OTS in open globe injuries (OGIs) in pediatric patients presenting at a pediatric ophthalmology emergency department in a tertiary hospital in Central India. In this study, we present new information about CT results in a cohort of 34 children diagnosed with OGIs. Our objective was to investigate the potential correlation between scores of OTS and POTS, as well as the kind and amount of CT findings reported. The findings of this study could potentially contribute valuable knowledge toward the formulation of preventive measures and prognostic predictions for visual impairment in children as well as the type and quantity of CT abnormalities documented.

This was a retrospective and descriptive study which included pediatric OGIs presenting to the ophthalmology department of our university hospital from January 1, 2020, to December 31, 24. The study adhered to the tenets of the Declaration of Helsinki, and approval from the institutional research ethics board was obtained for the study.

A comprehensive analysis was conducted on the hospital records of all patients, including ophthalmological consultations, operation notes, and patient follow-up files. A data file was created to record the demographic information of patients, including age, gender, and laterality. The primary clinical assessment was determining the best-corrected VA (BCVA) at first presentation, assessing the existence or absence of a RAPD and red reflex, and evaluating ocular motility. Subsequent to these procedures, a biomicroscopic evaluation was conducted to evaluate potential impairments in the anterior segment, including subconjunctival hemorrhage, corneal or scleral laceration, hyphema, inflammation, irregular pupil, iris prolapse, lens subluxation, and cataract. In addition, an assessment was made for any damage to the posterior segment, which includes vitreous hemorrhage, retinal detachment, and choroidal hemorrhage. The item that caused trauma was also detected. The classification of ocular injuries was conducted in accordance with the Birmingham eye trauma terminology methodology.[13] The dataset also included the ultimate BCVA, the average duration from the occurrence of trauma to the admission of the patient, as well as any accompanying ocular observations, such as endophthalmitis. Moreover, it included information on any additional surgical procedures, the length of the follow-up period, and the condition of the eye at its latest appointment. The study comprised individuals who had been diagnosed with OGIs that were clinically or surgically proven, and who had also received orbital CT scanning for cranio- or orbito-facial reasons. The CT images were then sent to the picture archiving and communication systems workstations, where the orbit was looked at using 3-D multiplanar reconstruction images with the right adjustments for bone and soft tissue. An experienced radiologist (Dr. P.G.) evaluated all images using clinical information. Exclusion criteria were patients with insufficient clinical records, low-quality CT scans, pseudophakia, or aphakia.

The CT findings of 34 pediatric trauma patients who suffered OGIs were classified into nine main categories: Scleral irregularity, lens dislocation, abnormal vitreous density, chorioretinal layer thickening, increased preseptal thickness, presence of IOFB and air, vitreous hemorrhage, retinal detachment, and perforation. A univariate analysis was performed to evaluate the association between different kinds and amounts of CT findings and POTS and OTS values. The OTS and the POTS were computed for every individual in the study population. The score is a numerical representation ranging from 0 to 100, determined by giving a raw point value to the initial VA measurement and then deducting points based on the clinical observations. The first raw points for POTS are determined based on the initial VA, the age of the patient, and the location (zone) of the lesion (Table 2). In cases where VA measurement was unattainable, the subsequent calculation used the following formula: the sum of the patient’s age and the site of the lesion, multiplied by two, with further deductions made based on the associated diseases.[9] The statistical analyses were performed using the SPSS for Windows, version 21.0 software application. The mean±standard deviation (SD) is used to represent continuous data, whereas percentages are used to represent categorical variables. A crosstab and Chi-square analysis were used to assess the relative frequency of distinct CT findings within OTS and POTS. The chi-square test was used to establish the associations between the quantity of CT findings and OTS and POTS. A significance level of <0.05 is considered statistically significant for the P-value

