Graefes Arch Clin Exp Ophthalmol DOI 10.1007/s00417-014-2809-x
The clinical characteristics of alcohol-related ocular rupture Liu Jian-wei & Hu Zhen-bo & Wang Shu-na & Zhu Yu-guang & Deng Ai-jun
Received: 15 March 2014 / Revised: 6 August 2014 / Accepted: 22 September 2014 # Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose To evaluate the characteristics and outcomes of drunken patients treated for ocular rupture, and to compare these results to patients injured without alcohol consumption. Design and methods The medical records of 182 patients with or without alcohol consumption before injury who were treated and followed up because of ocular rupture at the Affiliated Hospital of Weifang Medical University from October 2007 to October 2011 were evaluated retrospectively. The characteristics and outcomes of 45 alcohol-related injury patients were compared with the rest in the cohort. The clinical data included in this study were: anatomic sites and length of the wound, involvement of ocular adnexa injuries, evisceration rate, and final mean visual acuity. Results Wound locations were significantly different between the alcohol-related group and the non-alcohol-related one. Compared with the non-alcohol-related ocular rupture population, the anatomic sites of the drunken patients were more likely to be located at zone I and zone II (60.0 vs 40.1 %; χ2= 5.39,P<0.05). The difference of wound length between the alcohol-related group and the non-alcohol-related one was significant. The alcohol-related patients had a longer wound length (Z=−8.590,P<0.05). Compared with the non-alcohol population, the alcohol-consuming patients were more likely to suffer adnexa injuries (84.4 vs 59.8 %; χ2=5.86,P<0.05), and had worse final visual acuities (Z=−7.195,P<0.05). The evisceration rate of the alcohol-related patients was significantly higher than the non-alcohol patients (24.4 vs 9.4 %; χ2=6.62,P<0.05). L. Jian-wei : H. Zhen-bo : W. Shu-na : Z. Yu-guang : D. Ai-jun (*) Department of Ophthalmology, Affiliated Hospital of Weifang Medical University, Yu-He Street 2428, Weifang 261031, Shandong Province, China e-mail: [email protected] L. Jian-wei e-mail: [email protected]
Conclusions Drinking more easily leads to injury of the front part of eyes. Moreover, the drunken patients had a worse visual acuity outcome, longer wound length, higher evisceration rate, and were more prone to endure adnexa injuries. The importance of prevention and education to recognize the hazards of drinking cannot be overemphasized. Keywords Ocular trauma . Alcohol-related ocular rupture . Alcohol
Introduction Open-globe eye injury is a kind of severe eye disease that has a strong relationship with ocular morbidity and visual impairment. Open-globe eye injury means a full-thickness wound of the cornea and/or sclera . Open-globe eye injury is classified into two main types: ocular laceration and rupture. Eyeball rupture is the most devastating kind of open-globe injury, caused by a blunt object which leads to a sudden increase in intra-ocular pressure and disrupts the cornea or/and sclera integrity. Alcohol intake and alcohol-related injuries are very common in China. There is evidence that alcohol consumption is associated with an increased risk of injury . Alcohol-related ocular rupture is strongly associated with severe ocular damage and blindness. In addition, serious appendage injuries of the eye frequently occur, accompanied by an alcohol-related ocular rupture. Many factors affect the outcome of patients with open-globe eye injury. These factors include elapsed time between the injury and surgery, age of the patients, initial visual acuity, retinal detachment, injury in zone II or III, blunt object, rupture-type injury, the presence of endophthalmitis, relative afferent papillary defect, hyphema, and eyeball contents prolapse [3–5]. In our study, we found that alcohol intake had a significant negative impact on the prognosis of patients.
Graefes Arch Clin Exp Ophthalmol
This study aims to find out the clinical characteristics of alcohol-related ocular rupture.
Results The study population comprised 148 (63.2 %) male and 34 (36.8 %) female patients. The mean age was 32.5±18.7 years (range, 4–83).
Materials and methods 1. The anatomic site of the wound This study was approved by the Local Ethics Committee of our institution. A review of the medical records of patients of ocular rupture attending the Ophthalmology Department of the Affiliated Hospital of Weifang Medical University was undertaken duringthe period October 2006 to October 2011. Clinical data of all patients were recorded for this research. The mean follow-up duration was 24.5±17.2 months (range, 10– 53). Patients who failed to follow up or were unwilling to be included in the study were excluded from this analysis. There were no eyes with pathologic myopia in our study. The patients were divided into two groups: those with alcohol consumption (n = 45) and those without (n = 137). The difference of clinical characteristics was compared between the two groups. The definition of ocular rupture in this study was adopted according to the Ocular Trauma Classification Group guidelines and Birmingham Eye Trauma Terminology [6, 7]. The initial visual acuity is difficult to obtain due to the noncooperation of drunken patients. As a result, the Ocular Trauma Score (OTS) and the Organ Injury Scaling VII system were not adopted in this study. In addition, since we know that most ocular rupture patients have the signs of relative afferent papillary defect, hyphema, and eyeball contents prolapse, the above contents were not regarded as important in this study. To sum up, the clinical data included in this research were: the anatomic site and length of the wound, the involvement of severe ocular adnexa injuries, the final mean visual acuity, and the evisceration rate. The anatomic site of the wound was defined as zone I if the injury was confined to the cornea including the corneoscleral limbus, as zone II if the injury was located as far as 5 mm posterior into the sclera, and as zone III if the injury was located in the sclera posterior to zone II. Severe ocular adnexa injury refers to at least one of these injuries: eye lid laceration, orbit fracture, and optic nerve injury. Data were analyzed with SPSS version 17.0 (SPSS, Inc.). Statistical analysis of quantitative data, including descriptive statistics, parametric and non-parametric comparisons, was performed for all variables. Frequency analysis was performed using the chi-square test. The analysis of ranked data was performed using the rank-sum test. All P-values were two-sided, and a P-value less than 0.05 was considered statistically significant.
