1. Principal Investigator :Dr. Grace Nguyo
PATTERN AND OUTCOME OF POSTERIOR SEGMENT INJURIES AFTER OCULAR TRAUMA AT VITREORETINAL UNIT IN KIKUYU EYE HOSPITAL
Principal Investigator :Dr. Grace Nguyo
Supervisors:
Dr. Muchai Gachago
Dr. Njuguna Margaret
Dr. Jafferji Shafiq

2. Introduction
Ocular Trauma is injury to eye from mechanical trauma, chemical injury or radiation.1
Mechanical trauma the usual cause of trauma in post segment.
Posterior segment are injuries of:
Choroid
Vitreous
Retina and its blood vessels
Optic disc
IOFB in posterior segment
Can be a result of direct or indirect trauma
Blunt and penetrating injuries are causes of above injuries, blunt having better outcomes. 2
Posterior segment injuries carry a less favourable prognosis.2
1.bmj.com. Last accessed 25/05/2015
2. Sukati VN, Hansraj R. A retrospective analysis of eye injuries in rural KwaZulu-Natal , South Africa. 2012;71(4):86-94

3. Introduction
The Birmingham Eye Trauma Terminology (BETT) is used to define various eye injuries.3
Ocular Trauma Score (OTS) is used to predict final visual outcome.4
3. Kuhn F, Morris R, Witherspoon CD, Mester V. The Birmingham Eye Trauma Terminology system (BETT). J Fr Ophtalmol Feb;27(2):206–10.
4. Blanco Hernandez RMD LGV. Ocular trauma score at the initial evaluation of ocular trauma. Docstoc.com 2010;(78):209–13.
Kuhn F, Morris R, Witherspoon CD, Mester V. The Birmingham Eye Trauma Terminology system (BETT). J Fr Ophtalmol Feb;27(2):206–10.

4. Epidemiology 1.6 million people blind from eye injuries.5
In Kenya,2% of all ocular morbidity.6
In KNH, posterior vitreous, retina and optic nerve injuries account for 12.7% of all blunt trauma eye injuries.7
5.bmj.com. Last accessed 25/05/2015
6.National Strategic Plan For Eye Health and Blindness Prevention 2012 to 2018.p30.
7.Kikira S.,Sajabi SM. Ocular complications on blunt non perforating trauma in KNH: University of Nairobi MMed Thesis; 1992.

5. Management Observation Medical; AntiVGEF, intravitreal antibiotics
Surgical: PPV, Scleral buckle, cryopexy, laser or a combination of these.
Considerations in surgical repair include:
timing
presence of infection
other systemic complications.8
Ruiz- Moreno J.M, Ashok Garg. Clinical Diagnosis and Management of Ocular Trauma.1st ed. Jaypee Brothers Medical Publishers(P) Ltd;2009.p.65
High dose steroids for ON, intravitreal abx for Endophthalmitis ?vitrase for VH

6. Factors Determining Visual outcomes
Time interval between injury and visit to the hospital
Macula involvement
Initial visual acuity
Wound location: a more posterior wound having a poor visual outcome
Proliferative VitreoRetinopathy
OTS 9,10
9.Ying Qi F-YZ. Characteristics and visual outcomes of patients hospitalized for ocular trauma in central China: 2006–2011. Int J Ophthalmol – ;8(8(1)):162–8
10. Erdurman FC, , Sobaci G, Acikel CH, Ceylan MO, Durukan AH, et al. Anatomical and functional outcomes in contusion injuries of posterior segment. Eye Lond Engl Aug;25(8):1050–6.
PVR, optic nerve damage

7. Outcome after Management
Functional success: Final visual acuity of ≥ 20/100 (≥6/30) OR postoperative improvement in visual acuity of two lines on the Snellen Chart
Anatomic success is defined as eyes with attached retina and generally clear media,68-70% .11
Poor visual outcome: visual acuity of <20/ ,13
11.Warrasak S, Euswas A, Hongsakorn S. Posterior segment trauma: types of injuries, result of vitreo-retinal surgery and prophylactic broad encircling scleral buckle. J Med Assoc Thai. 2005;88(12)(88):1916–30.
12. Ersanli D, Sommez M. Management of retinal detachment due to closed globe injury by pars plana vitrectomy with and without scleral buckling. Retina. 2006;26(1)(January).
13. Erdurman FC, Erdurman FC, Sobaci G, Acikel CH, Ceylan MO, Durukan AH, et al. Anatomical and functional outcomes in contusion injuries of posterior segment. Eye Lond Engl Aug;25(8):1050–6.

