Trends in ocular injuries among major trauma patients in England and Wales from 2004 to 2021

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Major trauma demographics in the UK have changed but no contemporary studies report ocular injuries in this cohort. We aimed to investigate ocular injury epidemiology and trends amongst major trauma patients in England and Wales from 2004–2021. Methods A retrospective analysis of prospectively collected Trauma Audit and Research Network (TARN) registry data was conducted. Major trauma was defined as injury severity score > 15, and ocular injuries were identified using AIS codes. Demographics, injury profiles, and outcomes were extracted. Descriptive statistics and 3-yearly trend data are reported. Results Of 287 267 major trauma cases, 2368 (0.8%) had ocular injuries, decreasing significantly from 1.87% (2004/06) to 0.66% (2019/21) (P < 0.0001). Males comprised 72.2% and median age was 34.5 years which increased (p < 0.0001). Road traffic collisions declined from 43.1–25.3% of ocular injury cases while falls increased and became the predominant mechanism (37.6% in 2019/21). Nonaccidental injuries increased from 15% (2004/06) to 26.5% (2016/18) (p < 0.0001). Concomitant head injury was present in 86.6% of cases. Ophthalmic procedures increased from 1.2% (2004/06) to 5% (2019/21) (p < 0.0001). Compared to previous TARN data, retinal injuries increased 3-fold to 18.6% and corneal injuries decreased from 31–6.6%. Conclusions Identifying sight-threatening injuries in polytrauma is challenging. Ocular injury epidemiology has changed significantly, though overall incidence is low. These findings may inform guideline development, resource allocation, and training priorities. Health sciences/Diseases/Trauma Health sciences/Health care/Public health/Epidemiology Health sciences/Medical research/Epidemiology Figures Figure 1 Introduction Ocular trauma is a cause of impaired vision in 19 million individuals globally 1 and carries considerable economic burden 2, 3 . Eye injuries are common in polytraumatised patients and are associated with vision threatening pathology 4–8 . These injuries are often missed as primary surveys prioritise life threatening pathology and examination of the visual system in these patients, who are often unconscious or have concurrent periorbital injuries, is challenging 8–10 . Major trauma is defined by an injury severity score (ISS) of ≥ 16 and is associated with a 10% mortality 11, 12 . The epidemiology of major trauma in the UK has changed dramatically in recent decades. Older adults are emerging as the major demographic population and low falls are increasingly the predominant mechanism 13 . Improvements in outcomes have also been seen in these patients following the remodelling of major trauma care in England and Wales 14 . No recent epidemiological studies have investigated ocular trauma in this cohort in the UK. We carried out a retrospective study on a major UK trauma database to analyse epidemiology and trends in ocular injuries in major trauma patients from 2004 to 2021. Methods A registry-based study was conducted using data held by the Trauma Audit Research Network (TARN). TARN is a national trauma registry that aggregates and reports data for all trauma receiving hospitals in England and Wales. It includes patients who are admitted to hospital for ≥ 72 h, require critical care support, are transferred to a tertiary/specialist centre, or who die from their injuries and excludes patients aged > 65 years with an isolated fracture of the femoral neck or pubic ramus and those with single uncomplicated limb injuries. TARN records data up to 30 days of admission, or death, whichever occurred first. After a patient is identified for inclusion into TARN, a dataset of prospectively recorded variables is collated by local coordinators using a standard web-based case record form. Injury descriptions are generated from imaging, operative and necropsy reports, and all injuries are then coded centrally using the Abbreviated Injury Scale (AIS) which is an anatomical-based coding system that also grades the severity of each injury on a six-point scale, AIS 1 describes minor injuries and AIS 6 describes injuries which are incompatible with life 15 . The ISS is then calculated by adding the squares of the highest scoring injury from the three most injured body regions. ISS is used to grade the overall injury severity and cases with an ISS of 16 or more are considered major trauma. We included major trauma cases from 2004 to 2021 with any AIS codes relating to eye injuries or injuries to the second, third, fourth or sixth cranial nerves. Orbital fractures and adnexal injuries (other than tear duct lacerations) were not counted as ocular injuries and were instead coded as facial injuries. Eyelid injuries were also not included as these are not coded by the AIS. Extracted data for each patient included demographic information, a complete injury profile, hospital course, and mortality. Data were summarised for each 3-year window, e.g. 2004–2006, and trends were analysed using the Jonckheere-Terpstra test and the Chi square test for trend, for numerical and categorical data as appropriate. Ocular injuries were anatomically classified and tabulated, each injury was counted separately such that a case may include more than one injury per eye. Missing data were not included in analyses. A two-sided p-value of 0.05 was considered statistically significant. Analyses were carried out using R version 4.1.1 (R Core Team 2022) 16 . TARN analyses anonymised data with permissions granted by the Health Research Authority Clinical Advisory Group (CAG–PIAG Section 251). This project was registered within TARN (Project ID INC-117). Results TARN included 287 267 cases of major trauma between 2004 and 2021 (Fig. 1 ). 2368 (0.8%) had eye injuries and this proportion decreased from 1.87% in 2004/06 to 0.66% in 2019/21 (p < 0.0001) (Table 1 ). Males comprised 72.2% of eye injury cases and the median age was 34.5 years which increased (τb = 0.079, P < 0.0001). 93.9% of injuries were due to blunt trauma. The median ISS was 26 and mortality was 15.1% which remained stable over the 18-year period. Table 1 Table 1 : TARN population England & Wales with ocular injuries- 2004–2021 2004/06 2007/09 2010/12 2013/15 2016/18 2019/21 Total p-value Total 167 (1.87%) 180 (1.26%) 365 (1.03) 465 (0.78%) 611 (0.78%) 580 (0.66%) 2368 (0.82%) < 0.0001** Age, median (IQR†) 34.5 (12.7–45.9) 30.2 (18.1–48) 28.7 (1.1–53.4) 32.1 (0.5–60.2) 34.9 (0.7–64.1) 40 (19.8–66.3) 34.5 (3–59.5) < 0.0001* Male, n (%) 136 (81.4%) 138 (76.7%) 270 (74%) 345 (74.2%) 412 (67.4%) 409 (70.5%) 1710 (72.2%) 0.003** GCS††, median (IQR) 14 (7–15) 14 (9–15) 14 (8–15) 14 (8–15) 14 (9–15) 14 (8–15) 14 (8–15) 0.075* ISS†††, median(IQR) 26 (19–29) 26 (19–34) 26 (20–30) 27 (21–33) 27 (21–33) 27 (21–33) 26 (21–33) < 0.0001* Mechanism of injury RTC 72 (43.1%) 85 (47.2%) 122 (33.4%) 121 (26%) 156 (25.5%) 147 (25.3%) 703 (29.7%) 2m 15 (9%) 21 (11.7%) 37 (10.1%) 45 (9.7%) 51 (8.3%) 72 (12.4%) 241 (10.2%) Fall < 2m 12 (7.2%) 10 (5.6%) 45 (12.3%) 75 (16.1%) 115 (18.8%) 146 (25.2%) 403 (17%) Other 30 (18%) 19 (10.6%) 24 (6.6%) 48 (10.3%) 54 (8.8%) 56 (9.7%) 231 (9.8%) NAI under 16yrs 25 (15%) 25 (13.9%) 78 (21.4%) 126 (27.1%) 162 (26.5%) 94 (16.2%) 510 (21.5%) Assault 13 (7.8%) 20 (11.1%) 59 (16.2%) 50 (10.8%) 73 (11.9%) 65 (11.2%) 280 (11.8%) Injury type Blunt 153 (91.6%) 168 (93.3%) 338 (92.6%) 441 (94.8%) 575 (94.1%) 548 (94.5%) 2223 (93.9%) 0.581** Penetrating 14 (8.4%) 12 (6.7%) 27 (7.4%) 24 (5.2%) 36 (5.9%) 32 (5.5%) 145 (6.1%) Concomitant serious injuries: n (%) Head AIS3+ 138 (82.6%) 149 (82.8%) 322 (88.2%) 410 (88.2%) 525 (85.9%) 506 (87.2%) 2050 (86.6%) 0.238** Face AIS 3+ 30 (18%) 41 (22.8%) 29 (7.9%) 23 (4.9%) 32 (5.2%) 42 (7.2%) 197 (8.3%) < 0.0001** Chest AIS 3+ 44 (26.3%) 54 (30%) 112 (30.7%) 139 (29.9%) 156 (25.5%) 171 (29.5%) 676 (28.5%) 0.443** Abdomen AIS3+ 11 (6.6%) 9 (5%) 19 (5.2%) 19 (4.1%) 31 (5.1%) 22 (3.8%) 111 (4.7%) 0.665** Spine AIS3+ 6 (3.6%) 13 (7.2%) 15 (4.1%) 45 (9.7%) 94 (15.4%) 58 (10%) 231 (9.8%) < 0.0001** Pelvis AIS3+ 11 (6.6%) 19 (10.6%) 17 (4.7%) 15 (3.2%) 25 (4.1%) 21 (3.6%) 108 (4.6%) 0.001** Limb AIS3+ 18 (10.8%) 25 (13.9%) 29 (7.9%) 53 (11.4%) 60 (9.8%) 43 (7.4%) 228 (9.6%) 0.071** Interventions Any operation, n (%) 59 (35.3%) 82 (45.6%) 132 (36.2%) 161 (34.6%) 202 (33.1%) 218 (37.6%) 854 (36.1%) 0.063** Time to any operation (hours), median (IQR) 9 (2.7–30.6) 18.6 (4.7–89) 8.6 (3.8–31.4) 16.3 (3.4–71.1) 14.5 (3.1–59.6) 13.1 (4.4–37) 13.2 (3.6–47) 0.744* Eye operation, n (%) 2 (1.2%) 1 (0.6%) 6 (1.6%) 21 (4.5%) 43 (7%) 29 (5%) 102 (4.3%) < 0.0001** Time to eye operation (hours), median (IQR) 58.8 (58.8–58.8) 145 (145–145) 3.6 (2.7–8.6) 18.2 (11.7–51.9) 13.3 (4.7–23) 17.2 (7.1–34.5) 15.4 (5.5–32.7) 0.845* Outcome Mortality 18 (13.2%) 13 (8.8%) 37 (14.1%) 58 (17.5%) 67 (14.9%) 74 (16.6%) 267 (15.1%) 0.193** LOS (days) median (IQR) 11 (5–25) 12 (5.5–24) 11 (4–21) 10 (4–20) 9 (4–22) 9 (4–19) 10 (4–21) 0.002* †IQR Interquartile range; †† GCS: Glasgow Coma scale; †††ISS: Injury severity score *Jonckheere-Terpstra test; ** Chi square for trend Road traffic collisions (RTCs) were the most common mechanism of major trauma involving ocular injury in 2004/06 accounting for 43.1% of cases but significantly decreased to 25.3% by 2019/21. Conversely, falls increased significantly and, by 2019/21, were the most common mechanism of injury (37.6%). Low falls (< 2 metres) comprised the majority of these (25.2%). Nonaccidental injuries in children under 16 also increased significantly and accounted for as much as 26.5% of cases during 2016/18. Head and chest trauma comprised the most common serious (AIS 3+) concomitant injuries. These were present in 86.6% and 29.5% of cases respectively and remained stable over the period. Serious facial injuries were present in 18% of cases in 2004/06 and more than halved to 7.2% by 2019/21. 