Use of preoperative imaging in open globe injury management: a systematic review

Clinical Snapshot

Key Findings

• P Value: Not reported in abstract

• Effect Size: CT sensitivity for OGI detection: 74%; CT specificity for OGI detection: 93%; CT sensitivity for IOFB detection: 69%; B-scan US sensitivity for IOFB detection: 86%

• Primary Outcome: Sensitivity and specificity of CT for open globe injury (OGI) detection compared with clinical ophthalmologist examination as reference standard

• Nnt Or Sensitivity: Diagnostic accuracy metrics: CT sensitivity for OGI 74% (meaning approximately 1 in 4 OGIs may be missed on CT alone); CT sensitivity for IOFB 69% (approximately 1 in 3 IOFBs missed); B-scan US sensitivity for IOFB 86% (approximately 1 in 7 IOFBs missed). Likelihood ratios not reported. Negative predictive values not calculable from available data without prevalence estimates.

• Confidence Interval: CT OGI sensitivity: 95% CI 66.4%–80.0%; CT OGI specificity: 95% CI 88.2%–95.4%; CT IOFB sensitivity: 95% CI 51.4%–82.0%; B-scan US IOFB sensitivity: 95% CI 77%–92%

Clinical Application

CT is widely available in Australian tertiary and most secondary hospital emergency departments and is already standard practice in major ocular trauma workup. B-scan US is available in ophthalmology departments but requires trained operators and carries theoretical risk of globe pressure in OGI. The findings are immediately applicable to existing clinical workflows without requiring new infrastructure. In Australia, OGI management is guided by the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) and is consistent with international ocular trauma guidelines. CT orbits (typically 1 mm axial slices with coronal and sagittal reconstructions) is standard preoperative imaging at major trauma centres. This review reinforces current Australian practice: CT is a useful adjunct but cannot replace slit-lamp and indirect ophthalmoscopy assessment by an ophthalmologist. The finding that CT misses approximately 26% of OGIs and 31% of IOFBs is directly relevant to medico-legal documentation and consent processes in Australian practice. MRI, which is contraindicated when a metallic IOFB is suspected, is not addressed in this review. PBS and TGA considerations are not directly applicable as this review concerns imaging rather than pharmacotherapy or devices. The safety concern regarding B-scan US pressure on an open globe is particularly relevant to Australian emergency departments where non-ophthalmologist clinicians may perform bedside US. Adult and paediatric patients presenting with suspected or confirmed open globe injury in emergency or acute ophthalmology settings, particularly where preoperative imaging is being considered prior to primary surgical repair

Abstract

IMPORTANCE: Primary repair of open globe injury (OGI) is typically undertaken urgently. Imaging plays an important role in the preoperative assessment, including detection of an OGI and presence of an intraocular foreign body (IOFB). Evidence is lacking on the utility of preoperative imaging in diagnosing OGI and IOFB. OBJECTIVE: The primary objective is to assess the role of pre-operative imaging in OGI. Studies including patients who had sustained an OGI and reporting the findings of radiologic imaging in pre-operative assessment of OGI were eligible for inclusion. DATA SOURCES: A systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement, searching the Cochrane Central Register of Controlled Trials, PubMed, Medline and ClinicalTrials.gov. STUDY SELECTION: Prospective and retrospective studies reporting preoperative imaging assessment after OGI were included with no restriction on language or start date up until 15 December 2023. DATA EXTRACTION AND SYNTHESIS: Eleven studies, 10 retrospective and 1 prospective, with a total of 1126 patients were included, of which 8 assessed computed tomography (CT) detection of OGI and 3 assessed ultrasound for the detection of IOFB. Risk of bias was assessed using the Quality Assessment Tool for Diagnostic Accuracy Studies-2 (QUADAS-2) tool. MAIN OUTCOMES AND MEASURES: Sensitivity of CT detection for OGI compared with clinical examination by an ophthalmologist and IOFB detection using intraoperative examination findings as gold standard. Preoperative B Scan ultrasonography (US) sensitivity for IOFB detection compared with CT. RESULTS: CT was 74% sensitive (95% CI 66.4% to 80.0%) and 93% specific (95% CI 88.2% to 95.4%) in OGI detection compared with clinical diagnosis. CT findings associated with OGI included scleral deformity, altered anterior chamber (AC) depth, lens abnormality and vitreous haemorrhage. CT was 69% sensitive (95% CI 51.4% to 82.0%) for IOFB detection using intraoperative examination findings as the gold standard.Preoperative B Scan US was not examined for OGI detection but had 86% sensitivity for IOFB detection (95% CI 77% to 92%) compared with the gold standard of CT, but safety with respect to pressure on the globe extruding intraocular contents was not studied. CONCLUSIONS AND RELEVANCE: CT had moderate sensitivity but high specificity for OGI detection, and therefore cannot replace clinical assessment by an ophthalmologist. A negative CT does not exclude an IOFB.