Trends in ocular injuries among major trauma patients in England and Wales from 2004 to 2021

doi:10.21203/rs.3.rs-3634731/v1

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Trends in ocular injuries among major trauma patients in England and Wales from 2004 to 2021

https://doi.org/10.21203/rs.3.rs-3634731/v1

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published 24 May, 2024

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Background

Ocular trauma is a major cause of vision loss and injuries are often missed in multiply injured patients. Major trauma demographics in the UK have changed but no contemporary studies report ocular injuries in this cohort. We aimed to investigate ocular injury epidemiology and trends amongst major trauma patients in England and Wales from 2004–2021.

Methods

A retrospective analysis of prospectively collected Trauma Audit and Research Network (TARN) registry data was conducted. Major trauma was defined as injury severity score > 15, and ocular injuries were identified using AIS codes. Demographics, injury profiles, and outcomes were extracted. Descriptive statistics and 3-yearly trend data are reported.

Results

Of 287 267 major trauma cases, 2368 (0.8%) had ocular injuries, decreasing significantly from 1.87% (2004/06) to 0.66% (2019/21) (P < 0.0001). Males comprised 72.2% and median age was 34.5 years which increased (p < 0.0001). Road traffic collisions declined from 43.1–25.3% of ocular injury cases while falls increased and became the predominant mechanism (37.6% in 2019/21). Nonaccidental injuries increased from 15% (2004/06) to 26.5% (2016/18) (p < 0.0001). Concomitant head injury was present in 86.6% of cases. Ophthalmic procedures increased from 1.2% (2004/06) to 5% (2019/21) (p < 0.0001). Compared to previous TARN data, retinal injuries increased 3-fold to 18.6% and corneal injuries decreased from 31–6.6%.

Conclusions

Identifying sight-threatening injuries in polytrauma is challenging. Ocular injury epidemiology has changed significantly, though overall incidence is low. These findings may inform guideline development, resource allocation, and training priorities.

Health sciences/Diseases/Trauma

Health sciences/Health care/Public health/Epidemiology

Health sciences/Medical research/Epidemiology

Ocular trauma is a cause of impaired vision in 19 million individuals globally¹ and carries considerable economic burden^{2, 3}. Eye injuries are common in polytraumatised patients and are associated with vision threatening pathology^4–8. These injuries are often missed as primary surveys prioritise life threatening pathology and examination of the visual system in these patients, who are often unconscious or have concurrent periorbital injuries, is challenging^8–10.

Major trauma is defined by an injury severity score (ISS) of ≥ 16 and is associated with a 10% mortality^{11, 12}. The epidemiology of major trauma in the UK has changed dramatically in recent decades. Older adults are emerging as the major demographic population and low falls are increasingly the predominant mechanism¹³. Improvements in outcomes have also been seen in these patients following the remodelling of major trauma care in England and Wales¹⁴.

No recent epidemiological studies have investigated ocular trauma in this cohort in the UK. We carried out a retrospective study on a major UK trauma database to analyse epidemiology and trends in ocular injuries in major trauma patients from 2004 to 2021.

A registry-based study was conducted using data held by the Trauma Audit Research Network (TARN). TARN is a national trauma registry that aggregates and reports data for all trauma receiving hospitals in England and Wales. It includes patients who are admitted to hospital for ≥ 72 h, require critical care support, are transferred to a tertiary/specialist centre, or who die from their injuries and excludes patients aged > 65 years with an isolated fracture of the femoral neck or pubic ramus and those with single uncomplicated limb injuries. TARN records data up to 30 days of admission, or death, whichever occurred first.

After a patient is identified for inclusion into TARN, a dataset of prospectively recorded variables is collated by local coordinators using a standard web-based case record form. Injury descriptions are generated from imaging, operative and necropsy reports, and all injuries are then coded centrally using the Abbreviated Injury Scale (AIS) which is an anatomical-based coding system that also grades the severity of each injury on a six-point scale, AIS 1 describes minor injuries and AIS 6 describes injuries which are incompatible with life¹⁵. The ISS is then calculated by adding the squares of the highest scoring injury from the three most injured body regions. ISS is used to grade the overall injury severity and cases with an ISS of 16 or more are considered major trauma.

