Demographics, Presenting Features, and Outcomes of Adult Patients with Ocular Trauma

Introduction Ocular trauma is a common cause of permanent vision loss in adults. The combination of an accurate clinical examination and imaging offers the best prognostic indicators for patients and helps to navigate treatment modalities. This is a retrospective chart review of examination and imaging findings for ocular trauma and how they correlate with treatment course and visual acuity (VA) outcomes. Methods Adult patients with ocular trauma presenting to a single institution between January 2013 and December 2020 were evaluated. Initial examination and imaging findings were compared for associations with each other and with VA outcomes. Results 136 ocular traumas on 134 patients were included. The median presenting logMAR VA was 2.7 (interquartile range (IQR) 1.2–3.7) with 62% open globe injuries. The most commonly reported finding on initial CT scan was globe deformity (30%), on B-scan was choroidal detachment (20%), and on ultrasound biomicroscopy was intraocular foreign body, ciliochoroidal effusions, or angle recession (21% each). Worse vision was observed for patients positive for retinal detachment on initial B-scan compared to those negative for this finding at 6-month (median logMAR 2.7 vs. 0.5; P < 0.0001) and at final post-injury evaluation (median logMAR 3.7 vs. 0.4; P < 0.0001). Similarly, worse VA was observed for patients with choroidal detachment on initial B-scan compared to those without this finding at 6-month (median logMAR 1.4 vs. 0.5; P = 0.002) and at final post-injury evaluation (median logMAR 2.0 vs. 0.4; P < 0.0001). If positive conjunctiva/sclera examination findings were identified, 66% had positive findings on B-scan, whereas if the conjunctiva/sclera examination findings were absent, 41% had positive findings on B-scan (P = 0.005). If anterior chamber (AC) examination findings were positive, 59% had positive findings on B-scan, whereas if the AC examination findings were absent, 37% had positive findings on B-scan (P = 0.03). Discussion. The predictive value of examination findings in this study may offer insight as to long-term visual prognosis. Positive B-scan or CT findings should increase suspicion for open globe injuries.


Introduction
Ocular trauma is a common cause of permanent loss of vision in the adult population [1,2].According to a review by the World Health Organization, estimated 55 million injuries occur each year globally across all age groups, with 750,000 requiring hospitalization for these injuries [2].In an analysis of the United States Eye Injury Registry, no less than 27% of patients with severe eye injury had fnal visual outcomes meeting the criteria for legal blindness (less than 20/200 vision) [1].
According to the Birmingham Eye Trauma Terminology (BETT) system, ocular trauma can be grouped as open (secondary to blunt rupture or lacerations) or closed (secondary to contusions or lamellar lacerations) [3].At the time of patient presentation, fnal visual outcome can be predicted using the Ocular Trauma Score (OTS), which utilizes indicators such as initial visual acuity (VA), presence of rupture or perforating injury, endophthalmitis, retinal detachment, and an aferent pupillary defect (APD) [4].Open globe injuries are associated with worse fnal visual outcome as well as higher economic burden [2,[5][6][7][8].
Ocular examination is often limited in the setting of ocular trauma, particularly in those patients with open globe injuries.Fundus examination is often limited secondary to corneal trauma and media opacities including vitreous hemorrhage.Ancillary imaging can provide more detailed information in the setting of ocular trauma.In particular, computed tomography (CT) imaging is instrumental in the evaluation of open globes.In the setting of ocular trauma, the sensitivity and specifcity of CT scans in detecting open globe injuries have been reported to be as high as 75% and 93%, respectively [9].CT scans are particularly useful to evaluate intraocular foreign bodies (IOFBs), which are found in 18-41% of open globe injuries [10][11][12][13].A study by Patel et al. demonstrated that while clinical examination identifed 45.6% of IOFBs at presentation, CTscan of the orbits was successful in identifying 94.9% of such cases [11].B-scan imaging and ultrasound biomicroscopy (UBM) can also assist in characterizing anterior and posterior segment pathology in the setting of ocular trauma.UBM can elicit additional fndings such as cyclodialysis or angle recession [14,15].B-scan ultrasonography can provide information regarding potential globe rupture, IOFBs, lens dislocation, vitreous hemorrhage, membranes, retinal tears, and retinal or choroidal detachments [16].Tese imaging modalities are frequently applied in the setting of ocular trauma, and if urgent surgical repair is indicated, the opportunity for improved surgical planning is provided.
With the advancement of pars plana vitrectomy (PPV), fnal functional outcome in some traumatic cases has improved [1].A review of the United States Eye Injury Registry (USEIR) demonstrated that 60.5% of posttraumatic eyes had improved VA after surgery, 30.5% experienced no change in vision, and 9% of patients had worsening of their fnal VA [17].PPV has been implemented in the early removal of intraocular foreign bodies (IOFBs), clearing of vitreous hemorrhage, repair of complex retinal detachments, and treatment of endophthalmitis [18].However, patients may require a variable number of operations, with a small percentage still developing phthisis following surgical intervention, particularly in those patients initially presenting with ocular rupture [19].In a retrospective study of 113 patients who underwent PPV for ocular trauma, 7.3% of patients developed phthisis; half of the phthisical patients had presented with ocular rupture [19].Indicators such as a relative APD, poor preoperative VA, retinal detachment, scleral laceration beyond the rectus muscle insertion, traumatic cataract, hyphema, and loss of vitreous have been identifed as contributors to poor postoperative VA [6,20].
While imaging is typically considered to be ancillary to the clinical examination in the evaluation of a patient with ocular trauma, the combination of the two ofers the best prognostic indicators for patients.Associations between examination fndings, imaging results, and visual outcomes could ofer insight while navigating treatment modalities and surgical planning.Te authors propose this retrospective chart review of examination and imaging fndings at presentation and how they correlate with treatment course and fnal visual outcomes in these patients.

