A standardized language of trauma classification can have value for prognosis as well as description, according to Dr Dante Pieramici.
In the care of the ocular trauma patient, we had previously lacked standard terminology as well as standard assessment methods. Conversely, in other areas of ophthalmology, such as the care of patients with diabetic disease, we are very clear in the precise terms that we use. The use of these terms facilitates clinical care, and has become integral to patient management.
Better injury classification
Imagine a patient who had been hit in the eye by something, and that this material that traumatized the eye had entered eye. How would you describe this type of injury? Prior to the development of trauma-specific terms, this same injury might have been described as a ruptured globe, an open globe, a penetrating injury or a perforating injury. When one doctor is communicating with another who is using different terms, some confusion is bound to arise.
Standard language increases the value of literature reviews
Standard terminology also facilitates our understanding of trauma literature. If you go back to the early 1990s or 1980s, or even the 1970s, and look at a review of trauma patients, it is difficult to be really sure what the cases were about; whether these patients had perforating or through-and-through injuries of the eyes, or if their injuries were much less severe.
What we're trying to establish by reviewing older literature is to determine whether our outcomes are similar to historical outcomes; we can do this only when a direct comparison can be made, which is clearly impossible when the specifics of the case are unclear.
Now that we have standardized trauma terms, clinical research in this area can proceed. To enrol patients into clinical trials, for example, the first thing we would want to know is that the types of patients we're enrolling are of a similar calibre; by using the same specific terms, we can be more certain of this.
Our goal: clinically significant language
When we devised these terms, our goal was not simply to make trauma language standard and universal, though that clearly is an aim of the project; our goal was, rather, to choose terms that would not only be descriptive of or relate to the specifics of the injury, but to use terms that, in and of themselves, have prognostic significance.
If a patient presented with a perforating injury of the eye, where the foreign material entered and exited the eye, and we described it as such, any ophthalmologist would know, based on that term, that the pathophysiologic mechanisms that would come into play would make this a very severe injury.
By thinking about the terms and trying to classify an injury using specific terms, doctors are in effect going through a flow diagram in their minds. The flow diagram should give them prognostic significance; in addition, it will help them to think about how to manage their patients.
The Birmingham system
Their system really classifies and uses terms to describe mechanical injuries to the eye, where something sharp or blunt strikes the eye. When a patient has such an injury, our initial concerns are about whether it is an open globe or a closed globe injury. An open globe injury is defined as an injury where there is a hole in the eye wall itself, whereas a closed globe injury presents no such hole.
Already you can see that, by using and thinking about these terms, when a patient visits a clinic, the physician is going down the diagram and putting patients into different categories of management. This demonstrates that, not only by knowing and being specific with the terms we use but also by thinking about how we choose these terms, we can facilitate the management of the patient.
1. F. Kuhn, et al. Ophthalmology 1996;103:240–243.