In a comprehensive review, a total of 43 children with OGIs admitted to our clinic between 2010 and 2020. Following the exclusion of nine cases due to a lack of follow-up or incomplete records, as well as one case of chemical injury, 34 children met the inclusion criteria for our study. The demographics and injury characteristics of the patients are shown in Table 3. The mean ± SD of age was 6.61±3.10 years. 7 of 34 people were between the ages of 0–4 (20.6%), 15 of them were between the ages of 4–8 (44.1%), 8 of them were between the ages of 8–12 (23.5%), and 4 of them were between the ages of 12–18 (11.8%). There were 9 females (26.5%) and 25 males (73.5%) in the study, and the mean age was 6.61±3.10 (n=34). In all children, only one eye was injured (67.6% left eyes, n=23). The mean follow-up time was 2.89±0.77 years. The incident leading to trauma occurred most frequently at home (61.3%), and there were no chemical contacts in any injury; 19 were clean wounds (55.9%). All were mechanical injuries. None of the patients (98%) emerged after 48 h from the occurrence of ocular injuries, and surgical care was started for >95% of them within 6 h.

Table 4 presents the ocular injury patterns observed in the patients. The cornea emerged as the ocular structure most frequently affected by trauma. The most prevalent surgical indications were traumatic cataracts and corneal cuts (Table 4). Ocular surgery was carried out in all of patients as a result of trauma, with corneal cut repair being the mostly performed technique (n=11) (32.4%). Among eyes with an OGI, 2 had a full-thickness laceration (5.9%), 79.4% (n=27) had a penetrating injury, 7% (n=3) had a perforation, and 2.0% (n=1) had an IOFB (Table 4). In the study cohort, 52.9% of children (n=18) had a corneal laceration involving the visual axis in Zone 2 and Zone 3 scleral laceration was present in 35.2% (n=12) and 11.7% (n=4), respectively. The mean wound length was estimated to be 6.69±4.40 mm (n=34). The average value of POTS was found to be 63.05±25.74 (n=34), while the average value of OTS was determined to be 73.47±18.83 (n=23).

Table 5 presents the CT scan findings observed in the patients. The most common CT findings are scleral irregularity and increased preseptal thickness (n=16) (47.1%) (Table 5). Table 6 presents VA of the patients with ocular injury at initial presentation and last follow-up. Table 7 presents the association between various types of CT findings and POTS, along with OTS scores in 34 study eyes. The number of CT findings was grouped and compared according to their POTS and OTS. Since the number of patients with 4 or more CT findings in the OTS group decreased to 4, comparisons in terms of OTS could not be made. When the number of CT findings in terms of POTS was compared between groups, the difference was significant. When the groups were compared in terms of the number of CT findings, there was no significant difference between the group with 4 or more CT findings (median POTS value 45 [25–80]) and the group with 2 or 3 CT findings (median POTS value 60 [15–70]). A significant difference was observed between the group with 1 or fewer CT findings (median POTS value 80 [71.25–90.0]) and the group with 4 or more CT findings (P<0.05). There was a significant difference between the group with 2 or 3 CT findings and the group with 1 or fewer CT findings (P<0.05). As the number of CT findings increased, POTS gradually decreased indicating severe ocular trauma. While POTS was significant (P<0.05) in patients with abnormal vitreous density (median 45 [30–69.6]), OTS was not significant (P>0.05). There was no significant difference between POTS and OTS in other CT findings. A pairwise correlation analysis of CT findings and POTS is given in Table 8.

Table 1 showing the ocular trauma score variables and raw points for calculating the ocular trauma score (Kuhn et al. 2002)

Table 2 showing the pediatric ocular trauma score (POTS) variables and raw points (Acar et al., 2011)

 Table 3: The patients’ demographics and injury characteristics

Table 4: The pattern of ocular injuries of the patients

Table 5: Computerized tomography scan findings

Table 6: Visual acuity of the patients with ocular injury at initial presentation and last follow-up

BCVA: Best-corrected visual acuity; NLP: No light perception; LP: Light perception; HM: Hand motion; N/A: Non-applicable.