We included major trauma cases from 2004 to 2021 with any AIS codes relating to eye injuries or injuries to the second, third, fourth or sixth cranial nerves. Orbital fractures and adnexal injuries (other than tear duct lacerations) were not counted as ocular injuries and were instead coded as facial injuries. Eyelid injuries were also not included as these are not coded by the AIS. Extracted data for each patient included demographic information, a complete injury profile, hospital course, and mortality.

Data were summarised for each 3-year window, e.g. 2004–2006, and trends were analysed using the Jonckheere-Terpstra test and the Chi square test for trend, for numerical and categorical data as appropriate. Ocular injuries were anatomically classified and tabulated, each injury was counted separately such that a case may include more than one injury per eye. Missing data were not included in analyses. A two-sided p-value of 0.05 was considered statistically significant. Analyses were carried out using R version 4.1.1 (R Core Team 2022)¹⁶.

TARN analyses anonymised data with permissions granted by the Health Research Authority Clinical Advisory Group (CAG–PIAG Section 251). This project was registered within TARN (Project ID INC-117).

TARN included 287 267 cases of major trauma between 2004 and 2021 (Fig. 1). 2368 (0.8%) had eye injuries and this proportion decreased from 1.87% in 2004/06 to 0.66% in 2019/21 (p < 0.0001) (Table 1). Males comprised 72.2% of eye injury cases and the median age was 34.5 years which increased (τb = 0.079, P < 0.0001). 93.9% of injuries were due to blunt trauma. The median ISS was 26 and mortality was 15.1% which remained stable over the 18-year period.