4.3% of patients required an eye operation and this increased over time (P < 0.0001) while the proportion of patients requiring any surgical intervention was 36.1% and remained stable. Median time to ophthalmic surgery was 15.4 hours which was similar to the 13.2 hours for any operation. The most common injuries were to the conjunctiva (29.4%), retina (18.6%) and sclera (12.8%) (Fig. 1 ). Optic nerve injuries were present in 8.6% of cases and cranial nerves III, IV, and VI were damaged in 8.6%, 2.4% and 5.5% of patients respectively. Missingness was only seen in Glasgow Coma Scale measurements (n = 294, 12.4%). All other variables were complete for all cases. Discussion We present contemporary data, from a large national registry, for ocular injuries in the setting of major trauma in England and Wales. Ocular injuries occurred in 0.8% of patients with major trauma which is lower than other studies which report rates between 2.3% and 16% 4–8 . This can be partially explained as adnexal injuries and orbital fractures were not classified as ocular injuries in our cohort, whereas they were included in other studies. The prevalence of ocular injuries in this cohort decreased over the 18 year period and was less than the 2.3% reported in a historical (1989–2004) study of TARN data using identical case ascertainment criteria. 6 This apparent decline in ocular injuries is likely multifactorial and may be partially explained by nation-wide shifts in injury mechanisms in major trauma 13 . Additionally, this may represent a relative decrease in proportion of ocular injuries as there has been an overall improvement in identifying and classifying major trauma owing to the now widespread use of CT scanning 13, 17 . The demographics of major trauma have changed significantly in recent decades. Patients are older and are commonly suffering injuries second to low falls 13 , and this is reflected in our data. RTCs, while historically the predominant mechanism, only accounted for 25.3% of cases in 2019/21 and this may account for the reduction in patients with concomitant facial and pelvic injuries in our cohort as these are commonly associated with RTCs 18 . Similar changes in demographics and injury mechanism have also been demonstrated in ocular injury not associated with major trauma in American and Taiwanese populations 19, 20 . It has been suggested that older patients are at an increased risk of eye injury due to globe weakness second to previous ocular surgery 21 . Falls in this age group are associated with ocular contusions, eyelid lacerations, and open globe injuries 22, 23 and better understanding of falls related injury will enable improved recognition and management of ocular trauma in a demographic which is projected to continue to increase 24 . Head injury is reported in around a quarter of major trauma cases 25 and was the most common serious (AIS 3+) concomitant injury in this study, present in 86.7% of ocular trauma. The relationship between eye injury and head trauma is well described with ocular injuries present in 2.2–25.3% of these patients 26, 27 . Head injuries are most caused by RTCs and anterior segment injuries are commonly reported resulting from direct impact on the frontal bones and orbital margins 27 . Neuro-ophthalmic injuries are also reported and principally comprise traumatic ocular motor nerve palsies 27 . Identification of eye injuries in this cohort, however, is challenging, notably in the acute setting when patients may be agitated or unconscious. Ocular assessment in primary surveys, which prioritise recognising life-threatening injuries, is limited to assessing eye-opening and the identification of nerve palsies and which act as indicators of brain injury severity and are predictive of mortality 28 . A significant and increasing proportion of cases were children who had suffered injuries second to nonaccidental trauma. TARN do not report any concurrent increase in suspected physical abuse or assault in children with major trauma over the study period 29 . The reasons for this trend are unclear but may be due to an increased recognition and reporting of nonaccidental injury in children with eye injuries as up-to-date guidance is developed 30, 31 and reporting mechanisms are established 32 . Ocular pathologies are common in child abuse and may be varied in their presentation 33 . Retinal haemorrhages have been shown to have a high sensitivity and specificity for nonaccidental injuries in infants and, when accompanied with intracranial injuries, are pathognomonic 34 . The most common injuries were sustained to the conjunctiva (29.4%), retina (18.6%) and sclera (12.8%), while injury distributions were not analysed temporally, these can be compared with historical TARN data from 1989 to 2004 6 . Corneal injuries comprised 31% of injuries historically but only 6.6% in our contemporary cohort; this may be related to the decreased proportion of RTCs as an injury mechanism as these injuries are often associated with airbag deployment 35, 36 . Further, retinal injuries contributed to 5.9% of injuries historically and this seems to have increased threefold. Traumatic retinopathy is associated with high velocity blunt trauma 37 and this may represent the increase in patients surviving high-speed RTCs second to improvements in car crash safety mechanisms. Such injuries commonly include retinal tears and detachments for which urgent surgery is indicated 38 . An increase in traumatic retinopathy may contribute to trends seen in ophthalmic procedures which increased fourfold over the study period. While optic nerve and retinal injuries are often vision threatening, we do not report visual outcome data for cases. Amongst major trauma victims, those with lid lacerations, open globe injuries and optic nerve injuries are reported to have the worst visual outcomes 4, 5 . Clinically, the Ocular Trauma Score is a tool used to predict functional outcome after eye injury 39 and has been validated in patients with major trauma 4 , however its parameters include initial visual acuity and presence of afferent pupillary defect, which are challenging to ascertain in patients with impaired cognition, and periorbital swelling respectively 9 . For cases of suspected ocular nerve trauma, flash visually evoked potentials have also been used to assess nerve function in these patients and are highly predictive of final visual outcome 40 . The identification and management of ocular trauma in the multiply injured patient remains a challenge for emergency clinicians however excellent guidance has been published on the topic 9 . Advanced Trauma Life Support principles should be followed for all major trauma patients 41, 42 . Visual pathways injuries should be screened for in patients with head or facial trauma and early surveys should arguably be able to exclude a sight-threatening injury requiring emergent management, such as retrobulbar haemorrhage, even in unresponsive patients 9 . CT scanning, which is now standard in polytrauma, is sensitive and specific for many types of eye injuries and ocular and orbital CT should be undertaken in all patients with clinical suspicion 43 . Ophthalmology specialist opinion should be sought in all patients with at risk of visual pathology as important, sight saving intervention might be required. Strengths and limitations TARN captures data from every trauma receiving NHS hospital in England and Wales and best practice tariffs ensure high case ascertainment and completeness, and as such, the data reported are representative. However, as a big data source, there are missing data and these may differ systemically from those that are included. Additionally, patients in whom these injuries are identified or managed out with the TARN data collection period, or who are transferred to other hospitals after acute management of major trauma, are not included. This may represent a significant proportion of patients as detailed ocular assessment may not be possible in the early phase of admission. There are also limitations associated with the usage of a non-ophthalmic trauma registry. Injury data are reported as anatomical location and injury type (blunt vs penetrating) and these do not carry the same clinical relevance as specialised classifications such as the Birmingham Eye Trauma Terminology System which is widely used 44 . Further, important prognostic information such as visual acuity and the presence or absence of relative afferent pupillary defect are not recorded. Registries which are specialised for ophthalmic pathologies collect and code clinically relevant data and generally avoid these limitations. Examples of these include the Research in Sight (IRIS®) Registry which was established in 2014 and has produced important data with outcomes not routinely recorded in trauma registries 45–47 , and more recently, the International Globe and Adnexal Trauma Epidemiology Study (IGATES) Registry which has been established as an specialist registry with a focus on ocular trauma 48 . In conclusion, we report information about the trends of ocular trauma, in England and Wales, over an 18-year period. Ocular injuries are present in 0.8% of cases of major trauma and the most common concomitant injuries are to the head. RTCs are no longer the dominant mechanism of injury, which is increasingly being overtaken by falls, a pattern which mirrors major trauma trends across the UK. Fewer patients seem be suffering corneal injuries, there has been an increase in retinal injuries and those undergoing ophthalmic surgery. The findings of this study are important for health providers across the United Kingdom and may inform guideline development, resource allocation and training priorities. Declarations Acknowledgements We would like to thank TARN for collating and providing the data utilised in this study. Conflict of Interest The authors declare that they have no conflict of interest. Funding Statement This study was not funded. References Négrel AD, Thylefors B. The global impact of eye injuries. Ophthalmic epidemiology 1998; 5 (3) : 143-169. Schein OD, Hibberd PL, Shingleton BJ, Kunzweiler T, Frambach DA, Seddon JM et al. The spectrum and burden of ocular injury. Ophthalmology 1988; 95 (3) : 300-305. Iftikhar M, Junaid N, Lemus M, Mallick ZN, Mina SA, Hannan U et al. Epidemiology of Primary Ophthalmic Inpatient Admissions in the United States. American journal of ophthalmology 2018; 185: 101-109. Park J, Yang SC, Choi HY. Epidemiology and Clinical Patterns of Ocular Trauma at a Level 1 Trauma Center in Korea. Journal of Korean medical science 2021; 36 (1) : e5. Poon A, McCluskey PJ, Hill DA. Eye injuries in patients with major trauma. The Journal of trauma 1999; 46 (3) : 494-499. Guly CM, Guly HR, Bouamra O, Gray RH, Lecky FE. Ocular injuries in patients with major trauma. Emergency medicine journal : EMJ 2006; 23 (12) : 915-917. Sastry SM, Paul BK, Bain L, Champion HR. Ocular trauma among major trauma victims in a regional trauma center. The Journal of trauma 1993; 34 (2) : 223-226. Georgouli T, Pountos I, Chang BY, Giannoudis PV. Prevalence of ocular and orbital injuries in polytrauma patients. European journal of trauma and emergency surgery : official publication of the European Trauma Society 2011; 37 (2) : 135-140. Perry M, Moutray T. Advanced Trauma Life Support (ATLS) and facial trauma: can one size fit all? Part 4: 'can the patient see?' Timely diagnosis, dilemmas and pitfalls in the multiply injured, poorly responsive/unresponsive patient. International journal of oral and maxillofacial surgery 2008; 37 (6) : 505-514. Soni KG, Eustace P. Missed ocular perforations after road traffic accidents. Injury 1972; 4 (1) : 79-80. Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method. Trauma Score and the Injury Severity Score. The Journal of trauma 1987; 27 (4) : 370-378. Yates DW. ABC of major trauma. Scoring systems for trauma. BMJ (Clinical research ed) 1990; 301 (6760) : 1090-1094. Kehoe A, Smith JE, Edwards A, Yates D, Lecky F. The changing face of major trauma in the UK. Emergency medicine journal : EMJ 2015; 32 (12) : 911-915. Moran CG, Lecky F, Bouamra O, Lawrence T, Edwards A, Woodford M et al. Changing the System - Major Trauma Patients and Their Outcomes in the NHS (England) 2008-17. EClinicalMedicine 2018; 2-3: 13-21. Loftis KL, Price J, Gillich PJ. Evolution of the Abbreviated Injury Scale: 1990–2015. Traffic Injury Prevention 2018; 19 (sup2) : S109-S113. R: A language and environment for statistical computing. . R Foundation for Statistical Computing.: Vienna, Austria; 2022. Huber-Wagner S, Lefering R, Qvick LM, Körner M, Kay MV, Pfeifer KJ et al. Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet (London, England) 2009; 373 (9673) : 1455-1461. Nóbrega LM, Cavalcante GM, Lima MM, Madruga RC, Ramos-Jorge ML, d'Avila S. Prevalence of facial trauma and associated factors in victims of road traffic accidents. The American journal of emergency medicine 2014; 32 (11) : 1382-1386. Chang YS, Teng YT, Huang YH, Liu ML, Hung JH, Hsu SM et al. Major ocular trauma in Taiwan: 2002-2004 versus 2012-2014. Scientific reports 2018; 8 (1) : 7081. Iftikhar M, Latif A, Farid UZ, Usmani B, Canner JK, Shah SMA. Changes in the Incidence of Eye Trauma Hospitalizations in the United States From 2001 Through 2014. JAMA ophthalmology 2019; 137 (1) : 48-56. Andreoli MT, Andreoli CM. Geriatric traumatic open globe injuries. Ophthalmology 2011; 118 (1) : 156-159. Usmani B, Latif A, Iftikhar M, Sepah YJ, Parker C, Fliss JA et al. Eye trauma in falls presenting to the emergency department from 2006 through 2015. The British journal of ophthalmology 2021; 105 (2) : 198-204. Ying Fong YY, Yu M, Young AL, Jhanji V. Presentation and Management Outcomes of Corneal and Scleral Perforations in Geriatric Nursing Home Residents. Medicine 2015; 94 (36) : e1518-1510. Hartholt KA, Stevens JA, Polinder S, van der Cammen TJ, Patka P. Increase in fall-related hospitalizations in the United States, 2001-2008. The Journal of trauma 2011; 71 (1) : 255-258. Mohamed A, Mulcaire J, Clover AJP. Head and neck injury in major trauma in Ireland: a multicentre retrospective analysis of patterns and surgical workload. Irish Journal of Medical Science (1971 -) 2021; 190 (1) : 395-401. Huckhagel T, Regelsberger J, Westphal M, Nüchtern J, Lefering R. Damage to the eye and optic nerve in seriously traumatized patients with concomitant head injury: analysis of 84,627 cases from the TraumaRegister DGU® between 2002 and 2015. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2020; 28 (1) : 15. Odebode TO, Ademola-Popoola DS, Ojo TA, Ayanniyi AA. Ocular and visual complications of head injury. Eye 2005; 19 (5) : 561-566. Kulkarni AR, Aggarwal SP, Kulkarni RR, Deshpande MD, Walimbe PB, Labhsetwar AS. Ocular manifestations of head injury: a clinical study. Eye 2005; 19 (12) : 1257-1263. Fisher R, Coats T, Davis N, Davies P, Duane L, Edwards A et al. England and Wales: Severe Injury in Children January 2017 - December 2018 2019. NICE. Child maltreatment: when to suspect maltreatment in under 18s. Available at: https://www.nice.org.uk/guidance/cg89. RCOphth. Abusive Head Trauma and the Eye in Infancy. Available at: https://www.rcophth.ac.uk/resources-listing/abusive-head-trauma-and-the-eye-in-infancy/. NICE. Child abuse and neglect. Available at: https://www.nice.org.uk/guidance/ng76/chapter/Recommendations. Paul AR, Adamo MA. Non-accidental trauma in pediatric patients: a review of epidemiology, pathophysiology, diagnosis and treatment. Translational pediatrics 2014; 3 (3) : 195-207. Eisenbrey AB. Retinal hemorrhage in the battered child. Child's brain 1979; 5 (1) : 40-44. Armstrong GW, Chen AJ, Linakis JG, Mello MJ, Greenberg PB. Motor vehicle crash-associated eye injuries presenting to U.S. emergency departments. The western journal of emergency medicine 2014; 15 (6) : 693-700. Duma SM, Jernigan MV, Stitzel JD, Herring IP, Crowley JS, Brozoski FT et al. The effect of frontal air bags on eye injury patterns in automobile crashes. Archives of ophthalmology (Chicago, Ill : 1960) 2002; 120 (11) : 1517-1522. Liu X, Wang L, Wang C, Sun G, Liu S, Fan Y. Mechanism of traumatic retinal detachment in blunt impact: a finite element study. Journal of biomechanics 2013; 46 (7) : 1321-1327. Cooling RJ. Traumatic retinal detachment--mechanisms and management. Transactions of the ophthalmological societies of the United Kingdom 1986; 105 ( Pt 5): 575-579. Kuhn F, Maisiak R, Mann L, Mester V, Morris R, Witherspoon CD. The Ocular Trauma Score (OTS). Ophthalmology clinics of North America 2002; 15 (2) : 163-165, vi. Mohammed MA, Mossallam E, Allam IY. The Role of the Flash Visual Evoked Potential in Evaluating Visual Function in Patients with Indirect Traumatic Optic Neuropathy. Clinical ophthalmology (Auckland, NZ) 2021; 15: 1349-1355. Perry MJ, Moutray T. Advanced trauma life support (ATLS®): the ninth edition. The journal of trauma and acute care surgery 2013; 74 (5) : 1363-1366. Kruse C, Bruce JL, Bekker W, Clarke DL. The management of ocular and peri-ocular trauma needs to be co-ordinated according to ATLS principles and requires multi-disciplinary collaboration. Injury 2021; 52 (9) : 2606-2610. Wang D, Rizzuti A. Eye Trauma Imaging. StatPearls. StatPearls Publishing Copyright © 2022, StatPearls Publishing LLC.: Treasure Island (FL); 2022. Kuhn F, Morris R, Witherspoon CD, Mester V. The Birmingham Eye Trauma Terminology system (BETT). Journal francais d'ophtalmologie 2004; 27 (2) : 206-210. IRIS Registry. Available at: https://www.aao.org/iris-registry. Tomaiuolo M, Woreta FA, Li A, Yonekawa Y, Zhang QE, Sharpe JE et al. Open-Globe Injury Repairs in the American Academy of Ophthalmology IRIS® Registry 2014 through 2018: Incidence, Risk Factors, and Visual Outcomes. Ophthalmology 2023. Batchelor A, Lacy M, Hunt M, Lu R, Lee AY, Lee CS et al. Predictors of Long-term Ophthalmic Complications after Closed Globe Injuries Using the Intelligent Research in Sight (IRIS®) Registry. Ophthalmology science 2023; 3 (1) : 100237. Ng SMS, Low R, Hoskin AK, Rousselot A, Gunasekeran DV, Natarajan S et al. The application of clinical registries in ophthalmic trauma-the International Globe and Adnexal Trauma Epidemiology Study (IGATES). Graefe's archive for clinical and experimental ophthalmology = Albrecht von Graefes Archiv fur klinische und experimentelle Ophthalmologie 2022; 260 (4) : 1055-1067. Additional Declarations There is no conflict of interest Cite Share Download PDF Status: Published Journal Publication published 24 May, 2024 Read the published version in Eye → Version 1 posted Editorial decision: revise 02 Jan, 2024 Review # 2 received at journal 25 Dec, 2023 Reviewer # 2 agreed at journal 21 Dec, 2023 Review # 1 received at journal 21 Dec, 2023 Reviewer # 1 agreed at journal 19 Dec, 2023 Reviewers invited by journal 19 Dec, 2023 Editor assigned by journal 15 Dec, 2023 Submission checks completed at journal 20 Nov, 2023 First submitted to journal 19 Nov, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3634731","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":261155395,"identity":"caeb7c9e-76c3-4622-8ef1-884cf74f3ac7","order_by":0,"name":"Mohammed Bashir","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3UlEQVRIiWNgGAWjYFACHgYGxgYJBn725gNAnoQMYR1sUC2SPccSQFp4iNXCwGBww8cAaikBoDu/9+DHnzss8g1u8Hx+daPGgoeB/fDRDfi0mB3jS5bmPSNhOfN27zbrnGNAh/Gkpd3Ar4XHQJqxTcKA787ZbcY5bEAtEjxmhLQY//wJ1MJwI+eZcc4/4rSYSfACtQjcyGF+nNtGlJa8NGuQFmAgmzHn9knwsBH0y+Gzh2/+bKszAEbl48853+rk+NkPH8OrBRmwSYBJYpWDAPMHUlSPglEwCkbByAEAX2FHBItIgTkAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0002-1661-2373","institution":"University of Cambridge","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"","lastName":"Bashir","suffix":""},{"id":261155396,"identity":"c3b70134-78e2-434e-b2bf-eaa3d5207e8e","order_by":1,"name":"Omar Bouamra","email":"","orcid":"","institution":"","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Omar","middleName":"","lastName":"Bouamra","suffix":""},{"id":261155397,"identity":"79160783-fc69-4fbf-81fc-862d411d19ce","order_by":2,"name":"James Kirwan","email":"","orcid":"","institution":"Portsmouth Hospitals NHS Trust","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"James","middleName":"","lastName":"Kirwan","suffix":""},{"id":261155398,"identity":"9bbaaeda-ad21-44c3-b2f6-92fc63e60a29","order_by":3,"name":"Fiona Lecky","email":"","orcid":"","institution":"","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Fiona","middleName":"","lastName":"Lecky","suffix":""},{"id":261155399,"identity":"592cf65e-381d-46e7-ba43-900d1d504e67","order_by":4,"name":"Rupert Bourne","email":"","orcid":"","institution":"Cambridge University Hospitals","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Rupert","middleName":"","lastName":"Bourne","suffix":""}],"badges":[],"createdAt":"2023-11-19 13:10:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3634731/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3634731/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41433-024-03116-y","type":"published","date":"2024-05-24T04:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":48688550,"identity":"b3b5c579-560c-4e67-976c-53fb25dfb5fb","added_by":"auto","created_at":"2023-12-22 16:11:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":55511,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePRISMA Flow Diagram Showing