PROGNOSIS

The Ocular Trauma Score

Robert Scott and it has been particularly useful in the

Heiko Philippin
Medical Director: Moorfields Eye management of trauma cases in a multi-
Hospital, Dubai, United Arab Emirates.
disciplinary environment (pages 42­–43).
Next, the Ocular Trauma Classification
Relatively junior doctors or allied health Group analysed more than 100 variables
workers, with little or no training in for over 2,500 eye injuries recorded in the
ophthalmology, are often tasked with the United States and Hungarian Eye Injury
recognition and initial management of Registries in order to identify the best
eye trauma. In these situations, the lack predictors of outcome at 6 months after
of clear instructions and guidance to injury. From this, they developed the
support decision making has been a key Ocular Trauma Score (OTS), which is used
challenge, which has been compounded to predict the visual outcome of patients
by the inconsistent terminologies used after open-globe ocular trauma. The
The ocular trauma score supports
to describe eye injuries. score’s predictive value is used to counsel
decision making. TANZANIA
In order to standardise the description patients and their families and to manage
of mechanical eye injuries (excluding those their expectations. It provides guidance How to use the OTS score
caused by chemicals, electricity or heat), for the clinician before pursuing complex,
1 On first examination, assign an initial
and to link the correct management to the sometimes expensive interventions,
raw score based on the initial visual
actual clinical situation, an Ocular particularly in resource-limited settings.
acuity (VA) – see A in Table 1. For
Trauma Classification Group was OTS scores range from 1 (most severe
example, for perception of light (PL) or
convened in 1997. The group reviewed injury and worst prognosis at 6 months
hand movements (HM) 70 raw points
trauma classification systems in ophthal- follow-up) to 5 (least severe injury and
would be assigned.
mology and general medicine1 and then least poor prognosis at 6 months). Each
2 From this initial raw score, subtract
developed the Birmingham Eye Trauma score is associated with a range of
points for each of the following factors
Terminology System (BETTS) (see page predicted post-injury visual acuities. It has
(starting with the worst prognosis and
43). This became established as a a predictive accuracy of approximately
ending with the least poor prognosis):
standardised terminology used to 80%, which means that the OTS will be
globe rupture, endophthalmitis, perfo-
describe and share eye injury information, accurate 4 out of 5 times.
rating injury (with both an entrance and
Table 1. Computational method for deriving the OTS score an exit wound), retinal detachment,
and relative afferent pupillary defect
Initial visual factor Raw points (RAPD): see B to F in Table 1.
3 Once the raw score sum has been
A. Initial raw score (based on initial visual acuity) NPL = 60
calculated, find the relevant category in
PL or HM = 70
Table 2 and read off the corresponding
1/200 to 19/200 = 80
OTS score. For each OTS score, Table 2
20/200 to 20/50 = 90
gives the estimated probability of each
≥ 20/40 = 100
follow-up visual acuity category.
B. Globe rupture - 23
Limitations of the OTS
C. Endophthalmitis - 17 Similar to the BETTS, the OTS model
covers the description of both open- and
D. Perforating injury - 14
closed-globe eye injuries. It is easy to use,
E. Retinal detachment - 11 as the six predictive factors (A to F) are
readily assessed, and it can give realistic
F. Relative afferent pupillary defect (RAPD) - 10 expectations of the visual potential of an
open-globe injury. However, there is a
Raw score sum = sum of raw points 1-in-5 chance that the score may be
wrong, so its use to justify primary enucle-
Table 2. Estimated probability of follow-up visual acuity category at 6 months ation is hazardous. It is better to use the
Raw score OTS NPL PL/HM 1/200– 20/200 ≥ 20/40 OTS as a guideline in order to make
sum score 19/200 to 20/50 informed treatment decisions.2
An example of this uncertainty can be
0 – 44 1 73% 17% 7% 2% 1% seen in a recent trauma case where a
32-year-old female accidentally flicked a
45 – 65 2 28% 26% 18% 13% 15% tent peg into her eye with force and the
66 – 80 3 2% 11% 15% 28% 44% hook ripped the eye wall and retina. At
primary surgical repair, the VA was vague
81 – 91 4 1% 2% 2% 21% 74% PL, there was globe rupture, retinal
detachment, vitreous haemorrhage and
92 – 100 5 0% 1% 2% 5% 92% relative afferent pupillary defect (RAPD).
NPL: nil perception of light; PL: perception of light; HM: hand movements The raw score OTS from this was calcu-

