Eye injuries are the main cause of vision loss in one eye worldwide.
Annette Hoskin chats with Dr Maria Cabrera about the creation of an eye injury registry to understand when and where eye injuries happen, and better understand how we can manage those eye injuries.
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Maria Cabrera: Do you know that 9 out of 10 eye injuries which resulted in severe vision impairment or blindness are preventable?
Do you know that basketball, squash, badminton, rugby, and football are the leading causes of sports-related eye injuries?
Have you heard that men are more likely to suffer an eye injury than women?
By the end of this podcast, you’ll know…
· Who is more at risk of having an eye injury,
· The most common types of eye injury, and
· How an eye injury registry can help in designing prevention strategies
First, I will give a brief introduction about eye injuries and then I will chat with Annette Hoskin, a Research Fellow at the University of Sydney, Save Sight Institute, and at the University of Western Australia, Lions Eye Institute, who will tell us about the importance of having an eye injury registry for designing prevention strategies.
I am Maria Cabrera-Aguas. A Researcher at the University of Sydney, Save Sight Institute. Welcome to the Sydney Eye podcast!
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There are two main types of an eye injury: open or closed. An open injury is when the eye wall has a full thickness wound, for example a penetrating injury with a sharp object or foreign body. A closed injury is when the eye wall does not have a full thickness wound for example when someone or something hits you near the eye ball or the bones of the orbit. A study from 1995, showed that although open eye injuries accounted for only 2% of all eye injuries, they were responsible for nearly half of cost on eye injuries, which were estimated at about $155 million a year Australia wide. In 2017, a study from our research group reviewed the characteristics of patients who suffered an open eye injury over six years. The study reported 250 cases. 80% of patients were male. Two out of three patients had an injury due ‘exposure to an inanimate mechanical force’ for example via use of a hand tool or striking against or struck by sports equipment.Alcohol was implicated in 20 cases with 11 due to assault and falls occurred mostly in older patients. Penetrating injuries and foreign bodies occurred while working with metal. And patients who suffered from a foreign object or a penetrating injury had a reduced vision after treatment.
Now, let’s welcome Annette Hoskin, a Research Fellow at the University of Sydney, Save Sight Institute, and at the University of Western Australia, Lions Eye Institute. Currently, Annette is undertaking her PhD under the supervision of Prof Stephanie Watson who is the Head of the Corneal Research Group at the Save Sight Institute. We are going to chat about her project on establishing a registry to understand better the epidemiology of eye injuries.
Maria Cabrera (MC): Thank you Annette for joining us in our show today. Welcome!
Annette Hoskin (AH): Thanks, Maria, I really appreciate this opportunity.
MC: So Annette to start with, tell us about your project.
AH: so, eye injuries and how to prevent them is something that I've been really interested in for a very long time. And so the project that we're currently working on is to try understand when and where eye injuries happen, and to try and better understand how we can manage those eye injuries. But ultimately, by understanding when and where eye injuries happen, we can look towards preventing them and have some great strategies around what we can do to stop them from happening.
MC: When did you start this study? How many years ago?
AH: So the study is started, well, in fact, one of my collaborators Rupesh Agarwal, from Singapore, has been working on this project for a few more years than me, and it was something that he started. And when I met Rupesh in Singapore in 2018, he told me about the work that he was doing and I asked if I could be involved. And so really, the project has started to move forward from that time, and it's gone through different phases where we've started to collect initial data and we've had different platforms. And now we're at an even more exciting phase where we're looking at collecting data from many more centres internationally.
MC: I was reading your paper which describes the development of an eye trauma registry. How was the experience of building a registry? Were you the first to build it or others built it first and then you joined? How was that process?
AH: So the registry that we first set up was developed by Rupesh and a number about collaborators, and it was definitely something stand alone that we developed specifically to look at eye injuries. And we spent a lot of time initially with our other collaborators from all over the world trying, to understand, which were the parameters or the things that we really wanted to collect and identify. And all of that discussion, as you can imagine, takes quite a long time and quite a lot of negotiation and really trying to develop and understand the best data to collect so that we can have the best possible outcomes and the best opportunity to have an injury prevention strategy at the end of the day,
MC: Okay, how many countries are involved in this project?