Case Ascertainment and Ocular Injury Distribution from TARN 2004 - 2021\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e†ISS: Injury severity score; ††NFS: Injury Not Further Specified\u003c/p\u003e\n\u003cp\u003e*Total eye injury N=3205, patients can have more than one eye injury and more than one injury per eye\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3634731/v1/19f7df7cae496b7d21fe8ac4.png"},{"id":57125262,"identity":"663633a2-be9f-424d-9d72-54c289fbbe7e","added_by":"auto","created_at":"2024-05-25 07:08:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":683371,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3634731/v1/5a401f76-3f0d-4219-9ebf-cf5e127d0e9b.pdf"}],"financialInterests":"There is no conflict of interest","formattedTitle":"Trends in ocular injuries among major trauma patients in England and Wales from 2004 to 2021","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOcular trauma is a cause of impaired vision in 19\u0026nbsp;million individuals globally\u003csup\u003e1\u003c/sup\u003e and carries considerable economic burden\u003csup\u003e2, 3\u003c/sup\u003e. Eye injuries are common in polytraumatised patients and are associated with vision threatening pathology\u003csup\u003e4\u0026ndash;8\u003c/sup\u003e. These injuries are often missed as primary surveys prioritise life threatening pathology and examination of the visual system in these patients, who are often unconscious or have concurrent periorbital injuries, is challenging\u003csup\u003e8\u0026ndash;10\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eMajor trauma is defined by an injury severity score (ISS) of \u0026ge;\u0026thinsp;16 and is associated with a 10% mortality\u003csup\u003e11, 12\u003c/sup\u003e. The epidemiology of major trauma in the UK has changed dramatically in recent decades. Older adults are emerging as the major demographic population and low falls are increasingly the predominant mechanism\u003csup\u003e13\u003c/sup\u003e. Improvements in outcomes have also been seen in these patients following the remodelling of major trauma care in England and Wales\u003csup\u003e14\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eNo recent epidemiological studies have investigated ocular trauma in this cohort in the UK. We carried out a retrospective study on a major UK trauma database to analyse epidemiology and trends in ocular injuries in major trauma patients from 2004 to 2021.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA registry-based study was conducted using data held by the Trauma Audit Research Network (TARN). TARN is a national trauma registry that aggregates and reports data for all trauma receiving hospitals in England and Wales. It includes patients who are admitted to hospital for \u0026ge;\u0026thinsp;72 h, require critical care support, are transferred to a tertiary/specialist centre, or who die from their injuries and excludes patients aged\u0026thinsp;\u0026gt;\u0026thinsp;65 years with an isolated fracture of the femoral neck or pubic ramus and those with single uncomplicated limb injuries. TARN records data up to 30 days of admission, or death, whichever occurred first.\u003c/p\u003e \u003cp\u003eAfter a patient is identified for inclusion into TARN, a dataset of prospectively recorded variables is collated by local coordinators using a standard web-based case record form. Injury descriptions are generated from imaging, operative and necropsy reports, and all injuries are then coded centrally using the Abbreviated Injury Scale (AIS) which is an anatomical-based coding system that also grades the severity of each injury on a six-point scale, AIS 1 describes minor injuries and AIS 6 describes injuries which are incompatible with life\u003csup\u003e15\u003c/sup\u003e. The ISS is then calculated by adding the squares of the highest scoring injury from the three most injured body regions. ISS is used to grade the overall injury severity and cases with an ISS of 16 or more are considered major trauma.\u003c/p\u003e \u003cp\u003eWe included major trauma cases from 2004 to 2021 with any AIS codes relating to eye injuries or injuries to the second, third, fourth or sixth cranial nerves. Orbital fractures and adnexal injuries (other than tear duct lacerations) were not counted as ocular injuries and were instead coded as facial injuries. Eyelid injuries were also not included as these are not coded by the AIS. Extracted data for each patient included demographic information, a complete injury profile, hospital course, and mortality.\u003c/p\u003e \u003cp\u003eData were summarised for each 3-year window, e.g. 2004\u0026ndash;2006, and trends were analysed using the Jonckheere-Terpstra test and the Chi square test for trend, for numerical and categorical data as appropriate. Ocular injuries were anatomically classified and tabulated, each injury was counted separately such that a case may include more than one injury per eye. Missing data were not included in analyses. A two-sided p-value of 0.05 was considered statistically significant. Analyses were carried out using R version 4.1.1 (R Core Team 2022)\u003csup\u003e16\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTARN analyses anonymised data with permissions granted by the Health Research Authority Clinical Advisory Group (CAG\u0026ndash;PIAG Section 251). This project was registered within TARN (Project ID INC-117).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTARN included 287 267 cases of major trauma between 2004 and 2021 (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). 2368 (0.8%) had eye injuries and this proportion decreased from 1.87% in 2004/06 to 0.66% in 2019/21 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Males comprised 72.2% of eye injury cases and the median age was 34.5 years which increased (τb\u0026thinsp;=\u0026thinsp;0.079, P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). 93.9% of injuries were due to blunt trauma. The median ISS was 26 and mortality was 15.1% which remained stable over the 18-year period.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e: TARN population England \u0026amp; Wales with ocular injuries- 2004\u0026ndash;2021\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2004/06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2007/09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2010/12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2013/15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2016/18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2019/21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e167 (1.87%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e180 (1.26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e365 (1.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e465 (0.78%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e611 (0.78%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e580 (0.66%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2368 (0.82%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001** \u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, median (IQR\u0026dagger;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34.5 (12.7\u0026ndash;45.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.2 (18.1\u0026ndash;48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.7 (1.1\u0026ndash;53.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32.1 (0.5\u0026ndash;60.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e34.9 (0.7\u0026ndash;64.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e40 (19.8\u0026ndash;66.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e34.5 (3\u0026ndash;59.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e136 (81.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e138 (76.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e270 (74%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e345 (74.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e412 (67.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e409 (70.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1710 (72.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.003**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGCS\u0026dagger;\u0026dagger;, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (7\u0026ndash;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (9\u0026ndash;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (8\u0026ndash;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14 (8\u0026ndash;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14 (9\u0026ndash;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14 (8\u0026ndash;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e14 (8\u0026ndash;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.075*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eISS\u0026dagger;\u0026dagger;\u0026dagger;, median(IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (19\u0026ndash;29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (19\u0026ndash;34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26 (20\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27 (21\u0026ndash;33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27 (21\u0026ndash;33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e27 (21\u0026ndash;33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e26 (21\u0026ndash;33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eMechanism of injury\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRTC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72 (43.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85 (47.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e122 (33.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e121 (26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e156 (25.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e147 (25.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e703 (29.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFall\u0026thinsp;\u0026gt;\u0026thinsp;2m\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (11.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37 (10.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45 (9.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e51 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e72 (12.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e241 (10.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFall\u0026thinsp;\u0026lt;\u0026thinsp;2m\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (7.