Table 7: Association between various types of CT findings and POTS, along with OTS scores in 34 study eyes.

Table 8: Pairwise correlation analysis of computed tomography findings and pediatric ocular trauma scores (POTS)

Pediatric patients with trauma suspicious for OGI frequently have a limited ability to cooperate and examine due to pain, chemosis, or intraocular hemorrhage. CT scanning is frequently used as an adjunct in these circumstances. However, CT findings can be misleading. Here, we attempted to examine the predictivity of CT scanning for detecting OGI and characterize the associated findings. The primary aim of this study was to compare pediatric OGIs and their POTS and OTS outcomes and determine their correlation with CT findings. Results of our study indicate that young pediatric patients are most frequently aged <4–8 years (44.1%) when presenting to the emergency room with OGIs. These outcomes, which were consistent with earlier researches,[1,14-16] indicate that pre-schoolers spend more time at their houses and are consequently more likely to be injured inside. Hence, because of their susceptibility to amblyopia, these children experience the worst visual outcome.

The OTS and the POTS are the primary scoring systems used for predicting visual prognosis after open globe injury (OGI) in children. The OTS was established a decade ago to offer more reliable information on visual prognosis based on particular findings during the initial examination.[13] Recently, POTS was established to improve the reliability of prognosis for pediatric patients.[9] Predicting the visual result after ocular trauma is often challenging. Consequently, trauma scoring systems were devised to enhance the ability to estimate the visual consequences of such damage and provide a dependable prognosis for those responsible for the care of children. The accuracy and use of scoring systems, such as OTS and POTS, remain limited in the pediatric population, despite being considered acceptable. According to a recent study,[17] an alternative scoring system has been proposed as a more effective predictor of visual outcome in children following OGIs as an alternative to the existing scoring methods. The researchers’ new score method did not consider the patient’s age at the time of the injury, the presence of lens involvement, the type of injury (organic or undetermined), or any delays in surgical intervention as indicators of a poor visual outcome. The method is not yet widely used.

Imaging techniques play a crucial role in instances of ocular injuries when a full clinical assessment is unattainable and/or there exists a suspicion of an IOFB. The preferred diagnostic modality for assessing the extent and severity of acute eye injuries is orbital CT. Orbital CT scans give information about globe and orbital bone integrity and foreign body presence. When anterior segment details are clear, orbital CT is not useful as a clinical evaluation. When there are limitations in visual perception, ophthalmologists frequently encounter challenges in identifying an occult rupture. The findings of this study demonstrate that the utilization of a CT scan yields supplementary data that are valuable in the context of decision-making. The utilization of CT enables clinicians to visually assess the deformation or discontinuity of the globe wall and identify the presence of an IOFB. This imaging technique proves valuable in detecting ruptures that may not be readily apparent during a conventional clinical examination.

The CT results that indicate the presence of OGI include many features such as the presence of air inside the globe, the presence of a foreign body within it, abnormalities in the shape of the globe, or irregularities in the sclera. The presence of intraocular air and foreign bodies (IOFBs) are diagnostic indicators that strongly suggest OGI in eyes that have recently experienced trauma.[18]

In their study, Joseph et al.[19] identified scleral contour changes (75–95%), anterior chamber changes (48–86%), and lens position changes (65–83%) as the prevailing observations in cases of open-globe injuries. Similarly, Arey et al.[20] reported that vitreous hemorrhage (82%) was the most frequently observed finding in their investigation of patients with occult trauma. Scleral irregularity was found to be the predominant radiographic feature in our study, followed by preseptal thickness, abnormal vitreous density, and IOFB or air. While Joseph et al. documented vitreous hemorrhage in a range of 52–67% in their cases[19] (which was lower than the findings by Arey et al.),[20] our study revealed a vitreous hemorrhage incidence of 14.9% among the pediatric group. The lower vitreous hemorrhage rate observed in our research can be attributed to the fact that 20.6% of our cases exhibited solely corneal cuts, while 32.4% presented with conjunctival or corneal cuts. Moreover, the reduced incidence of vitreous bleeding after traumatic events, as shown by CT scans in the eyes of children, might be attributed to the presence of an intact vitreous gel that remains in a non-liquefied state. In addition, the tight adherence of the posterior vitreous cortex to the internal limiting membrane of the retina further contributes to this phenomenon. Vitreous syneresis and liquefaction are not seen in pediatric populations. The prevention of collagen fibril adhesion to one another in the vitreous is attributed to the presence of collagen type IX, which forms a protective layer on the external surface of type II collagen.[21] This phenomenon might potentially contribute to the development of a firmly adherent vitreoretinal interface.