Among the 45 alcohol-related rupture patients, there were six patients injured at the location of zone I, 21 at the location of zone II, and 18 at zone III, respectively. There were 19, 36, and 82 patients with a wound location of zone I, zone II, and zone III in the non-alcohol group, respectively (Table 1). The difference was significant between the two groups (χ2= 6.934,P<0.05).We regarded zone I and zone II as an anterior position and zone III as a posterior position, owing to the involvement of retina. Compared with the non-alcohol-related ocular rupture population, the anatomic site of the patients injured with alcohol consumption was more likely to be located at zone I and zone II (60.0 vs 40.1 %; χ2 = 5.39,P<0.05) 2. The wound length Of all the 45 alcohol-related rupture patients, there were four patients with a wound length not longer than 5 mm, 15 patients with a wound length from 5 mm to 10 mm, and 26 patients with a wound length longer than 10 mm (Table 2). The difference between groups was significant (Z = −8.590,P<0.05) . A wound length longer than 10 mm was regarded as a huge wound. The difference in the proportion of huge wounds between groups was significant (57.7 vs 37.2 %; χ2=5.86,P<0.05). 3. The involvement of adnexa injuries The adnexa injuries may occur alone or in various combinations. There were 18 patients with an eyelid laceration, 30 with an orbital fracture, six with optic nerve injury, and in total 38 who endured more than one kind of these injuries in the alcohol-related group (Table 3). Compared with the nonalcohol population, those in the alcohol group were more likely to develop adnexa injuries (84.4 vs 59.8 %; χ2= 5.86,P<0.05) 4. The final mean visual acuity The follow-up period ranged between 10–53 months (mean: 24.5±17.2 months), and post-operative best-corrected visual acuity was recorded at last follow-up. The final visual acuity was NLP in 12 patients, LP/HM in 20, 1/200–19/200 in eight, 20/200–20/50 in three, and≥ 20/40 in. two in the alcohol-related group (Table 4). Compared to the no-alcohol
Graefes Arch Clin Exp Ophthalmol Table 1 The location of the wound
Table 3 The involvement of adnexa injuries
Alcohol group Non-alcohol group
Location Zone I
group, the alcohol-related group had worse visual acuities (Z= −7.195,P<0.05). 5. The evisceration rate The causes of evisceration in this study were infection, ocular atrophy, and silicon oil dependent eye. Each patient’s visual acuity was NLP before they underwent the surgery of eye removal. In the alcohol-related patients, six had the eyeball removed due to eyeball atrophy and five due to silicon oil dependent eye (Table 5) . Compared with the non-alcoholrelated ocular rupture population, the evisceration rate of patients injured with alcohol consumption was significantly higher (24.4 vs 9.4 %; χ2=6.62,P<0.05).