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (5.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45 (12.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e75 (16.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e115 (18.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e146 (25.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e403 (17%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (10.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (6.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48 (10.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e54 (8.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e56 (9.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e231 (9.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNAI under 16yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (13.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e78 (21.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e126 (27.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e162 (26.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e94 (16.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e510 (21.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssault\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (7.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (11.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59 (16.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50 (10.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e73 (11.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e65 (11.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e280 (11.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eInjury type\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlunt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e153 (91.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e168 (93.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e338 (92.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e441 (94.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e575 (94.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e548 (94.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2223 (93.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.581**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePenetrating\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (8.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (6.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (7.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24 (5.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e36 (5.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e32 (5.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e145 (6.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eConcomitant serious injuries: n (%)\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHead AIS3+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e138 (82.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e149 (82.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e322 (88.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e410 (88.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e525 (85.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e506 (87.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2050 (86.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.238**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFace AIS 3+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (22.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29 (7.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23 (4.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32 (5.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e42 (7.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e197 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChest AIS 3+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (26.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54 (30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e112 (30.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e139 (29.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e156 (25.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e171 (29.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e676 (28.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.443**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdomen AIS3+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (6.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (5.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19 (4.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31 (5.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e22 (3.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e111 (4.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.665**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpine AIS3+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (3.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (7.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (4.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45 (9.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e94 (15.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e58 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e231 (9.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePelvis AIS3+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (6.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (10.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (4.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15 (3.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25 (4.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e21 (3.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e108 (4.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLimb AIS3+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (10.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (13.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29 (7.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e53 (11.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e60 (9.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e43 (7.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e228 (9.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.071**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eInterventions\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny operation, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59 (35.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82 (45.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e132 (36.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e161 (34.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e202 (33.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e218 (37.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e854 (36.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.063**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime to any operation (hours), median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (2.7\u0026ndash;30.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.6 (4.7\u0026ndash;89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.6 (3.8\u0026ndash;31.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.3 (3.4\u0026ndash;71.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14.5 (3.1\u0026ndash;59.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13.1 (4.4\u0026ndash;37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e13.2 (3.6\u0026ndash;47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.744*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEye operation, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21 (4.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e43 (7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e29 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e102 (4.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime to eye operation (hours), median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58.8 (58.8\u0026ndash;58.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e145 (145\u0026ndash;145)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.6 (2.7\u0026ndash;8.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18.2 (11.7\u0026ndash;51.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13.3 (4.7\u0026ndash;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e17.2 (7.1\u0026ndash;34.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e15.4 (5.5\u0026ndash;32.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.845*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eOutcome\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (13.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (8.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37 (14.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e58 (17.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e67 (14.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e74 (16.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e267 (15.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.193**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLOS (days) median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (5\u0026ndash;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (5.5\u0026ndash;24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (4\u0026ndash;21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 (4\u0026ndash;20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9 (4\u0026ndash;22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9 (4\u0026ndash;19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e10 (4\u0026ndash;21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.002*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u0026dagger;IQR Interquartile range; \u0026dagger;\u0026dagger; GCS: Glasgow Coma scale; \u0026dagger;\u0026dagger;\u0026dagger;ISS: Injury severity score\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e*Jonckheere-Terpstra test; ** Chi square for trend\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRoad traffic collisions (RTCs) were the most common mechanism of major trauma involving ocular injury in 2004/06 accounting for 43.1% of cases but significantly decreased to 25.3% by 2019/21. Conversely, falls increased significantly and, by 2019/21, were the most common mechanism of injury (37.6%). Low falls (\u0026lt;\u0026thinsp;2 metres) comprised the majority of these (25.2%). Nonaccidental injuries in children under 16 also increased significantly and accounted for as much as 26.5% of cases during 2016/18.