Inter-hospital transfer may delay primary closure of open globe injuries in cases of ocular trauma

Open globe injuries are a severe form of ocular trauma involving full-thickness disruption of the eyewall. Patients with open globe injuries require urgent evaluation by an ophthalmologist, and therefore, may need to be transferred to a Level I or II trauma center. The visual outcomes of an open globe injury rely on a wide variety of prognostic factors. Some risk factors that have been associated with worse prognosis include poor visual acuity at presentation, mode and setting of injury, ocular trauma score, zone of injury, presence of an intraocular foreign body (IOFB), endophthalmitis, and time elapsed between injury and primary wound closure. Knowledge of these risk factors can help physicians predict patient recovery and guide important management decisions.

It is well known that delaying surgical intervention by more than 24 hours increases the risk of endophthalmitis and reduced final visual acuity. In general, it has been determined that rapid surgical closure of an open globe injury promotes the best visual outcomes, and it is recommended that all open globe injuries be closed within 24 hours of injury.

Patients with open globe injuries are frequently transferred from community-based facilities to larger tertiary care hospitals for surgical intervention. The process of receiving, evaluating, and transferring a patient from an outside facility for definitive care inevitably results in a delay to surgical closure. While some of the effects of delaying globe repair by more than 24 hours have been investigated in prior studies, the effects of delaying closure by up to 24 hours are still unclear.

The purpose of this study by Fernandez et al was two-fold: (1) to determine the average delay in time between injury and primary repair of open globe patients that are transferred to a second trauma center before receiving surgical treatment as compared to patients that are not transferred, (2) to determine the final visual outcomes and incidence of postoperative complications in open globe injury patients that are transferred to a second trauma center for surgical repair as compared to patients that are not transferred.

This was a retrospective cohort study using data from UNC Hospitals trauma registry. Demographics, time of injury, final clinical outcomes, time to surgical intervention, and transfer history were extracted and analyzed. The study population includes open globe injury patients of all ages that were seen and treated at our institution from 2005 to 2020. Patients were divided based on transfer history. The transfer group consisted of patients who were transferred from an outside hospital to tertiary care facility for surgical treatment. The non-transfer group consisted of patients who arrived at tertiary care facility directly after injury.

In total, 238 open globe injuries were evaluated. Of those, 197 were transferred and 41 were not transferred. Compared to non-transfer patients, transfer patients had longer delays between injury and surgery, between presentation at the initial ED and surgery, and between injury and arrival at the tertiary care center. On average, the delay between injury and surgical intervention was 3 hours and 51 minutes longer for transfer patients compared to non-transfer patients. Eight patients in the transfer group were delayed >24 hours due to inter-hospital transfer. Additionally, transfer patients on average suffered from poorer final visual acuities, with an average final visual acuity of 1.84 logMAR in the transfer group and 1.35 logMAR in the non-transfer group.

It is widely accepted in the field of ophthalmology that open globe injuries should have primary closure within 24 hours of injury to prevent complications. This study shows that inter-hospital transfer within same state leads to a significant delay in primary closure of open globe injuries. Additionally, this study found that on average transferred patients had worse final visual acuities than their non-transferred counterparts. There was no difference in the incidence of enucleation or the need for additional surgeries between the two groups.

The study found that, on average, transfer subjects had worse final visual acuities than non-transfer subjects (p = 0.044). It is likely that the worse outcomes seen in the transfer group were the result of a variety of factors acting as mediators on final visual acuity. Possible mediators that may have influenced final visual outcomes in the transfer group include, but are not limited to, longer time from injury to surgical intervention, greater opportunity for non-medical globe manipulation with delayed closure, and longer travel distance for follow up appointments.

From these results, it can be hypothesized that open globe injuries with the greatest level of severity were most negatively affected by the process of inter-hospital transfer.

This study shows that inter-hospital transfer leads to an approximately 4-hour delay in surgical intervention for open globe injuries. In addition, the study found that transferred open globe injuries, on average, resulted in poorer final visual acuities. Many hospitals in this study transferred open globe patients despite having ophthalmology coverage or a closer Level I trauma center, which likely resulted in a delay to surgical intervention. Although the transferred subjects had worse final visual acuities in study, further investigation is required to rule out the possibility of OTS as a confounding variable. A larger, multi-center study that focuses on the effects of OTS on outcomes and accounts for the high variability between open globe cases is warranted to further our knowledge of trauma outcomes and time-tosurgery.

Source: Fernandez et al; Clinical Ophthalmology 2022:16

https://doi.org/10.2147/OPTH.S378049