EyeNet Magazine

Clinical Update: Trauma
Anticipating the Traumas of Summer
By Denny Smith, Senior Editor

Car crashes, fist fights, beer bottles, baseballs, paintballs, golf balls, power tools, lawnmowers, slingshots, fishhooks, fireworks, firearms, elbows and airbags: The major contributors to eye trauma are in steady supply over the sultry, school’s-out months of summer.

The causes of eye trauma may be legion, but some are a bit more predictable than others, and so might offer the community ophthalmologist useful prevention tips for their patients. Results from the Eye Injury Snapshot Project reveal that most ophthalmologists agree that the eye injuries they have encountered could have been prevented if those patients had worn protective eyewear. Moreover, 41 percent believe that the injuries could have been avoided with patient education. (For more results, visit www.aao.org and enter “snapshots” in search field.)

A majority of serious eye injuries are sustained by men under 30 years of age, and at least a third of them present with visual acuity no better than light perception in the injured eye. According to the United States Eye Injury Registry (www.useironline.org), sporting events, the workplace and motor vehicles each contribute about 13 percent to the total U.S. eye trauma burden. Not far behind, though, are injuries from assaults and fireworks, according to Jon M. Braverman, MD, associate clinical professor of ophthalmology at the University of Colorado in Denver. Dr. Braverman mentors ophthalmology residents at Denver Health Medical Center, and has seen many a patient with serious eye wounds in the emergency room there.

His first order of business is to assume the worst. “Our challenge in each case is to determine the depth and complexity of the trauma—how many layers of the eye and orbit are injured. Any severe head or facial wound could be also associated with a deeper injury in the central nervous system. As a first responder, we have to keep every exotic and unusual possibility in mind, and an analysis of the injury mechanism will help us not to miss a deeper neurologic injury or foreign body sequestration.”

Sunday afternoon and nowhere near help! Most summertime injuries happen during recreational hours—in the evening or on weekends. These are exactly the times when the offices of primary-care physicians and comprehensive ophthalmologists are closed, leaving acute-care facilities to handle a disproportionate percentage of injuries.

Like a number of metropolitan hospitals, Denver Health Medical Center is a Level I Trauma Center, and must be prepared at all times for every contingency, from the lone patient to large-scale disasters. But, said Dr. Braverman, that depth of preparedness is diminished in places like rural Colorado, where a fishing or climbing party may get into trouble far from state-of-the-art trauma care. “We get lots of referrals from physicians and facilities from mountain towns and remote areas, where local folks just aren’t comfortable handling the more worrisome injuries. Those patients are typically air-transported into Denver.”

New Trends in Trauma

Some statistical details of eye injuries may come as a surprise. “Countries in the industrialized world have seen the total number of eye injuries remain largely steady over the last decade,” said Ferenc P. Kuhn, MD, PhD. “But this does not mean there have not been changes. Thanks to government safety regulations in these countries, for example, workplace injuries have declined. But that good news has been offset by an increase in injuries occurring in the home.” Dr. Kuhn is associate clinical professor of ophthalmology at the University of Alabama in Birmingham, and a professor of ophthalmology at the University of Pecs in Hungary. He also helped develop the Eye Injury Registry, as well as the Birmingham Eye Trauma Terminology, an international standardized language for classifying ocular injuries.

Dr. Kuhn explained that the trendy home-improvement industry has inadvertently fostered a generation of accident-prone amateurs in both Europe and North America. “A lot of around-the-house jobs that once were relegated to professionals, like electricians, carpenters or plumbers, are now tackled by home owners. And they forget that eye protection is just as important for working at home as it is at their job. Simply hammering a nail into a surface can launch fragments of material back at the eye.”

Drs. Braverman and Kuhn had no trouble listing the most common injuries they see, and they agreed that many of these tend to peak in the hot, humid months of summer:

Fireworks, as always. “The Fourth of July is a time to celebrate, and that celebration is traditionally done with fireworks. But that is one of the saddest times of the year for those of us on ER call,” Dr. Braverman said. “By their nature, fireworks involve explosions, accelerants and projectiles, and injuries caused by them can be devastating to the eyes and the face. Among the worst are bottle rockets, which travel at high rates of speed and which can easily cause a severe contusion or rupture of the eye. So much of this is preventable, and yet it happens every year: We know that on July 4th, we’ll be seeing somebody with a severe eye injury. Many times it’s a child, but we see adults, too, who were horsing around.”

Assaults under the influence. Just as troubling, perhaps, are injuries attributed to what Dr. Braverman unaffectionately calls the “Denver Knife and Gun Club.” He said, “We see a lot of blunt trauma from fists, feet and knees. Barroom fights that involve bottles, in particular, can cause a lot of ocular lacerations and orbital fractures.” When firearms are involved, Dr. Kuhn noted, it takes little imagination to guess what a gunshot wound can do to an eye. And he believes that among industrialized societies, America is uniquely afflicted by an astonishing incidence of such injuries (see “Protecting the World From Bullets and Bubbly,” below).