\u003c/p\u003e \u003cp\u003eHead and chest trauma comprised the most common serious (AIS 3+) concomitant injuries. These were present in 86.6% and 29.5% of cases respectively and remained stable over the period. Serious facial injuries were present in 18% of cases in 2004/06 and more than halved to 7.2% by 2019/21.\u003c/p\u003e \u003cp\u003e4.3% of patients required an eye operation and this increased over time (P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) while the proportion of patients requiring \u003cem\u003eany\u003c/em\u003e surgical intervention was 36.1% and remained stable. Median time to ophthalmic surgery was 15.4 hours which was similar to the 13.2 hours for \u003cem\u003eany\u003c/em\u003e operation.\u003c/p\u003e \u003cp\u003eThe most common injuries were to the conjunctiva (29.4%), retina (18.6%) and sclera (12.8%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Optic nerve injuries were present in 8.6% of cases and cranial nerves III, IV, and VI were damaged in 8.6%, 2.4% and 5.5% of patients respectively.\u003c/p\u003e \u003cp\u003eMissingness was only seen in Glasgow Coma Scale measurements (n\u0026thinsp;=\u0026thinsp;294, 12.4%). All other variables were complete for all cases.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe present contemporary data, from a large national registry, for ocular injuries in the setting of major trauma in England and Wales. Ocular injuries occurred in 0.8% of patients with major trauma which is lower than other studies which report rates between 2.3% and 16%\u003csup\u003e4\u0026ndash;8\u003c/sup\u003e. This can be partially explained as adnexal injuries and orbital fractures were not classified as ocular injuries in our cohort, whereas they were included in other studies. The prevalence of ocular injuries in this cohort decreased over the 18 year period and was less than the 2.3% reported in a historical (1989\u0026ndash;2004) study of TARN data using identical case ascertainment criteria.\u003csup\u003e6\u003c/sup\u003e This apparent decline in ocular injuries is likely multifactorial and may be partially explained by nation-wide shifts in injury mechanisms in major trauma\u003csup\u003e13\u003c/sup\u003e. Additionally, this may represent a relative decrease in proportion of ocular injuries as there has been an overall improvement in identifying and classifying major trauma owing to the now widespread use of CT scanning\u003csup\u003e13, 17\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe demographics of major trauma have changed significantly in recent decades. Patients are older and are commonly suffering injuries second to low falls\u003csup\u003e13\u003c/sup\u003e, and this is reflected in our data. RTCs, while historically the predominant mechanism, only accounted for 25.3% of cases in 2019/21 and this may account for the reduction in patients with concomitant facial and pelvic injuries in our cohort as these are commonly associated with RTCs\u003csup\u003e18\u003c/sup\u003e. Similar changes in demographics and injury mechanism have also been demonstrated in ocular injury not associated with major trauma in American and Taiwanese populations\u003csup\u003e19, 20\u003c/sup\u003e. It has been suggested that older patients are at an increased risk of eye injury due to globe weakness second to previous ocular surgery\u003csup\u003e21\u003c/sup\u003e. Falls in this age group are associated with ocular contusions, eyelid lacerations, and open globe injuries\u003csup\u003e22, 23\u003c/sup\u003e and better understanding of falls related injury will enable improved recognition and management of ocular trauma in a demographic which is projected to continue to increase\u003csup\u003e24\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eHead injury is reported in around a quarter of major trauma cases\u003csup\u003e25\u003c/sup\u003e and was the most common serious (AIS 3+) concomitant injury in this study, present in 86.7% of ocular trauma. The relationship between eye injury and head trauma is well described with ocular injuries present in 2.2\u0026ndash;25.3% of these patients\u003csup\u003e26, 27\u003c/sup\u003e. Head injuries are most caused by RTCs and anterior segment injuries are commonly reported resulting from direct impact on the frontal bones and orbital margins\u003csup\u003e27\u003c/sup\u003e. Neuro-ophthalmic injuries are also reported and principally comprise traumatic ocular motor nerve palsies\u003csup\u003e27\u003c/sup\u003e. Identification of eye injuries in this cohort, however, is challenging, notably in the acute setting when patients may be agitated or unconscious. Ocular assessment in primary surveys, which prioritise recognising life-threatening injuries, is limited to assessing eye-opening and the identification of nerve palsies and which act as indicators of brain injury severity and are predictive of mortality\u003csup\u003e28\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eA significant and increasing proportion of cases were children who had suffered injuries second to nonaccidental trauma. TARN do not report any concurrent increase in suspected physical abuse or assault in children with major trauma over the study period\u003csup\u003e29\u003c/sup\u003e. The reasons for this trend are unclear but may be due to an increased recognition and reporting of nonaccidental injury in children with eye injuries as up-to-date guidance is developed\u003csup\u003e30, 31\u003c/sup\u003e and reporting mechanisms are established\u003csup\u003e32\u003c/sup\u003e. Ocular pathologies are common in child abuse and may be varied in their presentation\u003csup\u003e33\u003c/sup\u003e. Retinal haemorrhages have been shown to have a high sensitivity and specificity for nonaccidental injuries in infants and, when accompanied with intracranial injuries, are pathognomonic\u003csup\u003e34\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe most common injuries were sustained to the conjunctiva (29.4%), retina (18.6%) and sclera (12.8%), while injury distributions were not analysed temporally, these can be compared with historical TARN data from 1989 to 2004\u003csup\u003e6\u003c/sup\u003e. Corneal injuries comprised 31% of injuries historically but only 6.6% in our contemporary cohort; this may be related to the decreased proportion of RTCs as an injury mechanism as these injuries are often associated with airbag deployment\u003csup\u003e35, 36\u003c/sup\u003e. Further, retinal injuries contributed to 5.9% of injuries historically and this seems to have increased threefold. Traumatic retinopathy is associated with high velocity blunt trauma\u003csup\u003e37\u003c/sup\u003e and this may represent the increase in patients surviving high-speed RTCs second to improvements in car crash safety mechanisms. Such injuries commonly include retinal tears and detachments for which urgent surgery is indicated\u003csup\u003e38\u003c/sup\u003e. An increase in traumatic retinopathy may contribute to trends seen in ophthalmic procedures which increased fourfold over the study period.\u003c/p\u003e \u003cp\u003eWhile optic nerve and retinal injuries are often vision threatening, we do not report visual outcome data for cases. Amongst major trauma victims, those with lid lacerations, open globe injuries and optic nerve injuries are reported to have the worst visual outcomes\u003csup\u003e4, 5\u003c/sup\u003e. Clinically, the Ocular Trauma Score is a tool used to predict functional outcome after eye injury\u003csup\u003e39\u003c/sup\u003e and has been validated in patients with major trauma\u003csup\u003e4\u003c/sup\u003e, however its parameters include initial visual acuity and presence of afferent pupillary defect, which are challenging to ascertain in patients with impaired cognition, and periorbital swelling respectively\u003csup\u003e9\u003c/sup\u003e. For cases of suspected ocular nerve trauma, flash visually evoked potentials have also been used to assess nerve function in these patients and are highly predictive of final visual outcome\u003csup\u003e40\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe identification and management of ocular trauma in the multiply injured patient remains a challenge for emergency clinicians however excellent guidance has been published on the topic\u003csup\u003e9\u003c/sup\u003e. Advanced Trauma Life Support principles should be followed for all major trauma patients\u003csup\u003e41, 42\u003c/sup\u003e. Visual pathways injuries should be screened for in patients with head or facial trauma and early surveys should arguably be able to exclude a sight-threatening injury requiring emergent management, such as retrobulbar haemorrhage, even in unresponsive patients\u003csup\u003e9\u003c/sup\u003e. CT scanning, which is now standard in polytrauma, is sensitive and specific for many types of eye injuries and ocular and orbital CT should be undertaken in all patients with clinical suspicion\u003csup\u003e43\u003c/sup\u003e. Ophthalmology specialist opinion should be sought in all patients with at risk of visual pathology as important, sight saving intervention might be required.