Patient Population.
A retrospective chart review was performed on patients with a clinical diagnosis of ocular trauma presenting to the Cleveland Clinic Cole Eye Institute in Cleveland, Ohio, USA, between January 2013 and December 2020.Informed consent for inclusion in the study was waived due to the minimal risk to patient safety and confdentiality.Te Cleveland Clinic Institutional Review Board approved retrospective data collection for this study, which was in accordance with the Declaration of Helsinki and Health Insurance Portability and Accountability Act.Patients at least 18 years of age presenting for their initial ophthalmologic assessment in the setting of blunt, penetrating, and/or perforating ocular trauma were included in the retrospective study.Inclusion criteria for this dataset required having an ocular imaging modality (B-scan ultrasonography or UBM) ordered.Imaging information was collected at the time of presentation or at initial examination post globe repair.Patients with preexisting ocular disease, previous ocular trauma, and/or an initial ophthalmic exam at an outside institution were excluded from further review in the study.
It is notable that for most patients, urgent globe closure is performed and then B-scan or UBM imaging is performed at time of initial follow-up examination.Tis is valuable for prognostication as well as for presurgical planning if additional intervention is indicated (e.g., retinal detachment repair).UBM is contraindicated in the presence of an open globe with decreased intraocular pressure, as it will always slightly compress the globe in a very low-pressure eye.If the pressure is normal in the eye with suspected globe trauma, then UBM may be feasible.At our institution, B-scan is at times performed on eyes with suspected globe trauma and low intraocular pressure as long as particular precautions are followed by trained ophthalmic ultrasonographers.Tis includes scanning only through the lid with a copious amount of sterile ophthalmic gel.Te gel is pooled over the eyelids and the probe "foats" on the surface of the gel.Te probe should add very minimal to no pressure on the globe.Our ultrasonographers estimate that the pressure placed on the globe by the gel with probe is 0-1 mmHg.Te globe does not change the shape while the Bscan is performed while foating on the pool.

