Pediatric ocular trauma score as a prognostic tool in ...

Pediatric ocular trauma score as a prognostic tool in the management of pediatric traumatic cataracts Mehul A. Shah, Rupesh Agrawal, Ryan Teoh, Shreya M. Shah, Kashyap Patel, Satyam Gupta & Siddharth Gosai Graefe's Archive for Clinical and Experimental Ophthalmology Incorporating German Journal of Ophthalmology ISSN 0721-832X Volume 255 Number 5 Graefes Arch Clin Exp Ophthalmol (2017) 255:1027-1036 DOI 10.1007/s00417-017-3616-y

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Author's personal copy Graefes Arch Clin Exp Ophthalmol (2017) 255:1027–1036 DOI 10.1007/s00417-017-3616-y

TRAUMA

Pediatric ocular trauma score as a prognostic tool in the management of pediatric traumatic cataracts Mehul A. Shah 1 & Rupesh Agrawal 2 & Ryan Teoh 3 & Shreya M. Shah 1 & Kashyap Patel 1 & Satyam Gupta 1 & Siddharth Gosai 1

Received: 22 September 2016 / Revised: 22 December 2016 / Accepted: 8 February 2017 / Published online: 22 February 2017 # Springer-Verlag Berlin Heidelberg 2017

Abstract Objective To introduce and validate the pediatric ocular trauma score (POTS) — a mathematical model to predict visual outcome trauma in children with traumatic cataract Methods In this retrospective cohort study, medical records of consecutive children with traumatic cataracts aged 18 and below were retrieved and analysed. Data collected included age, gender, visual acuity, anterior segment and posterior segment findings, nature of surgery, treatment for amblyopia, follow-up, and final outcome was recorded on a precoded data information sheet. POTS was derived based on the ocular trauma score (OTS), adjusting for age of patient and location of the injury. Visual outcome was predicted using the OTS and the POTS and using receiver operating characteristic (ROC) curves. Results POTS predicted outcomes were more accurate compared to that of OTS (p = 0.014). Conclusion POTS is a more sensitive and specific score with more accurate predicted outcomes compared to OTS, and is a viable tool to predict visual outcomes of pediatric ocular trauma with traumatic cataract.

No financial support was received from any company or institution. This study is not presented at any conference or meeting. No conflicting relationship exists for any author. * Mehul A. Shah [email protected]

1

Drashti Netralaya, Nr. GIDC, Chakalia Road, Dahod 389151, Gujarat, India

2

National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Tan Tock Seng, Singapore

3

Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore

Keywords Ocular trauma score . BETTS . Pediatric ocular trauma score . Predictive model . Visual outcome

Introduction Trauma is a major cause of monocular blindness in urban populations, although few studies have addressed the problem of trauma in rural settings [1].The development of strategies for the prevention of injuries requires a good epidemiological database and knowledge of the causes and outcome following injury. The etiology of ocular injury is likely to differ between urban and rural areas, and is worthy of investigation [2–4]. In eye injuries, both the victim and the society bear a large, potentially preventable burden [3]. More appropriate targeting of resources toward preventing eye injuries may reduce this burden. One of the commonest complications of ocular trauma is the formation of cataracts [1]. Methods have been established for evaluating visual outcomes in eyes with cataracts due to trauma or other causes [5]. Damage to surrounding ocular tissues may compromise the visual gain in eyes after surgery for traumatic cataracts, decreasing the success rate compared to eyes with non-traumatic cataracts. Traumatic cataracts often have poor visual outcomes in children due to amblyopia and recurrent inflammation. The use of the Birmingham Eye Trauma Terminology System (BETTS) has standardized the definitions of ocular trauma [5], making it possible to compare visual outcomes following traumatic cataract surgery and to understand the determinants in predicting the outcomes. Various studies have reported visual outcomes of traumatic cataracts; however, most were case studies or were done with a small sample size [6–8]. Various models, including the ocular trauma score (OTS) and the Classification and Regression Tree (CART) [9, 10], have been proposed for predicting the visual outcome in

Author's personal copy 1028 Table 1

Graefes Arch Clin Exp Ophthalmol (2017) 255:1027–1036 Ocular trauma score Variables

A

Raw score

Table 3 Additional variables for pediatric ocular trauma score (POTS)

Variables G

Presenting vision

Raw points

Age (years) 0–5

−10

6–10 11–15

−7 −5

NPL

60

PL or HM 1/200 to 19/200

70 80

20/200 to 20/50 ≥20/40

90 100

Zone I Zone II

B

Globe rupture

−23

0 −5

Zone III

Endopthalmitis Perforating injury

−17 −14

−10

C D E F

Retinal detachment Relative afferent pupillary defect

−11 −10

H

patients with open-globe injuries based on the initial examination. Although both these models have been shown to be effective in the general population, only a few studies [11–14] have tried to validate these models in children, and these have reported variable results. The value of the OTS for predicting visual outcomes following surgery in children with traumatic cataracts has been validated [15, 16]. However, in the pediatric population the possibility of amblyopia has to be considered. Strabismus, refractive errors, or ocular opacity can result in amblyopia in children. If the possibility of amblyopia is not included in the score, then the predictive accuracy of OTS may be compromised. We have hence incorporated this into the OTS to derive a mathematical model for a pediatric ocular trauma score (POTS). The aim of this study was to validate our proposed mathematical model and to compare the predictive value of POTS with OTS for assessment of outcome in children with traumatic cataract.