8. Study Rationale
To provide information on outcome of posterior segment injuries in a standard vitreoretinal set up in our country
No similar studies done in Kenya
Providing baseline information in the region for future planning; e.g. equipment, training etc.
Ideal in terms of; cost to patient therefore affordable, VR equipment, VR surgeon. KEU has many patients referred to VR specialists
Planning on training, equipment of VR in our region

9. Objectives
Main Objective: To review the pattern and outcome of posterior segment injuries after ocular trauma as seen at the vitreoretinal unit at Kikuyu Eye Unit

10. Secondary objectives
To describe the cause and clinical presentation of posterior segment injuries
To describe types of interventions done
To determine outcomes after intervention
To describe factors that determine the visual outcome  

11. Study Design
Retrospective case series

12. Study Location
Kikuyu Eye Unit, part of Presbyterian Church of East Africa (P.C.E.A) Kikuyu Hospital
Referral hospital for vitreoretinal surgery for East African region
A UON Dept. of Ophthalmology collaborative centre
Patient seen /year in the whole eye unit
Estimated post segment pts; 5/month,(60/year) surgical management 2/month

13. Case Definition
Patient seen in KEU Vitreoretinal unit with ocular trauma involving posterior segment between January 2010 and December 2014.
Patient must have had a clear ocular media

14. Exclusion Criteria
Severe anterior segment injuries limiting posterior segment examination
Missing records

15. Flow of Data Collection
All Trauma Patients
Flow of Data Collection
Eliminate those with anterior segment injury only OR other injuries
Posterior segment OR Posterior and Anterior segment trauma patients
2. Eliminate those with missing records
Record demographic and clinical features

16. Outcome in BCVA at 1 wk,1 mo,6 mo and at final follow up
Management
Intervention
Observation
Medical
Surgical
Outcome in BCVA at 1 wk,1 mo,6 mo and at final follow up

17. Main Outcome Measures
Outcomes (visual acuity and anatomical) of patients with posterior segment trauma
Prognostic indicators of outcome

18. Study Materials Patients files from the records department at KEU
Theatre lists from KEU
Self-structured questionnaire
Excel data entry sheet

19. Personnel Principal investigator Theatre records in charge at KEU
Records clerk at KEU
Research assistants
Statistician

20. Sample Size Calculation
n' = sample size with finite population correction,
N = size of the target population = 150
Z = Z statistic for 95% level of confidence = 1.96
P = Estimated proportion of patients who achieved good visual acuity outcome after intervention= 71% (Erdurman et al, 2011) 13
d= margin of error = 5%
=102 eyes with posterior segment ocular injuries

21. Data Management and Analysis
Data entered into Ms Excel
Statistical Analysis with SPSS version 21.0.
Descriptive analysis: means/medians and percentages.
Determine the frequencies and proportions of the variables and present in tables and graphs

22. Data Management and Analysis
Chi square/ Fisher’s exact to test associations between the final BCVA visual outcome and initial VA
Odds ratios will be calculated for particular outcomes in the treatment groups
95% confidence interval for all tests

23. Ethical Consideration
Ethical permission from KNH/UON-ERC
Permission sought from the administrative heads of Kikuyu Eye Unit
Confidentiality:
Anonymity assured through use of coded questionnaires
Questionnaire accessible only to the investigators

24. Study Period Tasks Date
Proposal Preparation, Presentation and Department Approval
January 2015 to June 2015
Submission of Proposal for Ethical Approval
June 2015
Data Collection
September to October 2015
Data Analysis
November 2015
Report Writing
December 2015
Results Presentation
January 2016
Submission of Dissertation
February 2016

25. Study Period

26. Expected Study Limitations
Missing files
Combined anterior and posterior segment injuries making studying visual outcome not entirely due to posterior segment trauma