Table 1
Table 1: TARN population England & Wales with ocular injuries- 2004–2021
	2004/06	2007/09	2010/12	2013/15	2016/18	2019/21	Total	p-value
Total	167 (1.87%)	180 (1.26%)	365 (1.03)	465 (0.78%)	611 (0.78%)	580 (0.66%)	2368 (0.82%)	< 0.0001**
Age, median (IQR†)	34.5 (12.7–45.9)	30.2 (18.1–48)	28.7 (1.1–53.4)	32.1 (0.5–60.2)	34.9 (0.7–64.1)	40 (19.8–66.3)	34.5 (3–59.5)	< 0.0001*
Male, n (%)	136 (81.4%)	138 (76.7%)	270 (74%)	345 (74.2%)	412 (67.4%)	409 (70.5%)	1710 (72.2%)	0.003**
GCS††, median (IQR)	14 (7–15)	14 (9–15)	14 (8–15)	14 (8–15)	14 (9–15)	14 (8–15)	14 (8–15)	0.075*
ISS†††, median(IQR)	26 (19–29)	26 (19–34)	26 (20–30)	27 (21–33)	27 (21–33)	27 (21–33)	26 (21–33)	< 0.0001*
Mechanism of injury
RTC	72 (43.1%)	85 (47.2%)	122 (33.4%)	121 (26%)	156 (25.5%)	147 (25.3%)	703 (29.7%)	< 0.0001**
Fall > 2m	15 (9%)	21 (11.7%)	37 (10.1%)	45 (9.7%)	51 (8.3%)	72 (12.4%)	241 (10.2%)
Fall < 2m	12 (7.2%)	10 (5.6%)	45 (12.3%)	75 (16.1%)	115 (18.8%)	146 (25.2%)	403 (17%)
Other	30 (18%)	19 (10.6%)	24 (6.6%)	48 (10.3%)	54 (8.8%)	56 (9.7%)	231 (9.8%)
NAI under 16yrs	25 (15%)	25 (13.9%)	78 (21.4%)	126 (27.1%)	162 (26.5%)	94 (16.2%)	510 (21.5%)
Assault	13 (7.8%)	20 (11.1%)	59 (16.2%)	50 (10.8%)	73 (11.9%)	65 (11.2%)	280 (11.8%)
Injury type
Blunt	153 (91.6%)	168 (93.3%)	338 (92.6%)	441 (94.8%)	575 (94.1%)	548 (94.5%)	2223 (93.9%)	0.581**
Penetrating	14 (8.4%)	12 (6.7%)	27 (7.4%)	24 (5.2%)	36 (5.9%)	32 (5.5%)	145 (6.1%)	0.581**
Concomitant serious injuries: n (%)
Head AIS3+	138 (82.6%)	149 (82.8%)	322 (88.2%)	410 (88.2%)	525 (85.9%)	506 (87.2%)	2050 (86.6%)	0.238**
Face AIS 3+	30 (18%)	41 (22.8%)	29 (7.9%)	23 (4.9%)	32 (5.2%)	42 (7.2%)	197 (8.3%)	< 0.0001**
Chest AIS 3+	44 (26.3%)	54 (30%)	112 (30.7%)	139 (29.9%)	156 (25.5%)	171 (29.5%)	676 (28.5%)	0.443**
Abdomen AIS3+	11 (6.6%)	9 (5%)	19 (5.2%)	19 (4.1%)	31 (5.1%)	22 (3.8%)	111 (4.7%)	0.665**
Spine AIS3+	6 (3.6%)	13 (7.2%)	15 (4.1%)	45 (9.7%)	94 (15.4%)	58 (10%)	231 (9.8%)	< 0.0001**
Pelvis AIS3+	11 (6.6%)	19 (10.6%)	17 (4.7%)	15 (3.2%)	25 (4.1%)	21 (3.6%)	108 (4.6%)	0.001**
Limb AIS3+	18 (10.8%)	25 (13.9%)	29 (7.9%)	53 (11.4%)	60 (9.8%)	43 (7.4%)	228 (9.6%)	0.071**
Interventions
Any operation, n (%)	59 (35.3%)	82 (45.6%)	132 (36.2%)	161 (34.6%)	202 (33.1%)	218 (37.6%)	854 (36.1%)	0.063**
Time to any operation (hours), median (IQR)	9 (2.7–30.6)	18.6 (4.7–89)	8.6 (3.8–31.4)	16.3 (3.4–71.1)	14.5 (3.1–59.6)	13.1 (4.4–37)	13.2 (3.6–47)	0.744*
Eye operation, n (%)	2 (1.2%)	1 (0.6%)	6 (1.6%)	21 (4.5%)	43 (7%)	29 (5%)	102 (4.3%)	< 0.0001**
Time to eye operation (hours), median (IQR)	58.8 (58.8–58.8)	145 (145–145)	3.6 (2.7–8.6)	18.2 (11.7–51.9)	13.3 (4.7–23)	17.2 (7.1–34.5)	15.4 (5.5–32.7)	0.845*
Outcome
Mortality	18 (13.2%)	13 (8.8%)	37 (14.1%)	58 (17.5%)	67 (14.9%)	74 (16.6%)	267 (15.1%)	0.193**
LOS (days) median (IQR)	11 (5–25)	12 (5.5–24)	11 (4–21)	10 (4–20)	9 (4–22)	9 (4–19)	10 (4–21)	0.002*
†IQR Interquartile range; †† GCS: Glasgow Coma scale; †††ISS: Injury severity score
Jonckheere-Terpstra test; * Chi square for trend

Road traffic collisions (RTCs) were the most common mechanism of major trauma involving ocular injury in 2004/06 accounting for 43.1% of cases but significantly decreased to 25.3% by 2019/21. Conversely, falls increased significantly and, by 2019/21, were the most common mechanism of injury (37.6%). Low falls (< 2 metres) comprised the majority of these (25.2%). Nonaccidental injuries in children under 16 also increased significantly and accounted for as much as 26.5% of cases during 2016/18.

Head and chest trauma comprised the most common serious (AIS 3+) concomitant injuries. These were present in 86.6% and 29.5% of cases respectively and remained stable over the period. Serious facial injuries were present in 18% of cases in 2004/06 and more than halved to 7.2% by 2019/21.

4.3% of patients required an eye operation and this increased over time (P < 0.0001) while the proportion of patients requiring any surgical intervention was 36.1% and remained stable. Median time to ophthalmic surgery was 15.4 hours which was similar to the 13.2 hours for any operation.