Data Collection.
Clinical data including demographic information, mechanism of ocular injury, ophthalmic examination fndings, trauma-related imaging results, and ocular surgical procedures were collected for all patients from the electronic medical record (EMR).Demographic data comprised of patient age at presentation of ocular injury, gender, and ethnicity.Te logMAR equivalent to Snellen VA, intraocular pressure, if obtained, and zone of ocular injury from the initial assessment were recorded for each patient.Zone of ocular injury was defned according to the location of the most posterior full-thickness aspect of the globe opening for open globe injuries or most posterior identifed pathology for closed-globe injuries: Zone I limited to the cornea or corneoscleral limbus, Zone II involving the anterior 5 mm of the sclera, or Zone III at a location more than 5 mm posterior to the corneoscleral limbus [21].Te collection of relevant slit lamp exam and fundus ophthalmoscopy fndings on initial ocular exam included, but was not limited to, subconjunctival hemorrhage, scleral laceration, corneal laceration, hyphema, angle recession, iridodialysis, lens capsular violation, lens subluxation or dislocation, vitreous hemorrhage, retinal tear and/or detachment, choroidal rupture, and optic nerve changes.CT scans, B-scan ultrasonography, and UBM fndings in relation to the ocular trauma were recorded for the study population.Te logMAR equivalent of Snellen visual acuity at the 6-month post-injury and fnal ophthalmologic clinic visit were recorded.Patients with no-light-perception (NLP) vision were assigned a logMAR score of 4.700, logMAR 3.700 for light perception (LP) vision, logMAR 2.700 for hand motion (HM) vision, and logMAR 1.400 for counting fngers (CF) vision [22].Whether the patient underwent immediate surgical intervention at the time of ocular injury and information on any subsequent eye surgeries was collected.

Main Outcome
Measures.Te primary study outcomes were the relative incidence of open versus closed globe ocular trauma occurring at our institution and the relation between type of injury and ocular fndings at initial ophthalmologic examination.In addition, we explored the relationship between ocular examination fndings, imaging results, logMAR VA in the setting of globe trauma at 6-month post-injury and at the fnal post-injury evaluation, and requirement of immediate or delayed surgery.Te 6-month logMAR VA was restricted to be a measurement occurring between 119 and 241 days post-injury (representing 6 months ± 2 months).Te fnal post-injury evaluation logMAR VA was the VA obtained at the last recorded visit.

Statistical Analysis.
Patient characteristics and zone of ocular injury are summarized with descriptive statistics including count (%) and median (IQR � Q 1 -Q 3 � interquartile range between the frst and third quartiles).Visual acuity measured by logMAR scores at both 6-month and the fnal post-injury evaluation were compared among groups, positive and negative, for various examination or imaging fndings with Wilcoxon rank-sum tests.Te proportion of open globe injuries was compared among groups, positive and negative, for various examination or imaging fndings with chi-square or Fisher's exact tests.Patients were categorized according to their CT scan fndings, and the proportion of those patients with positive examination fndings was compared for various anatomical locations with chi-square or Fisher's exact tests.In addition, patients were categorized according to their examination fndings, and the proportion of those which had positive imaging fndings (B-scan and UBM) was compared with chi-square or Fisher's exact tests.A signifcance level of 5% was utilized.All analyses were conducted with JMP Pro version 16.1.0(SAS Institute, Cary, NC) statistical software.

Population Characteristics.
A total of 136 unique ocular traumas on 134 patients were included in this investigation.Ninety-seven eyes of males (71%) and 39 eyes of female (29%) patients were analyzed.Ages ranged from 18 to 96 years, with a median of 55 years (IQR � 39-71).Population demographics and presenting clinical characteristics can be found in Table 1.
In addition to presenting visual acuity, logMAR visual acuity was recorded for 102 injuries (75%) at the 6-month post-injury time point.Te time between injury and fnal post-injury evaluation for all patients ranged from 1 day to 7.8 years, with a median of 1.2 years (IQR � 0.4-3.0years).Te median logMAR visual acuity at the 6-month post-injury time point was 0.70 (IQR � 0.3-1.4) and at the fnal post-injury evaluation was 0.5 (IQR � 0.2 to 2.7).Within 6 months or by the fnal post-injury evaluation, 31 eyes had required additional surgeries beyond initial globe repair and 3 eyes required enucleation.