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eTARN captures data from every trauma receiving NHS hospital in England and Wales and best practice tariffs ensure high case ascertainment and completeness, and as such, the data reported are representative. However, as a big data source, there are missing data and these may differ systemically from those that are included. Additionally, patients in whom these injuries are identified or managed out with the TARN data collection period, or who are transferred to other hospitals after acute management of major trauma, are not included. This may represent a significant proportion of patients as detailed ocular assessment may not be possible in the early phase of admission. There are also limitations associated with the usage of a non-ophthalmic trauma registry. Injury data are reported as anatomical location and injury type (blunt vs penetrating) and these do not carry the same clinical relevance as specialised classifications such as the Birmingham Eye Trauma Terminology System which is widely used\u003csup\u003e44\u003c/sup\u003e. Further, important prognostic information such as visual acuity and the presence or absence of relative afferent pupillary defect are not recorded. Registries which are specialised for ophthalmic pathologies collect and code clinically relevant data and generally avoid these limitations. Examples of these include the Research in Sight (IRIS\u0026reg;) Registry which was established in 2014 and has produced important data with outcomes not routinely recorded in trauma registries\u003csup\u003e45\u0026ndash;47\u003c/sup\u003e, and more recently, the International Globe and Adnexal Trauma Epidemiology Study (IGATES) Registry which has been established as an specialist registry with a focus on ocular trauma\u003csup\u003e48\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn conclusion, we report information about the trends of ocular trauma, in England and Wales, over an 18-year period. Ocular injuries are present in 0.8% of cases of major trauma and the most common concomitant injuries are to the head. RTCs are no longer the dominant mechanism of injury, which is increasingly being overtaken by falls, a pattern which mirrors major trauma trends across the UK. Fewer patients seem be suffering corneal injuries, there has been an increase in retinal injuries and those undergoing ophthalmic surgery. The findings of this study are important for health providers across the United Kingdom and may inform guideline development, resource allocation and training priorities.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank TARN for collating and providing the data utilised in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was not funded.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eN\u0026eacute;grel AD, Thylefors B. The global impact of eye injuries. \u003cem\u003eOphthalmic epidemiology \u003c/em\u003e1998; \u003cstrong\u003e5\u003c/strong\u003e(3)\u003cstrong\u003e: \u003c/strong\u003e143-169.\u003c/li\u003e\n\u003cli\u003eSchein OD, Hibberd PL, Shingleton BJ, Kunzweiler T, Frambach DA, Seddon JM\u003cem\u003e et al.\u003c/em\u003e The spectrum and burden of ocular injury. \u003cem\u003eOphthalmology \u003c/em\u003e1988; \u003cstrong\u003e95\u003c/strong\u003e(3)\u003cstrong\u003e: \u003c/strong\u003e300-305.\u003c/li\u003e\n\u003cli\u003eIftikhar M, Junaid N, Lemus M, Mallick ZN, Mina SA, Hannan U\u003cem\u003e et al.\u003c/em\u003e Epidemiology of Primary Ophthalmic Inpatient Admissions in the United States. \u003cem\u003eAmerican journal of ophthalmology \u003c/em\u003e2018; \u003cstrong\u003e185: \u003c/strong\u003e101-109.\u003c/li\u003e\n\u003cli\u003ePark J, Yang SC, Choi HY. Epidemiology and Clinical Patterns of Ocular Trauma at a Level 1 Trauma Center in Korea. \u003cem\u003eJournal of Korean medical science \u003c/em\u003e2021; \u003cstrong\u003e36\u003c/strong\u003e(1)\u003cstrong\u003e: \u003c/strong\u003ee5.\u003c/li\u003e\n\u003cli\u003ePoon A, McCluskey PJ, Hill DA. Eye injuries in patients with major trauma. \u003cem\u003eThe Journal of trauma \u003c/em\u003e1999; \u003cstrong\u003e46\u003c/strong\u003e(3)\u003cstrong\u003e: \u003c/strong\u003e494-499.\u003c/li\u003e\n\u003cli\u003eGuly CM, Guly HR, Bouamra O, Gray RH, Lecky FE. Ocular injuries in patients with major trauma. \u003cem\u003eEmergency medicine journal : EMJ \u003c/em\u003e2006; \u003cstrong\u003e23\u003c/strong\u003e(12)\u003cstrong\u003e: \u003c/strong\u003e915-917.\u003c/li\u003e\n\u003cli\u003eSastry SM, Paul BK, Bain L, Champion HR. Ocular trauma among major trauma victims in a regional trauma center. \u003cem\u003eThe Journal of trauma \u003c/em\u003e1993; \u003cstrong\u003e34\u003c/strong\u003e(2)\u003cstrong\u003e: \u003c/strong\u003e223-226.\u003c/li\u003e\n\u003cli\u003eGeorgouli T, Pountos I, Chang BY, Giannoudis PV. Prevalence of ocular and orbital injuries in polytrauma patients. \u003cem\u003eEuropean journal of trauma and emergency surgery : official publication of the European Trauma Society \u003c/em\u003e2011; \u003cstrong\u003e37\u003c/strong\u003e(2)\u003cstrong\u003e: \u003c/strong\u003e135-140.\u003c/li\u003e\n\u003cli\u003ePerry M, Moutray T. Advanced Trauma Life Support (ATLS) and facial trauma: can one size fit all? Part 4: \u0026apos;can the patient see?\u0026apos; Timely diagnosis, dilemmas and pitfalls in the multiply injured, poorly responsive/unresponsive patient. \u003cem\u003eInternational journal of oral and maxillofacial surgery \u003c/em\u003e2008; \u003cstrong\u003e37\u003c/strong\u003e(6)\u003cstrong\u003e: \u003c/strong\u003e505-514.\u003c/li\u003e\n\u003cli\u003eSoni KG, Eustace P. Missed ocular perforations after road traffic accidents. \u003cem\u003eInjury \u003c/em\u003e1972; \u003cstrong\u003e4\u003c/strong\u003e(1)\u003cstrong\u003e: \u003c/strong\u003e79-80.\u003c/li\u003e\n\u003cli\u003eBoyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method. Trauma Score and the Injury Severity Score. \u003cem\u003eThe Journal of trauma \u003c/em\u003e1987; \u003cstrong\u003e27\u003c/strong\u003e(4)\u003cstrong\u003e: \u003c/strong\u003e370-378.\u003c/li\u003e\n\u003cli\u003eYates DW. ABC of major trauma. Scoring systems for trauma. \u003cem\u003eBMJ (Clinical research ed) \u003c/em\u003e1990; \u003cstrong\u003e301\u003c/strong\u003e(6760)\u003cstrong\u003e: \u003c/strong\u003e1090-1094.\u003c/li\u003e\n\u003cli\u003eKehoe A, Smith JE, Edwards A, Yates D, Lecky F. The changing face of major trauma in the UK. \u003cem\u003eEmergency medicine journal : EMJ \u003c/em\u003e2015; \u003cstrong\u003e32\u003c/strong\u003e(12)\u003cstrong\u003e: \u003c/strong\u003e911-915.\u003c/li\u003e\n\u003cli\u003eMoran CG, Lecky F, Bouamra O, Lawrence T, Edwards A, Woodford M\u003cem\u003e et al.\u003c/em\u003e Changing the System - Major Trauma Patients and Their Outcomes in the NHS (England) 2008-17. \u003cem\u003eEClinicalMedicine \u003c/em\u003e2018; \u003cstrong\u003e2-3: \u003c/strong\u003e13-21.\u003c/li\u003e\n\u003cli\u003eLoftis KL, Price J, Gillich PJ. Evolution of the Abbreviated Injury Scale: 1990\u0026ndash;2015. \u003cem\u003eTraffic Injury Prevention \u003c/em\u003e2018; \u003cstrong\u003e19\u003c/strong\u003e(sup2)\u003cstrong\u003e: \u003c/strong\u003eS109-S113.\u003c/li\u003e\n\u003cli\u003e\u003cem\u003eR: A language and environment for statistical computing. \u003c/em\u003e. R Foundation for Statistical Computing.: Vienna, Austria; 2022.\u003c/li\u003e\n\u003cli\u003eHuber-Wagner S, Lefering R, Qvick LM, K\u0026ouml;rner M, Kay MV, Pfeifer KJ\u003cem\u003e et al.\u003c/em\u003e Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. \u003cem\u003eLancet (London, England) \u003c/em\u003e2009; \u003cstrong\u003e373\u003c/strong\u003e(9673)\u003cstrong\u003e: \u003c/strong\u003e1455-1461.\u003c/li\u003e\n\u003cli\u003eN\u0026oacute;brega LM, Cavalcante GM, Lima MM, Madruga RC, Ramos-Jorge ML, d\u0026apos;Avila S. Prevalence of facial trauma and associated factors in victims of road traffic accidents. \u003cem\u003eThe American journal of emergency medicine \u003c/em\u003e2014; \u003cstrong\u003e32\u003c/strong\u003e(11)\u003cstrong\u003e: \u003c/strong\u003e1382-1386.\u003c/li\u003e\n\u003cli\u003eChang YS, Teng YT, Huang YH, Liu ML, Hung JH, Hsu SM\u003cem\u003e et al.\u003c/em\u003e Major ocular trauma in Taiwan: 2002-2004 versus 2012-2014. \u003cem\u003eScientific reports \u003c/em\u003e2018; \u003cstrong\u003e8\u003c/strong\u003e(1)\u003cstrong\u003e: \u003c/strong\u003e7081.\u003c/li\u003e\n\u003cli\u003eIftikhar M, Latif A, Farid UZ, Usmani B, Canner JK, Shah SMA. Changes in the Incidence of Eye Trauma Hospitalizations in the United States From 2001 Through 2014. \u003cem\u003eJAMA ophthalmology \u003c/em\u003e2019; \u003cstrong\u003e137\u003c/strong\u003e(1)\u003cstrong\u003e: \u003c/strong\u003e48-56.\u003c/li\u003e\n\u003cli\u003eAndreoli MT, Andreoli CM. Geriatric traumatic open globe injuries. \u003cem\u003eOphthalmology \u003c/em\u003e2011; \u003cstrong\u003e118\u003c/strong\u003e(1)\u003cstrong\u003e: \u003c/strong\u003e156-159.\u003c/li\u003e\n\u003cli\u003eUsmani B, Latif A, Iftikhar M, Sepah YJ, Parker C, Fliss JA\u003cem\u003e et al.\u003c/em\u003e Eye trauma in falls presenting to the emergency department from 2006 through 2015. \u003cem\u003eThe British journal of ophthalmology \u003c/em\u003e2021; \u003cstrong\u003e105\u003c/strong\u003e(2)\u003cstrong\u003e: \u003c/strong\u003e198-204.\u003c/li\u003e\n\u003cli\u003eYing Fong YY, Yu M, Young AL, Jhanji V. Presentation and Management Outcomes of Corneal and Scleral Perforations in Geriatric Nursing Home Residents. \u003cem\u003eMedicine \u003c/em\u003e2015; \u003cstrong\u003e94\u003c/strong\u003e(36)\u003cstrong\u003e: \u003c/strong\u003ee1518-1510.\u003c/li\u003e\n\u003cli\u003eHartholt KA, Stevens JA, Polinder S, van der Cammen TJ, Patka P. Increase in fall-related hospitalizations in the United States, 2001-2008. \u003cem\u003eThe Journal of trauma \u003c/em\u003e2011; \u003cstrong\u003e71\u003c/strong\u003e(1)\u003cstrong\u003e: \u003c/strong\u003e255-258.\u003c/li\u003e\n\u003cli\u003eMohamed A, Mulcaire J, Clover AJP. Head and neck injury in major trauma in Ireland: a multicentre retrospective analysis of patterns and surgical workload. \u003cem\u003eIrish Journal of Medical Science (1971 -) \u003c/em\u003e2021; \u003cstrong\u003e190\u003c/strong\u003e(1)\u003cstrong\u003e: \u003c/strong\u003e395-401.\u003c/li\u003e\n\u003cli\u003eHuckhagel T, Regelsberger J, Westphal M, N\u0026uuml;chtern J, Lefering R. Damage to the eye and optic nerve in seriously traumatized patients with concomitant head injury: analysis of 84,627 cases from the TraumaRegister DGU\u0026reg; between 2002 and 2015. \u003cem\u003eScandinavian Journal of Trauma, Resuscitation and Emergency Medicine \u003c/em\u003e2020; \u003cstrong\u003e28\u003c/strong\u003e(1)\u003cstrong\u003e: \u003c/strong\u003e15.\u003c/li\u003e\n\u003cli\u003eOdebode TO, Ademola-Popoola DS, Ojo TA, Ayanniyi AA. Ocular and visual complications of head injury. \u003cem\u003eEye \u003c/em\u003e2005; \u003cstrong\u003e19\u003c/strong\u003e(5)\u003cstrong\u003e: \u003c/strong\u003e561-566.\u003c/li\u003e\n\u003cli\u003eKulkarni AR, Aggarwal SP, Kulkarni RR, Deshpande MD, Walimbe PB, Labhsetwar AS. Ocular manifestations of head injury: a clinical study. \u003cem\u003eEye \u003c/em\u003e2005; \u003cstrong\u003e19\u003c/strong\u003e(12)\u003cstrong\u003e: \u003c/strong\u003e1257-1263.\u003c/li\u003e\n\u003cli\u003eFisher R, Coats T, Davis N, Davies P, Duane L, Edwards A\u003cem\u003e et al.