The most common injuries were to the conjunctiva (29.4%), retina (18.6%) and sclera (12.8%) (Fig. 1). Optic nerve injuries were present in 8.6% of cases and cranial nerves III, IV, and VI were damaged in 8.6%, 2.4% and 5.5% of patients respectively.

Missingness was only seen in Glasgow Coma Scale measurements (n = 294, 12.4%). All other variables were complete for all cases.

We present contemporary data, from a large national registry, for ocular injuries in the setting of major trauma in England and Wales. Ocular injuries occurred in 0.8% of patients with major trauma which is lower than other studies which report rates between 2.3% and 16%^4–8. This can be partially explained as adnexal injuries and orbital fractures were not classified as ocular injuries in our cohort, whereas they were included in other studies. The prevalence of ocular injuries in this cohort decreased over the 18 year period and was less than the 2.3% reported in a historical (1989–2004) study of TARN data using identical case ascertainment criteria.⁶ This apparent decline in ocular injuries is likely multifactorial and may be partially explained by nation-wide shifts in injury mechanisms in major trauma¹³. Additionally, this may represent a relative decrease in proportion of ocular injuries as there has been an overall improvement in identifying and classifying major trauma owing to the now widespread use of CT scanning^{13, 17}.

The demographics of major trauma have changed significantly in recent decades. Patients are older and are commonly suffering injuries second to low falls¹³, and this is reflected in our data. RTCs, while historically the predominant mechanism, only accounted for 25.3% of cases in 2019/21 and this may account for the reduction in patients with concomitant facial and pelvic injuries in our cohort as these are commonly associated with RTCs¹⁸. Similar changes in demographics and injury mechanism have also been demonstrated in ocular injury not associated with major trauma in American and Taiwanese populations^{19, 20}. It has been suggested that older patients are at an increased risk of eye injury due to globe weakness second to previous ocular surgery²¹. Falls in this age group are associated with ocular contusions, eyelid lacerations, and open globe injuries^{22, 23} and better understanding of falls related injury will enable improved recognition and management of ocular trauma in a demographic which is projected to continue to increase²⁴.

Head injury is reported in around a quarter of major trauma cases²⁵ and was the most common serious (AIS 3+) concomitant injury in this study, present in 86.7% of ocular trauma. The relationship between eye injury and head trauma is well described with ocular injuries present in 2.2–25.3% of these patients^{26, 27}. Head injuries are most caused by RTCs and anterior segment injuries are commonly reported resulting from direct impact on the frontal bones and orbital margins²⁷. Neuro-ophthalmic injuries are also reported and principally comprise traumatic ocular motor nerve palsies²⁷. Identification of eye injuries in this cohort, however, is challenging, notably in the acute setting when patients may be agitated or unconscious. Ocular assessment in primary surveys, which prioritise recognising life-threatening injuries, is limited to assessing eye-opening and the identification of nerve palsies and which act as indicators of brain injury severity and are predictive of mortality²⁸.

A significant and increasing proportion of cases were children who had suffered injuries second to nonaccidental trauma. TARN do not report any concurrent increase in suspected physical abuse or assault in children with major trauma over the study period²⁹. The reasons for this trend are unclear but may be due to an increased recognition and reporting of nonaccidental injury in children with eye injuries as up-to-date guidance is developed^{30, 31} and reporting mechanisms are established³². Ocular pathologies are common in child abuse and may be varied in their presentation³³. Retinal haemorrhages have been shown to have a high sensitivity and specificity for nonaccidental injuries in infants and, when accompanied with intracranial injuries, are pathognomonic³⁴.