Association of Examination and Imaging Findings with
Visual Acuity Outcomes.Tere was no signifcant diference in VA at 6-month or fnal postoperative evaluation between patients with diferent zones of injury, regardless of open or closed globe status (Figure 1).However, in the open globe category, there was a general trend towards worse vision  with more posterior zones of injury (zones 2 and 3).Te presence of positive examination fndings (defned in Table 2) in the conjunctiva/sclera (compared to no fndings) was associated with worse VA at 6-month (P � 0.04) and fnal post-injury (P � 0.003) evaluation.Te presence of positive examination fndings in the optic nerve (compared to no fndings) was associated with worse VA at 6-month (P � 0.02) and fnal post-injury (P � 0.02) evaluation (Table 3).Te presence of examination fndings in the vitreous (compared to no fndings) was associated with better VA at 6-month (P � 0.047) and fnal post-injury (P � 0.02) evaluation.Te presence of fndings in the periphery (compared to no fndings) was associated with better VA at the fnal post-injury evaluation (P � 0.02), but this was not statistically signifcant at the 6-month post-injury time point (P � 0.49).Te other examination fndings were not signifcantly associated with vision at 6-month or fnal postinjury evaluation (Table 3).
Positive fndings on initial B-scan (compared to negative, or absent, fndings) were associated with worse VA at 6-month (P � 0.04) and fnal post-injury (P � 0.004) evaluation.More specifcally, there was signifcantly worse vision in patients initially determined on B-scan to have a retinal detachment (compared to absence of retinal detachment) (median logMAR 2.7 vs. 0.5; P < 0.0001) or patients initially determined on B-scan to have a choroidal detachment (compared to absence of choroidal detachment) (median logMAR 1.4 vs. 0.5; P � 0.03) at the 6-month post-injury.Results were similar at the fnal post-injury evaluation (median logMAR 3.7 vs. 0.4; P < 0.0001 for retinal detachment vs. no retinal detachment and median logMAR 1.4 vs. 0.4; P � 0.01 for choroidal detachment vs. no choroidal detachment).Patients positive for membranes or linear sheetlike structures on B-scan were found to have worse vision than those with negative fndings at the 6-month post-injury (median logMAR 4.2 vs. 0.7; P � 0.04), but this was only marginally signifcant at the fnal post-injury (median log-MAR 3.0 vs. 0.5; P � 0.07) evaluation.Patients positive for vitreous hemorrhage on B-scan were found to have better vision than those without these fndings at 6-month postinjury (median logMAR 0.3 vs 1.0; P � 0.03) and fnal postinjury (median logMAR 0.2 vs. 0.7; P � 0.04) evaluation.Patients positive for an intraocular foreign body on B-scan had better vision than those negative for these fndings at 6 months (median logMAR 0 vs. 0.8; P � 0.004), but this was not signifcant at the fnal post-injury evaluation (median logMAR 0.2 vs. 0.5; P � 0.12).Diferences in VA outcomes were not observed when comparing patients with positive fndings on CT scan to those negative for fndings at 6-month (P � 0.26) nor at the fnal post-injury (P � 0.20) evaluation.Similarly, diferences in VA outcomes were not observed when comparing patients with positive fndings on UBM to those with negative (or absent) fndings at 6-month (P � 0.43) nor at the fnal post-injury (P � 0.78) (Table 3) evaluation.