AH: At the moment we have more than 10 we have through the Asia Pacific Ophthalmic Trauma Society as well as a number of other Trauma Society's internationally. We have collaborators from all of those groups, so we have representation from South America, The Asia Pacific, US and Europe as well, you know obviously I include Australia in the Asia Pacific region, so we have a lot of a lot of collaborators that we're working with and a core a core team from each of those continents. I guess that’s helping to guide the process as we move through.
MC: In what year did you start collecting the data?
AH: So the first data that we've collected was probably in about 2019 and in fact, when we first collected that data, we're really trying to understand what form the registry would best take, and we've really revised our opinion about what it will be and we've now opted for an online form, which is which is more secure in the way that we've set it up. And we're just about to start collecting more data. So So we did stop from period after the initial data collection and now about to restart the data collection. So So this year, in the next couple of months, we have to restart again.
MC: Oh, well I suppose, this is for ophthalmologists or eye health professionals. So when they have, I suppose, a patient with an eye trauma the idea is that they after the initial consultation or maybe, I don't know sometime after, they sit down with the medical record and then they enter the data on a website, is this how it works?
AH: So it can, actually, depending on the way the different institutions or hospitals work. They can enter the data offline or online. And so we've set it up that way so that it makes it much easier for the different institutions to navigate the ethics approvals that they need. And if they're entering it online, it means they go on to a secure website and they have their own password that they enter for their specific hospital. And they could either enter the data live and prospectively, actually, when they have the patient arriving, or they could go in after and enter it retrospectively to include all of the information. So it really depends on what's the easiest way for the ophthalmologists or the health care professionals to enter the data. And obviously there, you know, we're talking about people that are pretty time poor, so we've tried to make the system as easy as possible for them to enter the data at the time that most suits them.
MC: Okay, for example, how long does it take them to enter one case into the system?
AH: So, with we've changed a lot, actually, since we've started with the registry first back in 2019. So the latest iteration, the latest version of the registry that with we're about to deploy it should only take the practitioners about 10 minutes to enter all of the data. And what we're trying to do is focus on the key critical information that we need so that when we go through in review, we have the maximum number of data points. And then if there's other information that we would like to collect, for example about different treatment strategies, then we'll be able to dive deeper with that data at a later point. But we've really tried to focus in on a live key information that we need relating to the circumstances of the injury and exactly what was the object involved and whether they were wearing eye protection, what their vision was when they first presented and what the visual outcome is that they had. So all of that information is really critical for us to understand in terms of how we best intervene in the future.
MC: Well, how often you're planning to release the reports?
AH: So I think the based on the registry in its current form that we're about to deploy, we would like to at least collect one year of data so that we can then review the efficacy of the form and make sure that people are filling it in correctly and all the missing items after, you know, we do an initial trial period. So we have already submitted to papers for publication on the initial data that we collected. And I'm imagining that with this refined and revised data collection system or registry that we'd like to collect another year of data that will then allow us to re validate and move forward and start collect more and more data. And ultimately, my vision would be that we would have some kind of widget or piece of information where we could show in a relatively time efficient way. Exactly when eye injuries are happening and who they're happening too. So we can respond or not more quickly to any changes that is in the profile of injuries. And if we have a really good set of data globally than that enables us to be able to report in a more in a more you know, for definite timeframe in shorter time frames to be able to use the data more effectively.
MC: The paper that described the registry reported the data globally no per country, right?
AH: So we did both in the data in the data that we've already published, we've got it includes the global data as well as the individual country data. And I guess depending on how many collaborators we end up having having, then we may do the same type of thing. So it's really important to understand that in different countries the profile of eye injuries can be quite different. So in Australia we're seeing more injuries at home. And when people are playing sports, whereas in countries like India and China, they're they're seeing more eye injuries relating to work related incidents. And that's, you know, those profiles are interesting and helpful to have and again helps us define the best prevention strategy.