Abnormal vitreous density statistically correlated with both POTS and OTS (P=0.03 and P=0.08, respectively). Since vitreous opacities are rare in children, the observed effect can be explained by a greater risk of post-traumatic densities. IOFB and/or air presence has a significant association with POTS but not OTS in our study group. Due to the limited patient population, the occurrence of this phenomenon cannot be expected or considered probable. In addition, it should be remembered that organic foreign bodies are less likely to appear on CT. Furthermore, even one CT finding in our study patients statistically correlated with POTS but not in OTS group. In circumstances where vision cannot be obtained, CT findings can be used to estimate the prognosis using the score formula. This necessitates large-scale investigations with planned long-term follow-up for a large number of patients.

The limitations of our study derive from its retrospective design. To evaluate the accuracy of the imaging-based diagnosis, however, the included cases were those requiring primary repair and were confirmed and followed-up clinical cases. Furthermore, not all patients’ information was always available, causing the sample size to vary. Since the original study group consisted of a limited number of participants, we were unable to employ a logistic regression model for the anticipation of an unfavorable visual result, and we could not use a univariable analysis or the unadjusted odds ratio to create a prognostic score scale. Although our case series contains a brief 2-year follow-up time across an 18-year age OGI, we recognize that the report’s shortcoming is the study’s retrospective and non-randomized character. Furthermore, treatment selection bias may alter the findings. This study also includes a substantial number of cases with various injury mechanisms. This makes our study an important contribution to the literature on the use of orbital CT to determine the condition of the globe in at least one eye.

There is a consensus that CT scans serve as an adjunct to clinical findings rather than as an alternative for them. While the findings of our study indicate that CT scans may provide dependable information, it is important to note that they should not be the primary basis for diagnosis in all cases with open-globe injuries. A CT scan might not always show the presence of a foreign body or air; an open-globe injury may still exist. However, within the given scenario, CT imaging proves to be extremely advantageous.

When clinical information is not available, studies have found that CT imaging has a sensitivity of 75% and a specificity of 93% in predicting open-globe injury [18] Existing literature reviews indicate a consensus about the use of CT scanning as the preferred imaging modality in the majority of trauma patients.[22]

In children with OGI, the POTS stage and visual prognosis may be predicted by the quantity and type of CT findings. The number of CT findings can help predict POTS stage, and therefore, visual prognosis in pediatric patients with OGIs.

To the best of our knowledge, this is the first study to look at the correlation between CT results and OTS and POTS in children. Although both OTS and POTS are acceptable ocular trauma staging methods, collecting the data needed to calculate the score can be problematic, especially in situations involving children. Because CT scans may be easily obtained regardless of the patient’s cooperation or systemic condition, they can assist forecast the severity of ocular injuries and possibly the long-term visual result in emergency cases where good clinical data is not available. This data would allow for a direct link between early CT findings and long-term vision outcomes.

In pediatric patients with OGIs, the frequency of CT findings can assist in predicting POTS stage and thus visual prognosis. When enough clinical data are unavailable in an emergency, objective finding from CT can assist in predicting the degree of ocular injuries and possibly the long-term visual outcome. In addition, more research is required to define and standardize a CT-based grading system that is as accurate as POTS staging for OGIs in children.

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