Association among Examination and Imaging Findings.
We examined the agreement of imaging fndings with examination fndings.Te proportion of positive B-scan fndings on acquired imaging was compared among patients with a positive versus negative examination fnding.Examination fndings were not associated with positive CT or UBM fndings.Positive conjunctiva/sclera examination fndings were associated with positive fndings on B-scan (positive examination fndings � 66% positive B-scan; absent examination fndings � 41% positive B-scan; P � 0.005).More specifcally, patients with subconjunctival hemorrhage on examination were more likely to have choroidal detachment on B-scan than without this fnding (positive examination fndings � 44% choroidal detachment; absent examination fndings � 21% choroidal detachment; P � 0.007; Table 5).Membranes were more likely to be seen on the B-scan of patients with scleral laceration observed on the examination (positive � 29% membranes; negative � 0% membranes; P < 0.0001) or patients with uveal prolapse observed on examination (positive � 50% membranes; negative � 0% membranes; P < 0.0001).Pathology in the anterior chamber examination was associated with positive fndings overall on B-scan (positive examination fndings � 59% positive B-scan; negative examination fndings � 37% positive B-scan; P � 0.03).In particular, patients presenting with a hyphema on examination compared to without were more likely to have a dislocated native or implanted intraocular lens seen on B-scan (positive examination fndings � 11% dislocated lens/IOL; negative examination fndings � 0% dislocated lens/IOL; P � 0.01).Patients with a shallow or fat anterior chamber compared to without were more likely to have choroidal detachment (positive examination fndings � 56% choroidal detachment; negative examination fndings � 27% choroidal detachment; P � 0.02) (Table 5).

Discussion
Te classifcation of ophthalmic injury as determined by clinical examination is imperative in the initial assessment of ocular trauma.We found that 62% of the cases reviewed presented with open globe injuries, and that location of injury was slightly more common in Zone III (38%) although evenly spread across Zones I and II (30% and 32%, respectively).Madan AH et al. found that in a pediatric population, 64% of patients with globe injuries were identifed as having open globe injuries, with the majority of all patients having Zone I injuries [23].In a geriatric population, open globe injuries are more commonly seen in Zones II and III as compared to younger patients and are less frequently associated with IOFBs [24].Our study varies from general trends in the literature in that a statistically signifcant diference between visual acuity outcomes and presenting zone of injury was not identifed for either closed or open globe injuries [25][26][27].Tere was a trend towards better fnal visual acuity in patients with Zone I open globe injuries, although this was not statistically signifcant (Figures 1(a) and 1(b)).Similarly, a trend for better visual acuity outcomes in Zones II and III closedglobe injuries was seen although not statistically signifcant (Figures 1(c) and 1(d)).