Car collisions. The most horrible injuries associated with motor vehicle accidents have been mitigated by airbag technology. But the first airbags were actually a mixed blessing. “Curiously enough, when auto makers were first installing airbags, we saw a bump in eye injuries,” said Dr. Braverman. “They were going off too frequently, and the accelerants used to expand the bag were causing periocular burns if the bag ruptured. These problems have decreased as the bags have been better tuned not to deploy at low impact. Other injuries from car accidents can include traumatic optic neuropathy. Even without any other obvious ocular damage, vision loss after blunt orbital or head trauma should alert the ophthalmologist to possible optic neuropathy.”

Flying fishhooks. Dr. Kuhn said that fishhooks and sinkers can both cause serious trauma. Dr. Braverman added that such injuries do not usually happen, as might be suspected, while the line and bait are being cast through the air. “The most common mechanism I see is when the line is snagged on something, leading the fisherman to pull sharply on it, releasing the hook and launching it slingshot-fashion back toward the face, usually at great speed, and striking the eye.”

One lousy swing. Golf-related injuries are some of the worst, said Dr. Kuhn, and often lead to extremely poor prognoses. “Both the club and the ball can be sources of impact. The problem with the golf ball is that it perfectly fits the eye socket. Baseballs, which are stopped by the face’s bony prominences, are more likely to fracture the orbit, while the golf ball will easily rupture the globe.”

Let's play ball (safely)! “Many sports are associated with blunt trauma. Elbows seem to find eye sockets in basketball games, for example,” said Dr. Braverman. “The schools are getting better about instituting preventive measures in athletics, but it helps a lot when kids see professional players wearing the protective Plexiglas eyeforms.” Dr. Kuhn agreed. “Hockey and baseball, in particular, are amazing for their neglect of this obvious fact. Hockey pucks can reach a hundred miles an hour, and the only person mandated to wear protection is the goalie. I have seen excellent players lose an eye this way.” Paintball is another culprit. “The popularity of this game is increasing around the world. And if eye protection is not being worn when a paintball hits someone’s eye, it’s not an insignificant trauma.”

Abuse of the helpless. Family violence cannot be left off this list. “Shaken Baby cases seem to peak in the summertime, for a number of reasons,” said Dr. Braverman. “These are very, very sad cases, and the ocular injury mechanism is somewhat unique. If it were just an eye injury, these kids might recover some vision. But many cases involve such severe neurotrauma, in such a little person, that oftentimes Shaken Baby Syndrome leads to significant multisystem morbidity and mortality.”

Protecting the World From Bullets and Bubbly

Dr. Kuhn said that while eye injury statistics are fairly uniform among the developed nations, one glaring exception distinguishes the United States from all other industrialized countries: trauma related to weapons. “Firearms are not legal in the vast majority of developed countries, and so are simply not a problem. But they are responsible for almost 5 percent of serious eye injuries in the United States.” The problem, said Dr. Kuhn, is not just the availability of guns. “Switzerland, for example, is unusual in the European com- munity in that a great number of Swiss citizens own firearms. And yet there is virtually no violence involving guns in Switzerland.” For reasons that baffle Europeans, he said, U.S. culture tolerates a morbid intersection of gun ownership and social violence.

Where policy varies, injury varies. Even within the United States, Dr. Kuhn noted, local laws can either fuel or fight the incidence of trauma. “In those states that permit individual sales of ‘class C’ fireworks, eye injuries are tremendously higher compared with those states that only allow publicly controlled firework displays. An interesting European example of the value of regulation can be found in Hungary. The individual purchase of fireworks was not permitted under communist administration of the government. But when Hungary switched to a more open society, both fireworks and related eye injuries proliferated. Now fireworks are again forbidden.”

Hungary offers another interesting case of regulation as well. Champagne corks, happily abundant in many cultures at summer weddings and sports victory parties, boast a famously dark side. “I never remove an injured eye unless there is absolutely no chance for it to be pieced together. And yet I have had to enucleate a number of cork-ruptured eyes,” Dr. Kuhn said. Oddly, eye injuries from champagne corks are a hundredfold more common in Hungary than the United States. Why? “Because in the U.S. there are warning labels on these bottles, and in Hungary there are none. Even in an unshaken, well-chilled bottle of champagne, the pressure is three times higher than the pressure in your car tire. That cork leaves the bottle at a fantastic speed. And so a warning label is both warranted and, apparently, effective.”

Calling all policy-makers. Beyond the random, unavoidable accident, and beyond the benefits of community health education, could more muscular social policies make a difference? Yes, said Dr. Kuhn, better regulation of sports, fireworks and firearms could prevent much of the worst eye trauma. “The most powerful tool we have is regulation. No one, including me, wants excessive regulation, of course, and so common sense must be the guiding rule. But what really works is a mandate. A few decades ago, Canada legislated the mandatory use of masks in youth hockey, and after that the eye injuries just disappeared.They were not simply reduced; they disappeared.”

Dr. Braverman echoed the possibility that hope could replace tragedy. “I think of trauma as an epidemic disease. There is, undeniably, a large fraction of our population prone to eye injury. But the fact remains that these injuries are mostly preventable.”

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