MC: You just mentioned some common eye injuries found in Australia, so from this report in Australia, what would be the typical or the most common patient presenting with an eye injury?
AH: so almost universally in all types of injuries, not just eye injuries, males are always more represented than females. And the only time that that seems to vary, you know, significantly is when with very young children. So usually children that are not walking yet, and they are more predisposed to falling, all with very old female. So it's partly to do with the gender distribution as people get older. So other than those two ends of the spectrum, mostly we see it's males that are injured. And even though we have helped to reduce eye injuries at work by using appropriate eye protection, we still see a lot of eye injuries at work. And what we increasingly see is as I said before eye injuries relating to things that people do at home. And I think maybe there is some evidence to show that COVID has been a bit of a change, even from the different confinements that people had, but certainly the work that people do at homes. They tend not to protect themselves in the same way that they would do at work. So somebody who's at home who's constructing something and they might be using a drill or a hammer and they're working with metal. Then they end up having eye injuries purely because they're not really thinking about the injuries that might happen or the hazards that there are there. And they're not wearing eye protection. So definitely we could do a lot more to help send that message to try make sure that people protect themselves at home in the same way that they protect themselves at work.
MC: Well, so you are saying the young boys are more prone to have injuries. So, for example, what kind of injuries did you find in the registry?
AH: so if we talk about primary school age children, a lot of the injuries were related to play that young boys might do, but they were in a similar way, they relate to sport and the sorts of eye injuries that they can often have fractures to the bones around their eye or something called a blunt trauma where they have no penetration of the eye globe itself. But some kind of impact on the eye and that could result in bleeding in the eye which is called a hyphema or a retinal detachment where that that special layer at the back of your eye moves away and they can lose vision in that part of the eye. So sports and being poked in the eye, pens and pencils, things that kids use around the home. They're definitely all factors that we saw in the registry that are associated with eye injuries
MC: So, for example, what kind of what kind of sports?
AH: So the sports that children and you know all people, in fact most at risk other ones where there is a bat or a ball or is there or is there some risk of collision with another player, and so if you think of the classic examples like softball, basketball, volleyball, obviously in Australia all codes of football are fairly highly represented, but equally things like golf, you know, if somebody is hit by a golf ball ,it speeds, and that's and you know, often clubs and other things. If people are obviously not paying attention to his around them. Badminton is another one, and particularly when people are playing doubles and potentially somebody standing at the net is hit by the shuttlecock coming at speed over the net, and they close close to hitting them, and they would often end up with some kind of blunt eye injury as result. So even sometimes the things that appear quite innocuous, that you wouldn't expect to have an eye injury like badminton because you know the shuttlecock is small and light, you can still have an eye injury. The other one that commonly happens is squash. And I guess I'm so much more in the nineties and in earlier periods when squash was more popular. And we probably don't see the same number of eye injuries from squash anymore, just because it's not as popular, there are definitely standards, and eye protection available for the full games like squash, these should always be used as well. The thing about squash is that the ball itself is just small enough to fit inside the bony orbit around your eye. So it not only hits the globe, the eyeball itself, but it also pushes through the bones and squashes the eyeball so you can end up with quite nasty eye injuries and potentially lose vision in the eye altogether.
MC: Okay, and for old ladies, what kind of injuries do they experience?
AH: What we're actually seeing with the elderly population increasingly is eye injuries from falls, and often these are more than more devastating type of eye injury. The thing that's more likely to lead to vision loss is an open globe injury. And that means that the eye itself, the eyeball is penetrated, or you know that there is essentially a hole in the surface of the eye, and that could result in quite severe vision loss. So what we've seen in some of the studies were done in Australia, but this is being seen internationally is that people who have had a previous injury or previous surgeries, so cataract surgery is common in elderly population, they are falling and falling onto sharp objects so it might be the bedside table that might be the coffee table, and add to that the fact that they might be wearing glasses that are not necessarily impact resistant. Then they can, the glasses can shutter or the object that they fall onto is his sharp or results in some kind of penetration to the eye. So this is what we're seeing increasingly, and I think as the population ages and we have more people represented in that part of the spectrum, this is going to be seeing more and more. And it's something that we need to definitely keep an eye in the future try to have better intervention strategies.