Materials and methods This was a retrospective cohort study conducted at a tertiary referral eye care hospital in Western India. Institutional ethical Table 2 Estimated probability of follow-up visual acuity at 6 months using OTS Raw score sum

OTS

0–44 45–65 66–80 81–91 92 –100

1 2 3 4 5

NPL

73% 28% 2% 1% 0%

PLHM

17% 26% 11% 2% 1%

1/200– 19/200

20/200– 20/50

20/40– 20/20

7% 18% 15% 2% 2%

2% 13% 28% 21% 5%

1% 15% 44% 74% 92%

Wound location

approval with waiver of informed consent was obtained for this study. Medical records of children, aged 18 and under, with traumatic cataracts who were seen and operated on between January 2007 and December 2015 were analysed. Demographics of the patient including a detailed history with regard to the injury as well as details of the treatment and surgery were recorded. Data for both the initial and follow-up reports were collected using the online BETTS form [5]. Details of the surgery were also collected using a specific pretested online form (Appendix 1). Demographic details included patient characteristics, activity at the time of injury, cause of injury, details of the ocular examination and treatment were entered into a precoded datasheet. Visual acuity was reported according to age using the American Association of Pediatric Ophthalmology (AAPOS) guidelines [17]. The cases were classified using BETTS: they were first divided into two groups — open-globe and closed-globe injury groups. open-globe injuries were further categorized into laceration and rupture groups. Lacerations of the eyeball were subcategorized as perforating injury, penetrating injury, and injury involving an intraocular foreign body. The closed-globe group was divided into lamellar laceration and contusion groups. Cataracts were classified based on lenticular opacity. Cataracts with no clear lens matter between the capsule and nucleus were classified as total cataracts. Those in which the capsule and organized matter were fused to form a membrane of varying density were classified as membranous cataracts. When loose cortical material was observed in the anterior chamber together with a ruptured lens capsule, the cataract was classified as a white soft

Table 4 Age and sex distribution

Age (years)

0–2 3–5 6–10 >10 TOTAL

Sex

Total

F

M

13 47 111 131 302

15 91 283 379 768

28 138 394 510 1,070

Author's personal copy Graefes Arch Clin Exp Ophthalmol (2017) 255:1027–1036 Table 5 Object causing injury

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Object

Percentage (%)

Ball

1.4

Cattle horn

1.7

Cattle tail Finger

0.3 0.8

Location of injury and visual outcome

Post-treatment vision

Fire

2.8

Glass

1.1

Thorn Other

3.4 8.8

Sharp object Stone

8.8 10.7

Unknown

7.9

Stick Total

51.4 100.0

20/200 (Table 6). A significant difference was observed between location of open-globe injury and final visual acuity (Table 7). OTS and POTS predictions and actual achieved vision compared in children with traumatic cataracts are presented in Tables 8 and 9. Predicted visual outcomes predicted by OTS and POTS were found to be significantly different (Table 10). When OTS was compared with POTS, we found a significant difference between predicted and actual final visual outcome (Table 11, p < 0.001) Table 11 shows the difference in percentages of predicted and achieved visual acuities for both OTS and POTS. The difference is shown to be significantly smaller in POTS. The

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Fig. 2 Comparative study of ROC curve between OTS and POTS for category 2

results suggest that POTS is better in predicting the final visual outcome than OTS in children with traumatic cataract. The area under ROC curve was compared to test sensitivity and specificity of predictive models, and was found to be different for all categories (Figs. 1, 2, 3, 4, and 5 and Table 12)

Discussion Visual gain following surgery for traumatic cataracts is a complex issue, as lens pathology alone does not decide the visual outcome. It is particularly complex in the case of children because amblyopia is a consideration [11]. Electrophysiological


[14] and radio-imaging [6, 21, 22] investigations are important tools for assessing co-morbidities associated with an opaque lens. In this study, a satisfactory grade of vision following the management of traumatic cataracts was achieved (Table 3). Many studies have documented visual outcomes in children with traumatic cataracts — Shah et al. [4] reported a visual acuity > 20/60 in 56% of cases, Krishnamachary [21] reported a visual acuity >20/60 in 74% of cases, Kumar [22] reported a visual acuity >6/18 in 50% of cases, Staffieri [23] reported a visual acuity >6/ 12 in 35% of cases, Bekibele [24] reported a visual acuity >6/18 in 35.6% of cases, Gradin [7] reported a visual acuity >20/60 in 64.7% of cases, and Cheema [25]