6
Journal of Ophthalmology While all patients with open globe injuries required initial surgical repair, it is important to note that a signifcant number of patients (31 eyes, 23%) required additional surgery during the follow-up period.Examples of subsequent posttraumatic surgical repair include secondary surgery for traumatic cataract, retinal detachment, traumatic glaucoma, or other anterior segment reconstructive surgeries.In a retrospective study of patients presenting with open globe injury, Dulz et al. revealed that almost half of patients (49%) presenting with Zone III injuries underwent additional surgical intervention for posttraumatic retinal detachment [28].
Te predictive value of examination fndings in this study may ofer insight as to a long-term visual prognosis.Positive examination fndings in the conjunctiva/sclera category (compared to negative fndings) were associated with worse logMAR VA at follow-up for reviewed patients (median logMar 1.2 with fndings vs 0.5 without; P � 0.04).Te worse visual acuity outcomes for patients with positive conjunctiva/sclera examination fndings (compared to negative fndings) were largely driven by those patients with subconjunctival hemorrhage (median logMAR 1.1 vs. 0.4; P � 0.02).While conjunctiva/sclera fndings as a whole were not associated with a higher proportion of open globe injuries, the presence of a subconjunctival hemorrhage on examination was associated with choroidal detachment on B-scan (positive examination fndings � 44% choroidal detachment; negative examination fndings � 21% choroidal detachment; P � 0.007).Te authors would suggest that the presence of subconjunctival hemorrhage should prompt thorough examination or imaging to rule out posterior segment involvement, but its absence does not exclude posterior segment involvement.Furthermore, positive Bscan or CT fndings should increase suspicion for open globe injuries, prompting possible globe exploration.Positive examination fndings in the optic nerve category were also associated with worse visual acuity outcomes.Traumatic optic neuropathy is known to produce long-standing detrimental efects on visual acuity, with no clearly benefcial treatment options [29].
Better VA outcomes were noted for those patients positive for a vitreous hemorrhage (compared with negative fndings for this) on examination at 6-month (median logMAR 0.5 with positive fnding vs. 0.8 negative fndings; P � 0.047) and at fnal post-injury (median logMAR 0.3 positive fnding vs 0.7 negative fndings; P � 0.02) evaluation.Prior studies have determined that vitreous hemorrhage is associated with the worse visual prognosis in patients with largely Zone II injuries; however, as positive fndings for vitreous hemorrhage was not subcategorized according to the zone for this analysis, the authors propose that the visualization and documentation of vitreous Journal of Ophthalmology hemorrhage in this study imply the lack of corneal or other anterior segment pathology (such as dense hyphema) which would obstruct view and could more readily be addressed or repaired with subsequent surgery [30].Similarly, having an IOFB on initial examination in the present study was associated with better visual acuity at 6 months (median logMAR 0 positive for IOFB vs. 0.8 negative for IOFB; P � 0.004).Visualization of an IOFB on initial examination suggests the presence of an adequate view through the anterior segment (i.e., the absence of fndings such as a total hyphema or lens/cornea disruption) and more localized posterior pathology which is likely to be improved with surgery.
It is of interest that the visual acuity was better at 6month post-injury than at the fnal visit for those patients with vitreous hemorrhage on presentation.Tere is potential for formation of cataract (induced by trauma or by subsequent pars plana vitrectomy) at fnal follow-up which could cause worse vision at fnal follow-up than at 6 months.In addition, there is likely a component of selection bias as those patients with more signifcant visual defcits could continue presenting for ophthalmic care, whereas those patients with better vision are discharged from care.Both possibilities are beyond the current analysis of this study and present as potential limitations.
In the setting of trauma, CT scan is adjunctive to clinical examination when evaluating for pathology including orbital fractures or foreign bodies, retrobulbar hemorrhage, globe integrity, or intraocular foreign bodies.It is a helpful tool, but not sensitive enough to rule out open globe injury alone [9].Eyelid, cornea, and lens fndings on examination were more frequently associated with positive CT scan fndings in this study.CT scans positive for an IOFB or globe deformity were more commonly associated with open globe injuries (P � 0.02 and P � 0.08, respectively).Joseph et al. determined that patients who had a poor fnal VA (VA <2/ 200, Snellen: 20/2000) or who underwent enucleation had signifcantly more CT fndings than patients with good fnal VA, indicating that CT scans may have some predictive values [9].However, in the present study, positive fndings on CT imaging were not associated with a diference in VA at either follow-up point (P � 0.26 at 6-month and P � 0.20 at fnal post-injury evaluation).
In the ophthalmic population, B-scan imaging is routinely utilized to evaluate the globe when the view to the fundus is obstructed by anterior segment pathology or other media opacities.Tese same factors likely infuence longterm visual acuity as found in this population; unsurprisingly, positive fndings on B-scan were associated with worse VA at follow-up (P � 0.04 at 6-month and P � 0.004 at fnal post-injury evaluation).Retinal and choroidal detachments on B-scan were more commonly found in patients with open globe injuries at the time of presentation (P � 0.009 and P � 0.002, respectively).Patients with  Journal of Ophthalmology subconjunctival hemorrhage on initial examination were more likely to have choroidal detachment seen on B-scan (P � 0.007).Tose with scleral laceration or uveal prolapse on examination were more likely to have membranes on Bscan (P < 0.001 for each).Tis is unsurprising as violation of the sclera or uvea indicates a more serious injury that likely prompts a robust intraocular infammatory response that leads to membrane formation.Tus, patients presenting with these fndings should undergo a serious conversation with their ophthalmologists regarding the possible development of vision-threatening membranes.Patients with hyphema were more likely to have a dislocated native or implanted lens on B-scan (P � 0.01).A shallow or fat anterior chamber was associated with choroidal detachment (P � 0.02).Knowledge of the status of the posterior segment structures is critical for surgical planning, and B-scan imaging often provides insights to optimize outcomes.As the utility of UBM is largely to investigate the organization of anterior segment structures or to evaluate for a retained IOFB, it is not surprising that positive fndings here were not correlated with an open globe injury or fnal visual acuity in this population.Potential limitations to this study include its status as a retrospective cohort study, relying on past documentation and nonstandardized follow-up schedule.In addition, the clinical skills of the examining ophthalmologist varied widely, as the study included patients initially examined by clinical residents and fellows at various stages of their training.Tis might have had an impact on the exam documented as well as imaging modalities that were obtained and interpreted.Te relatively small number of patients undergoing certain imaging modalities could potentially bias conclusions, while decreasing the statistical power for respective imaging investigations.In addition, 25% of patients did not have a 6-month follow-up visit, which limits the conclusions one can draw regarding visual acuity at this point.However, almost all patients (98%) were included in the fnal post-injury evaluation analysis, which is why we present analysis of both time points.Unfortunately, the fnal post-injury evaluation also had a large range of 1 day to 7.8 years.Another limitation is the inherent selection bias for patients who have undergone ancillary imaging following trauma.Tese patients tend to have difcult exams or exam elements that are not assessable (i.e., posterior segment exam in a patient with 8-ball hyphema).Tese patients also tend to have more severe initial injury compared to patients who do not require ancillary testing.