MC: Well, I also read on your paper that data from follow up visits are also collected. What were the visual outcomes in these patients?
AH: definitely we try to follow up for at least until they've finished their treatment, which maybe into the months and years, or it may be relatively short, depending on how bad the injuries, but what we did as as an over overall picture what we saw of all of the open globe injuries that we looked, adding our first study was that again, the open globe injuries other more devastating or the more the the more likely to end up with vision loss. Probably about 20% of those ended up with vision less than 6 60. So that means that the vision was quite poor and that eye and definitely the impact of that vision loss would be significant from the patient's perspective. And if you think about normal everyday vision and the sorts of things that we do every day to give you an idea, somebody who has vision less than 6/12 is not able to drive a car, and obviously 6/60 is much worse than that. So they would have very little functional vision left. And that was one in five of the injuries that we saw were were falling into that category.
MC: Well, based on these data, can you give us like, three prevention strategies to finalise our conversation?
AH: Sure, and it's probably there's so many that come to mind and to try and think about the best possible prevention strategies is tricky but trying to pick the top three. I think whenever you think about prevention, it's really important to think about the hierarchy, what we call the hierarchy of controls. Obviously, the best thing we could possibly do is eliminate the hazards all together. And that means, you know, if you're thinking about a work site where they use a particular chemical that's caustic or toxic to the eye that we would not use that chemical on would replace it with the safe one. So this is sort of the gold standard in terms of injury prevention is to try and get rid of the hazard altogether. But where that's not possible and in many circumstances, we can't anticipate the hazards or the injuries happening. Then eye protection is is a great way of preventing eye injuries, and obviously that those that are doing DYI at home and you know the sorts of projects that people might be doing that essentially are equivalent to many of the occupations that we see eye injuries in like hammering or drilling that they should wear the right side of sort of eye protection that protects their eye and make sure that there's minimised the gaps around the side of your eyes. The other the other area that we really want to work on is to try and introduce more eye protection for the sports that we see lots of eye injuries in and I mentioned some of those and to try to have better standards for those different types of sports. So they would be the first two, I would say, and then the third one is probably relating to falls and eye injuries, which we talked a little bit about and to try and have better education. And there is already a lot of activity relating to falls and helping to try and prevent these and this is not just an Australia issue, this is globally. And so as part of that education, trying to make the patient's aware off the consequences if they have a fall and it may be a simple as not having a bedside table or not having coffee tables so that if they do have a full, the consequences are not are not as bad. Obviously, we want to prevent the falls and all the other interventions around balance and other strategies to minimise trip hazards and things like that in the home for elderly people are really good start that also minimising the consequences if they do have a fall.
MC: well Annette this was very informative and thank you so much for sharing your project with us today. If people want to contact you, what would be the best way to do it?
AH: I'm more than happy to talk to potential collaborators if they want to contact me by email, and we can add that in that information in after the podcast. Also happy to connect with people on Twitter or Linkedin if you have questions in particular about any of the things that we talked about today.
You can contact Annette via email to [email protected], via twitter @Annette_hoskin or via linkedin. I will leave her details on the comment section of the podcast.
To recap, boys and elder women are more at risk of having an eye injury
Boys may suffer an eye injury when playing sports due to the risk of collision with other players. Sports with more risk of eye injuries are basketball, squash, badminton, rugby and football. Falls are the main mechanism of injury in elder women. Prevention strategies include hazard elimination, use of protection glasses and education related to falls in the elderly population.
I am Maria Cabrera-Aguas, thanks for joining me today in the episode number 4 of the Sydney Eye podcast. If you haven’t yet subscribed to this podcast you are invited to consider that to receive a notification when a new episode is released.
If you have any questions, comments or suggestions please send them to [email protected] and connect with us on Twitter @CabreraMarie, it’s
C-A-B-R-E-R-A-M-A-R-I-E or @cornealresearch using the hashtag S-Y-D-E-Y-E-P-O-D. Until next time. Bye!