44 COMMUNITY EYE HEALTH JOURNAL | VOLUME 28 ISSUE 91 | 2015

CEHJ91_OA.indd 4 06/01/2016 15:38

 lated as follows: 70 for the VA of PL, -23 icant facial and ocular adnexal injuries. It irrefutable form to which they responded.4
for globe rupture, -11 for retinal does not factor in results from ancillary Overall, it remains a useful system that
detachment and - 10 for RAPD, giving a tests including X-ray, computed tomog- allows communication between clinicians
total raw score of 26 and OTS of 1, which raphy, or ultrasound ‘B’ scans that inform of different grades, specialties and
is associated with a 90% predicted the examination of the eye, especially nationalities, enabling them to efficiently
outcome of between NPL and PL vision where there is no view of the posterior plan, manage and monitor the full range of
(i.e., 73% for NPL plus 17% for PL) and segment. The clinician must interpret ocular injuries due to mechanical trauma.
only a 3% chance of vision better then these other clinical and investigational In your setting, there may be other
6/60. She underwent a vitrectomy and findings to help refine the prognosis methods that are used to guide clinicians.
cryopexy procedure with silicone oil predicted by the OTS.3 You can share these on the Community
internal tamponade. Following this Eye Health Journal Facebook page.
treatment, her final VA in the affected eye Additional uses of the OTS References
was 6/24 – unexpectedly useful vision. Perhaps the greatest benefit of the OTS is 1 Pieramici DJ, Sternberg P Jr., et al. A system for classi-
However, the initial score had been useful its use as a reference point when auditing fying mechanical injuries of the eye (globe). Am J
Ophthalmol 1997;123(6): 820-831.
in preoperative counselling of the patient surgical results of cases due to mechanical 2 Yu Wai Man C and Steel D. Visual outcome after open
and it reinforced the guarded prognosis of trauma. It can provide useful pointers to globe injury: a comparison of two prognostic models –
the Ocular Trauma Score and the Classification and
the operation, even though the eventual guide service redesign in order to maximise Regression Tree. Eye (Lond) 2010;24(1): 84-89.
outcome was good. In resource-limited outcomes. When managing ocular trauma 3 Breeze J and Bryant D. Current concepts in the epidemiology
settings this predictor may mean better sustained during the Afghanistan and Iraq and management of battlefield head, face and neck
trauma. JR Army Med Corps 2009;155(4): 274-278.
management of expectations, or result in wars, it became apparent that improved 4 Blanch RJ, Bindra MS, et al. Ophthalmic injuries in
the development of appropriate referral surgical provision and techniques were not British Armed Forces in Iraq and Afghanistan. Eye
(Lond) 2011;25(2): 218-223.
systems for trauma. improving outcomes from the worst injuries
There are drawbacks to using such a and that the worst injuries were shrapnel Further reading
Kuhn F, Maisiak R, et al. The Ocular Trauma Score (OTS).
simplified system. It does not include injuries. To counter this, the enforced use Ophthalmol Clin North Am 2002;15(2): 163-165, vi.
associated injuries that have a bearing on of combat eye protection reduced the Schmidt GW, Broman AT, et al. Vision survival after open
the outcome of the mechanical injury, incidence and severity of eye injuries signif- globe injury predicted by classification and regression tree
analysis. Ophthalmology 2008;115(1): 202-209.
such as chemical, electrical, and thermal icantly. In this case, the OTS was used to Scott R. The injured eye. Philos Trans R Soc Lond B Biol Sci
ocular injuries, nor does it include signif- highlight the problem to policy makers in an 2011;366(1562): 251-260.