Conclusions
Tese results suggest that while examination fndings are imperative in the initial classifcation of ocular trauma, specifc examination fndings are associated with positive fndings on ancillary imaging which may aid in surgical planning and help predict the visual prognosis.Further investigation with a prospective study where all patients receive the same ancillary tests would be needed to determine if specifc imaging fndings are truly predictive of fnal outcomes and an eventual need for secondary surgery.

Figure 1 :
Figure 1: Six-month post-injury and fnal post-injury evaluation logMAR vision by injury zone and type box and Whisker's plots summarizing the distribution of logMAR scores by zone of injury at 6-month and fnal post-injury visit for open and closed globe injuries.Te horizontal solid black line within the box represents the median while the bottom and top of the box represent the frst and third quartiles.Te horizontal dashed blue line indicates the group mean.

Table 1 :
Clinical and demographic characteristics of the study population.
Descriptive statistics are reported as either count (%) or median (Q 1 -Q 3 ).* Missing for 61 injuries.* * Including immediate postoperative period if urgent surgery is required.
UBMCiliochoroidal efusion, angle recession, IOFB, cyclodialysis, and iris/ciliary body rotation Type of Injury.Te proportion of patients presenting with open globe injuries was investigated, as they are related to diferent examination or imaging fndings (Table 4).Patients with positive corneal examination fndings were more likely to have open globe injuries (positive fndings � 72% open globe; negative fndings � 45% open globe; P � 0.002), which was largely driven by examination fndings of corneal lac-

Table 3 :
Associations among examination and imaging fndings and post-injury logMAR visual acuity.Reported as median (Q 1 -Q 3 ) � interquartile range (frst quartile to the third quartile).P values result from Wilcoxon rank-sum tests.CT: computed tomography and UBM: ultrasound biomicroscopy.Te bold numbers indicate statistically signifcant P values.

Table 4 :
Associations among examination and imaging fndings and type of trauma.
P values result from chi-square tests unless indicated as a Fisher's exact test F .Bold values are statistically signifcant P values.8Journal of Ophthalmology

Table 5 :
Individual components of associations among conjunctiva/sclera and B-scan fndings and anterior chamber and B-scan fndings.
Data reported are the proportion with positive imaging B-scan fndings among those with positive examination fndings versus those with negative (or absent) examination fndings.P values result from Fisher's exact tests.Bold values are statistically signifcant P values.