\u003c/em\u003e \u003cem\u003eEngland and Wales: Severe Injury in Children January 2017 - December 2018\u003c/em\u003e 2019.\u003c/li\u003e\n\u003cli\u003eNICE. Child maltreatment: when to suspect maltreatment in under 18s. Available at: https://www.nice.org.uk/guidance/cg89.\u003c/li\u003e\n\u003cli\u003eRCOphth. Abusive Head Trauma and the Eye in Infancy. Available at: https://www.rcophth.ac.uk/resources-listing/abusive-head-trauma-and-the-eye-in-infancy/.\u003c/li\u003e\n\u003cli\u003eNICE. Child abuse and neglect. Available at: https://www.nice.org.uk/guidance/ng76/chapter/Recommendations.\u003c/li\u003e\n\u003cli\u003ePaul AR, Adamo MA. Non-accidental trauma in pediatric patients: a review of epidemiology, pathophysiology, diagnosis and treatment. \u003cem\u003eTranslational pediatrics \u003c/em\u003e2014; \u003cstrong\u003e3\u003c/strong\u003e(3)\u003cstrong\u003e: \u003c/strong\u003e195-207.\u003c/li\u003e\n\u003cli\u003eEisenbrey AB. Retinal hemorrhage in the battered child. \u003cem\u003eChild\u0026apos;s brain \u003c/em\u003e1979; \u003cstrong\u003e5\u003c/strong\u003e(1)\u003cstrong\u003e: \u003c/strong\u003e40-44.\u003c/li\u003e\n\u003cli\u003eArmstrong GW, Chen AJ, Linakis JG, Mello MJ, Greenberg PB. Motor vehicle crash-associated eye injuries presenting to U.S. emergency departments. \u003cem\u003eThe western journal of emergency medicine \u003c/em\u003e2014; \u003cstrong\u003e15\u003c/strong\u003e(6)\u003cstrong\u003e: \u003c/strong\u003e693-700.\u003c/li\u003e\n\u003cli\u003eDuma SM, Jernigan MV, Stitzel JD, Herring IP, Crowley JS, Brozoski FT\u003cem\u003e et al.\u003c/em\u003e The effect of frontal air bags on eye injury patterns in automobile crashes. \u003cem\u003eArchives of ophthalmology (Chicago, Ill : 1960) \u003c/em\u003e2002; \u003cstrong\u003e120\u003c/strong\u003e(11)\u003cstrong\u003e: \u003c/strong\u003e1517-1522.\u003c/li\u003e\n\u003cli\u003eLiu X, Wang L, Wang C, Sun G, Liu S, Fan Y. Mechanism of traumatic retinal detachment in blunt impact: a finite element study. \u003cem\u003eJournal of biomechanics \u003c/em\u003e2013; \u003cstrong\u003e46\u003c/strong\u003e(7)\u003cstrong\u003e: \u003c/strong\u003e1321-1327.\u003c/li\u003e\n\u003cli\u003eCooling RJ. Traumatic retinal detachment--mechanisms and management. \u003cem\u003eTransactions of the ophthalmological societies of the United Kingdom \u003c/em\u003e1986; \u003cstrong\u003e105 ( Pt 5): \u003c/strong\u003e575-579.\u003c/li\u003e\n\u003cli\u003eKuhn F, Maisiak R, Mann L, Mester V, Morris R, Witherspoon CD. The Ocular Trauma Score (OTS). \u003cem\u003eOphthalmology clinics of North America \u003c/em\u003e2002; \u003cstrong\u003e15\u003c/strong\u003e(2)\u003cstrong\u003e: \u003c/strong\u003e163-165, vi.\u003c/li\u003e\n\u003cli\u003eMohammed MA, Mossallam E, Allam IY. The Role of the Flash Visual Evoked Potential in Evaluating Visual Function in Patients with Indirect Traumatic Optic Neuropathy. \u003cem\u003eClinical ophthalmology (Auckland, NZ) \u003c/em\u003e2021; \u003cstrong\u003e15: \u003c/strong\u003e1349-1355.\u003c/li\u003e\n\u003cli\u003ePerry MJ, Moutray T. Advanced trauma life support (ATLS\u0026reg;): the ninth edition. \u003cem\u003eThe journal of trauma and acute care surgery \u003c/em\u003e2013; \u003cstrong\u003e74\u003c/strong\u003e(5)\u003cstrong\u003e: \u003c/strong\u003e1363-1366.\u003c/li\u003e\n\u003cli\u003eKruse C, Bruce JL, Bekker W, Clarke DL. The management of ocular and peri-ocular trauma needs to be co-ordinated according to ATLS principles and requires multi-disciplinary collaboration. \u003cem\u003eInjury \u003c/em\u003e2021; \u003cstrong\u003e52\u003c/strong\u003e(9)\u003cstrong\u003e: \u003c/strong\u003e2606-2610.\u003c/li\u003e\n\u003cli\u003eWang D, Rizzuti A. Eye Trauma Imaging. StatPearls. StatPearls Publishing Copyright \u0026copy; 2022, StatPearls Publishing LLC.: Treasure Island (FL); 2022.\u003c/li\u003e\n\u003cli\u003eKuhn F, Morris R, Witherspoon CD, Mester V. The Birmingham Eye Trauma Terminology system (BETT). \u003cem\u003eJournal francais d\u0026apos;ophtalmologie \u003c/em\u003e2004; \u003cstrong\u003e27\u003c/strong\u003e(2)\u003cstrong\u003e: \u003c/strong\u003e206-210.\u003c/li\u003e\n\u003cli\u003eIRIS Registry. Available at: https://www.aao.org/iris-registry.\u003c/li\u003e\n\u003cli\u003eTomaiuolo M, Woreta FA, Li A, Yonekawa Y, Zhang QE, Sharpe JE\u003cem\u003e et al.\u003c/em\u003e Open-Globe Injury Repairs in the American Academy of Ophthalmology IRIS\u0026reg; Registry 2014 through 2018: Incidence, Risk Factors, and Visual Outcomes. \u003cem\u003eOphthalmology \u003c/em\u003e2023.\u003c/li\u003e\n\u003cli\u003eBatchelor A, Lacy M, Hunt M, Lu R, Lee AY, Lee CS\u003cem\u003e et al.\u003c/em\u003e Predictors of Long-term Ophthalmic Complications after Closed Globe Injuries Using the Intelligent Research in Sight (IRIS\u0026reg;) Registry. \u003cem\u003eOphthalmology science \u003c/em\u003e2023; \u003cstrong\u003e3\u003c/strong\u003e(1)\u003cstrong\u003e: \u003c/strong\u003e100237.\u003c/li\u003e\n\u003cli\u003eNg SMS, Low R, Hoskin AK, Rousselot A, Gunasekeran DV, Natarajan S\u003cem\u003e et al.\u003c/em\u003e The application of clinical registries in ophthalmic trauma-the International Globe and Adnexal Trauma Epidemiology Study (IGATES). \u003cem\u003eGraefe\u0026apos;s archive for clinical and experimental ophthalmology = Albrecht von Graefes Archiv fur klinische und experimentelle Ophthalmologie \u003c/em\u003e2022; \u003cstrong\u003e260\u003c/strong\u003e(4)\u003cstrong\u003e: \u003c/strong\u003e1055-1067.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"eye","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"eye","sideBox":"Learn more about [Eye](http://www.nature.com/eye/)","snPcode":"41433","submissionUrl":"https://mts-eye.nature.com/cgi-bin/main.plex","title":"Eye","twitterHandle":"@eye_journal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-3634731/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3634731/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eOcular trauma is a major cause of vision loss and injuries are often missed in multiply injured patients. Major trauma demographics in the UK have changed but no contemporary studies report ocular injuries in this cohort. We aimed to investigate ocular injury epidemiology and trends amongst major trauma patients in England and Wales from 2004\u0026ndash;2021.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective analysis of prospectively collected Trauma Audit and Research Network (TARN) registry data was conducted. Major trauma was defined as injury severity score\u0026thinsp;\u0026gt;\u0026thinsp;15, and ocular injuries were identified using AIS codes. Demographics, injury profiles, and outcomes were extracted. Descriptive statistics and 3-yearly trend data are reported.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf 287 267 major trauma cases, 2368 (0.8%) had ocular injuries, decreasing significantly from 1.87% (2004/06) to 0.66% (2019/21) (P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Males comprised 72.2% and median age was 34.5 years which increased (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Road traffic collisions declined from 43.1\u0026ndash;25.3% of ocular injury cases while falls increased and became the predominant mechanism (37.6% in 2019/21). Nonaccidental injuries increased from 15% (2004/06) to 26.5% (2016/18) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Concomitant head injury was present in 86.6% of cases. Ophthalmic procedures increased from 1.2% (2004/06) to 5% (2019/21) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Compared to previous TARN data, retinal injuries increased 3-fold to 18.6% and corneal injuries decreased from 31\u0026ndash;6.6%.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIdentifying sight-threatening injuries in polytrauma is challenging. Ocular injury epidemiology has changed significantly, though overall incidence is low. These findings may inform guideline development, resource allocation, and training priorities.\u003c/p\u003e","manuscriptTitle":"Trends in ocular injuries among major trauma patients in England and Wales from 2004 to 2021","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-12-22 16:11:50","doi":"10.21203/rs.3.rs-3634731/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"revise","date":"2024-01-02T08:17:51+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"This content is not available.","date":"2023-12-25T15:53:13+00:00","index":2,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2023-12-21T11:19:26+00:00","index":2,"fulltext":"This content is not available."},{"type":"editorInvitedReview","content":"This content is not available.","date":"2023-12-21T10:01:58+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2023-12-19T08:25:28+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewersInvited","content":"","date":"2023-12-19T07:50:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-12-15T15:45:10+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-11-20T15:53:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"Eye","date":"2023-11-19T13:05:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"eye","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"eye","sideBox":"Learn more about [Eye](http://www.nature.com/eye/)","snPcode":"41433","submissionUrl":"https://mts-eye.nature.com/cgi-bin/main.plex","title":"Eye","twitterHandle":"@eye_journal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"c985d2b7-780f-4df5-9416-eb4f5de04e57","owner":[],"postedDate":"December 22nd, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":27564999,"name":"Health sciences/Diseases/Trauma"},{"id":27565000,"name":"Health sciences/Health care/Public health/Epidemiology"},{"id":27565001,"name":"Health sciences/Medical research/Epidemiology"}],"tags":[],"updatedAt":"2024-05-25T07:08:43+00:00","versionOfRecord":{"articleIdentity":"rs-3634731","link":"https://doi.org/10.1038/s41433-024-03116-y","journal":{"identity":"eye","isVorOnly":false,"title":"Eye"},"publishedOn":"2024-05-24 04:00:00","publishedOnDateReadable":"May 24th, 2024"},"versionCreatedAt":"2023-12-22 16:11:50","video":"","vorDoi":"10.1038/s41433-024-03116-y","vorDoiUrl":"https://doi.org/10.1038/s41433-024-03116-y","workflowStages":[]},"version":"v1","identity":"rs-3634731","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3634731","identity":"rs-3634731","version":["v1"]},"buildId":"-HB7Z8yhvgn0wM9Nzuekk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}