Implementing and applying the Ocular Trauma Score: the challenges

desk used for writing the notes, serving as

Desirée C Murray
Desirée C Murray
Lecturer in Ophthalmology: a reminder to use it. It was decided that the
The University of the West Indies, score would be part of the presentation to
St Augustine, Trinidad and Tobago, the consultant on call and would be used to
West Indies.
inform management decisions and discussion
Ocular trauma is a significant cause of with the patients and their families.
unilateral blindness in the Caribbean in Unfortunately, the use of the OTS was
both adults and children.1,2,3 In Trinidad not sustained in the long term. Initially,
and Tobago, blunt ocular injury will typically there was inconsistent use of the OTS by
account for around a third of all referrals the different ophthalmology trainees; the
from the Accident and Emergency consultants also did not request the OTS A copy of ocular trauma score was
department to the ophthalmology unit.4 score when the trainees presented each prominently displayed. WEST INDIES
The Ocular Trauma Score (OTS) aims case to them. Then, when there was a
to estimate a patient’s visual acuity six change of staff at the junior and senior with varying levels of experience to have
months after an eye injury. A higher OTS levels, its use was discontinued. a common understanding of prognosis. It
score indicates a better visual prognosis. is also an appropriate aid for counselling
The OTS was introduced at the Eric Lessons learnt as it helps patients to understand their
Williams Medical Sciences Complex, the Critical analysis of the OTS in an visual prognosis, which reduces unreal-
main teaching hospital of the University of academic classroom environment istic expectations. However, it is not a
the West Indies, in 2012. The elements (during the postgraduate teaching replacement for good clinical judgement
used to calculate the OTS (visual acuity, session), and displaying the OTS score – and the score is only applicable if all
rupture, endophthalmitis, perforating prominently in examination rooms, efforts are made to provide the correct
injury, retinal detachment, relative helped to make clinicians aware of it and management of the injury.
afferent pupillary defect [RAPD]), were encouraged them to use it in their
References
already routinely recorded during initial consultations with patients. However, 1 Mowatt L, McDonald A, Ferron-Boothe D. Hospitalization
assessment of ocular trauma patients at this was not enough. The OTS should be trends in adult ocular trauma at the University Hospital
the unit. It was expected that this would implemented as unit policy and incorpo- of the West Indies. West Indian Med J. 2012;61(6):605.
2 Mowatt L, McDonald A, Ferron-Boothe D. Paediatric
make the OTS easy to implement. rated in all protocols and treatment Ocular Trauma Admissions to the University Hospital of
The OTS was first discussed during a guidelines in order to ensure its the West Indies. West Indian Med J. 2012;61(6):598.
postgraduate teaching session on ocular 3 Mowatt L. Epidemiology of pediatric ocular trauma
continued use. Capturing eye trauma admissions. Survey of ophthalmology. 2014;59(4):480.
trauma. It was decided that the first patients' OTS scores for auditing purposes 4 Anisa Ali SR, Greer Iton, Nived Moonasar, Shivana
on-call officer would calculate the score and analysing these data regularly will Persad, Michael Ramjitsingh-Samuel, Andrei Chang
Kit, Ronnie Bhola, Robin Seemongal-Dass, Desirée
following initial assessment in the doctors’ also help to demonstrate its usefulness. Murray. An audit of emergency referrals to a Tertiary
on-call examination room. A copy of the It is worth the effort. The simplicity of Level Ophthalmology Unit in Trinidad & Tobago. West
OTS was prominently displayed on the the OTS allows medical and nursing staff Indian Medical Journal 2011;60(Suppl 3):1-32.

© The author/s and Community Eye Health Journal 2015. This is an Open Access COMMUNITY EYE HEALTH JOURNAL | VOLUME 28 ISSUE 91 | 2015 45
article distributed under the Creative Commons Attribution Non-Commercial License.

CEHJ91_OA.indd 5 06/01/2016 15:38