Discussion Alcohol consumption is very prevalent in China and frequently results in trauma [8, 9]. Alcohol consumption has been shown to potentiate aggressive behavior as a psychomotor stimulant  and increase the risk of ocular trauma [11, 12]. Smith AR et al. found that alcohol accounts for 76.2 % of all assault-related ocular trauma in Australian patients . We have often dealt with ocular trauma patients with alcohol consumption in our clinical work, and have found some distinguishing features of them. As we know, open-globe trauma can be divided into zone I, zone II, and zone III injuries in terms of the different anatomic site of the wound. From this study, we found that defects of zoneI and zone II are more likely to happen in patients with alcohol intake (χ2=5.39, P<0.05) . As generally believed, the prognosis of zone I and zone II is better than that of zone III because retinal detachment—which has a relationship with a
Adnexa injuries Eyelid laceration
Optic nerve injury
worse outcome—may exist when this part is damaged [14, 15]. But this doesn’t mean that the outcome of zone I and zone II patients with alcohol consumption is better than that of zone III patients without alcohol consumption. Usually, the damage is so huge and devastating that eyeball structures such as vitreous body, ciliary body, and even retina may prolapse and severe intraocular hemorrhage may occur on drunken patients. If the eye contents drop out through a cornea wound, the first-aid repair operation and the later reconstructive surgery will be very difficult to do. In addition to wound location, the length of wound is another important indicator of prognosis. Lieb DF et al. found that shorter wound length had a relationship with better visual acuity outcomes [14, 16]. We found that the wound length of alcohol-intake patients was longer than those of normal ones (Z=−8.590,P<0.05). The state of inebriation made the selfprotection capabilities of drunk patients decline, and they were more prone to be injured. This state may continue until surgery treatment is undertaken, and during this period further damage may occur. Eyelid fit and function are important for maintaining ocular surface health. Eyelid contusion or hematoma is very common in ocular rupture. If the impact is very huge, an eyelid laceration may occurm accompanied by an eyeball rupture. In addition to eyelid laceration, other adnexal damage such as orbit fracture and optic nerve contusion also often occurs with severe ocular rupture. A blow-out fracture of the orbital floor is typically caused by a sudden increase in the orbital pressure caused by a striking object which is greater than 5 cm in diameter. Patients with this kind of fracture often suffer from seriously damaged appearance and significant dysfunction such as diplopia . Han SB et al. found that orbital wall fracture showed a significant association with alcohol consumption . Optic nerve injury is uncommon accompanied Table 4 The final visual acuity
Graefes Arch Clin Exp Ophthalmol Table 5 Reasons for evisceration Group
Reasons Infection Eyeball atrophy Silicon oil Total dependent eye
Non-alcohol group 2
with eyeball rupture. However, once it occurs, the outcome may be devastating . Thus, diagnosis of a traumatic optic neuropathy in the early stages is very important. For the benefit of open globe injury patients, a CT examination should be given if necessary before a surgery. If an optic nerve thickening or/and optic canal fracture exist, systemic steroids should be used. In our clinical work, we found that alcohol-related ocular rupture patients have more possibilities to develop at least one kind of severe adnexal injury. From the study, we found that 84.4 % of patients had compound injuries of ocular rupture and adnexa injuries in the alcohol-consumption group, which was much higher than the normal group (χ2=5.86,P<0.05). This indicates that the impact of drunken patients is more severe than that of normal ones, or that the patient’s selfdefense capability declines due to alcohol, which leads to further damage. Compared with adnexa injuries, most ophthalmologists may pay more attention to ocular trauma. However, appendage damage may have a more serious outcome (such as diplopia, severe eyelid deformity, or epiphora) than ocular rupture itself. When an open-globe patient comes to us, careful examination and delicate treatment should also be given to the adnexa injuries. Visual acuity is a measure of the spatial resolution of the eye. It is the most important part of visual function. It is very difficult to acquire an accurate visual acuity for an inebriated patient because he may be uncooperative or unconscious due to intoxication when he first comes to the emergency department. Entezari et al. found that in 36 % of open-globe injuries, final visual acuity were less than 20/200 . He Cao et al. found that 71.2 % of open-globe injured eyes had a final visual acuity lower than 0.3 . From our study, we found that 81.7 % of normal ocular rupture patients had a final visual acuity less than 20/200. The situation is even worse for alcohol-consumption patients, among whom 88.8 % have a final vision less than 20/200. A large proportion of them are dependent on silicon oil tamponade, and may finally have evisceration performed. So the results suggest that alcohol can induce more serious destruction to eyes. Eye trauma is a very important reason for eye removal. Kagmeni G et al. found that it accounted for 17.40 % of all eye-removal patients . Primary evisceration should not be performed even for the most severe and seemingly irreversibly
damaged eyes. Even in situations in which evisceration seems inevitable, the ophthalmologist should discuss with the patient about the options before making a final decision. For patients with sympathetic ophthalmia with potential of bilateral blindness, evisceration may be performed for the benefit of the other eye if the patients have no light perception. The incidence of traumatic endophthalmitis may be very low due to immediate wound closure and prompt initiation of antibiotics [23, 24]. Most infection can be successfully managed with vitrectomy and the use of intravitreal antibiotics, and only very virulent organisms can lead to an uncontrolled infection result in endophthalmitis. Eyes being silicon oil dependent means that the structure and function of eyes can only be maintained with silicone oil tamponade . Once the silicon oil is removed, the eye will atrophy in a short time. Eyeball atrophy is a common reason for evisceration. The ocular coating may be injured severely and most of intraocular content such as retina, iris, and ciliary body may drop out. It is very hard to reconstruct the structure and function of the eyeball even through a series of surgeries including vitrectomy and silicone oil tamponade. Despite the reasons for evisceration, it is obvious that there is a close association between injury severity and the evisceration rate. Only the most serious trauma can lead to an evisceration. As can be seen from the great differences in evisceration rate between the two groups, alcohol can lead to a more devastating injury. As we know, ocular rupture is only a kind of eye trauma; it accounts for 31.4 %  of all the ocular trauma inpatients. Because the clinical features of different types of eye injury differ greatly, other kinds of ocular trauma were not enrolled in this study. As well as in eyes, alcohol can induce injuries in other parts of the body . Thus, the importance of prevention and education to recognize the hazards of drinking cannot be overemphasized.
Conflict of interest None
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