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reported a visual acuity >6/18 in 68% of cases. Brar [26] reported a visual acuity >0.2 in 62% of cases, Karim [27] reported a visual acuity >0.2 in 62% of cases, Knight-Nanan [28] reported a visual acuity >20/60 in 64% of cases, Bienfait [29] reported a visual acuity >0.7 in 27% of cases, and Anwar [30] reported a visual acuity >20/40 in 73% of cases. The visual outcomes with polymethyl methacrylate lens implants reported by Verma [31] were similar to the findings in our study. Eckstein [32] and Gupta [33] showed that a primary intraocular lens (IOL) could improve visual outcome, again similar to the results observed in our study. Vajpayee [34] and Zou [20] suggested that the primary insertion of an IOL for posterior capsular rupture was also important. The same trend was observed in our study. According to Shah [35], improved visual outcome can


be achieved when intervention is performed between 5 and 30 days after injury in adults with traumatic cataracts. Rumelt [30] found no significant difference between primary and secondary implants, again supporting the results from our study. Staffieri [23] reported the use of a primary implant in 62% of the cases in his study, while a primary implant was used in 80.2% of the cases in the present study. This study is the first large study comparing the final visual outcome in children between open-globe and closed-globe injury groups classified by BETTS. Shah et al. [36] made this comparison in adults, but a study using a large cohort of successfully treated traumatic cataracts in children has not yet been documented. In our study, final visual outcomes were achieved according to the OTS prediction in children with

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Table 12 Comparative study of area under ROC curve between OTS and POTS Category

POTS-AUROC

OTS-AUROC

1

399

419

2

489

488

3 4

665 524

661 521

5

548

520

traumatic cataracts [37]. Although similar findings have been reported by other studies [11–14], our study presents one of the largest reported databases following cases of pediatric traumatic cataracts classified according to BETTS. Despite the time delay between injury and treatment observed in many cases in this study, the OTS was still found to be relevant. Lesniak [37] reported no significant differences between the final visual acuities and the visual acuities predicted by OTS in children. Sharma [11] proposed that the OTS calculated at the initial examination might be of prognostic value in children with penetrating eye injuries. However, Unver [12] suggested that OTS calculations might have limited value as predictors of visual outcome in a pediatric population. Lima-Gomez [13] and Unver reported estimates for a 6-month visual prognosis, but some of the variables required evaluation by an ophthalmologist. Using the OTS, 98.9% of the eyes in the general population could be graded in a trauma room. Knyazer [14] reported the prognostic value of the OTS in zone-3 open-globe injuries, and Man [10] claimed equal prognostic effectiveness of the OTS and CART in the general population. The use of OTS in the pediatric population was validated in a study of 354 children with traumatic cataracts.

We propose a POTS which includes amblyopia as an important factor, and this study shows that POTS is more accurate than OTS in the pediatric population. A significantly smaller difference between predicated and achieved visual outcomes was found between POTS and OTS (Table 10, p < 0.001). The area under ROC curve for each category for OTS and POTS respectively show that POTS is more sensitive and specific for higher raw scores (Table 4, Figs. 1, 2, 3, 4, 5, 6, 7, 8, and 9). One limitation of our study is that while POTS is more specific and sensitive in case of higher raw scores, it does not predict outcomes as accurately with lower raw scores. In such cases, the OTS can be utilised to give more accurate predictions of the outcome. Lili et al. reported similar findings in a study of 81 cases with only penetrating injury [38].

Fig. 6 Traumatic cataract with total cataract

Fig. 8 Traumatic cataract with fusion of anterior and posterior capsule

Fig. 7 Traumatic cataract with ruptured anterior capsule

Author's personal copy Graefes Arch Clin Exp Ophthalmol (2017) 255:1027–1036

1035 relationships, affiliations, knowledge, or beliefs) in the subject matter or materials discussed in this manuscript. Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required.

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2. Fig. 9 Traumatic cataract with rosette 3.

Also, an intraocular lens was implanted in 90.1% of the cases, and the remaining aphakic 9.9% were not accounted for in the results. This may have given a seemingly poorer actual visual outcome, which may lead to a false impression of improved accuracy of the POTS over the OTS. However, this was unaccounted for in the calculations for both the OTS and POTS raw scores and predicted visual outcomes; hence, predicted versus actual visual outcomes for both scores can still be compared. The inclusion of aphakic patients in the study also gives a representation of patients who have suffered from severe ocular trauma, and allows POTS to be utilized for such patients in future clinical practice. Lastly, while the final visual outcome was ideally assessed at 1-year follow-up, the mean follow-up time was 116.4 days. The shortest follow-up time in this study was 3 months. Once again, this was consistent across calculations for OTS and POTS raw scores, which allows for comparison.

Conclusion

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In this study, the POTS was shown to be a usefultool to calculate and predict final visual outcome in pediatric patient ocular injuries with traumatic cataracts. POTS can also be applied universally as a tool for communication and discussion between traumatologists managing pediatric ocular trauma. Compliance with ethical standards Funding No funding was received for this research. Conflict of Interest All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional

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