The most common injuries were sustained to the conjunctiva (29.4%), retina (18.6%) and sclera (12.8%), while injury distributions were not analysed temporally, these can be compared with historical TARN data from 1989 to 2004⁶. Corneal injuries comprised 31% of injuries historically but only 6.6% in our contemporary cohort; this may be related to the decreased proportion of RTCs as an injury mechanism as these injuries are often associated with airbag deployment^{35, 36}. Further, retinal injuries contributed to 5.9% of injuries historically and this seems to have increased threefold. Traumatic retinopathy is associated with high velocity blunt trauma³⁷ and this may represent the increase in patients surviving high-speed RTCs second to improvements in car crash safety mechanisms. Such injuries commonly include retinal tears and detachments for which urgent surgery is indicated³⁸. An increase in traumatic retinopathy may contribute to trends seen in ophthalmic procedures which increased fourfold over the study period.

While optic nerve and retinal injuries are often vision threatening, we do not report visual outcome data for cases. Amongst major trauma victims, those with lid lacerations, open globe injuries and optic nerve injuries are reported to have the worst visual outcomes^{4, 5}. Clinically, the Ocular Trauma Score is a tool used to predict functional outcome after eye injury³⁹ and has been validated in patients with major trauma⁴, however its parameters include initial visual acuity and presence of afferent pupillary defect, which are challenging to ascertain in patients with impaired cognition, and periorbital swelling respectively⁹. For cases of suspected ocular nerve trauma, flash visually evoked potentials have also been used to assess nerve function in these patients and are highly predictive of final visual outcome⁴⁰.

The identification and management of ocular trauma in the multiply injured patient remains a challenge for emergency clinicians however excellent guidance has been published on the topic⁹. Advanced Trauma Life Support principles should be followed for all major trauma patients^{41, 42}. Visual pathways injuries should be screened for in patients with head or facial trauma and early surveys should arguably be able to exclude a sight-threatening injury requiring emergent management, such as retrobulbar haemorrhage, even in unresponsive patients⁹. CT scanning, which is now standard in polytrauma, is sensitive and specific for many types of eye injuries and ocular and orbital CT should be undertaken in all patients with clinical suspicion⁴³. Ophthalmology specialist opinion should be sought in all patients with at risk of visual pathology as important, sight saving intervention might be required.

Strengths and limitations

TARN captures data from every trauma receiving NHS hospital in England and Wales and best practice tariffs ensure high case ascertainment and completeness, and as such, the data reported are representative. However, as a big data source, there are missing data and these may differ systemically from those that are included. Additionally, patients in whom these injuries are identified or managed out with the TARN data collection period, or who are transferred to other hospitals after acute management of major trauma, are not included. This may represent a significant proportion of patients as detailed ocular assessment may not be possible in the early phase of admission. There are also limitations associated with the usage of a non-ophthalmic trauma registry. Injury data are reported as anatomical location and injury type (blunt vs penetrating) and these do not carry the same clinical relevance as specialised classifications such as the Birmingham Eye Trauma Terminology System which is widely used⁴⁴. Further, important prognostic information such as visual acuity and the presence or absence of relative afferent pupillary defect are not recorded. Registries which are specialised for ophthalmic pathologies collect and code clinically relevant data and generally avoid these limitations. Examples of these include the Research in Sight (IRIS®) Registry which was established in 2014 and has produced important data with outcomes not routinely recorded in trauma registries^45–47, and more recently, the International Globe and Adnexal Trauma Epidemiology Study (IGATES) Registry which has been established as an specialist registry with a focus on ocular trauma⁴⁸.

In conclusion, we report information about the trends of ocular trauma, in England and Wales, over an 18-year period. Ocular injuries are present in 0.8% of cases of major trauma and the most common concomitant injuries are to the head. RTCs are no longer the dominant mechanism of injury, which is increasingly being overtaken by falls, a pattern which mirrors major trauma trends across the UK. Fewer patients seem be suffering corneal injuries, there has been an increase in retinal injuries and those undergoing ophthalmic surgery. The findings of this study are important for health providers across the United Kingdom and may inform guideline development, resource allocation and training priorities.

Acknowledgements

We would like to thank TARN for collating and providing the data utilised in this study.

Conflict of Interest

The authors declare that they have no conflict of interest.

Funding Statement

This study was not funded.

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Trends in ocular injuries among major trauma patients in England and Wales from 2004 to 2021

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Conclusions

Figures

Introduction

Methods

Results

Discussion

Strengths and limitations

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1