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J Fr. Ophtalmol.

, 2004; 27, 2, 206-210 COMMUNICATION ET INFORMATION


© Masson, Paris, 2004.

F
M The Birmingham Eye Trauma Terminology system
C (BETT)
F. Kuhn (1, 2, 3), R. Morris (1, 2), C.D. Witherspoon (1, 2), V. Mester (3, 4)

(1) American Society of Ocular Trauma, Birmingham, USA.


(2) Department of Ophthalmology, University of Birmingham at Alabama, Birmingham, USA.
(3) Department of Ophthalmology, University of Pécs, Hungary.
(4) Mafraq Hospital, Abu Dhabi, United Arab Emirates.
Correspondance : F. Kuhn, 1201 11th Avenue South, Suite 300, Birmingham, AL 35205, USA. E-mail : fkuhn@mindspring.com
Reçu le 24 mars 2003. Accepté le 20 juin 2003.

La Birmingham Eye Trauma Terminology (BETT) : un système de classification Without a standardized system unam-
standardisé pour la traumatologie oculaire biguously defining the type of mecha-
F. Kuhn, R. Morris, C.D. Witherspoon, V. Mester nical trauma an eye sustains, it is
J. Fr. Ophtalmol., 2004; 27, 2: 206-210 impossible for ophthalmologists to
Introduction : L’utilisation inadaptée du vocabulaire en traumatologie oculaire peut conduire properly communicate the globes
à une mauvaise interprétation à l’origine d’une description erronée de la lésion en clinique ou condition. The use of standardized
de confusion lors de la présentation des résultats d’une étude clinique. C’est à la suite de ces terms is required in daily practice as
constatations qu’il a semblé nécessaire de faire le point sur les conceptions actuelles en trau- much as in publications and presen-
matologie oculaire afin de proposer une terminologie standardisée pour les lésions oculaires
d’origine mécanique.
tations. Inconsistent use of ocular
Matériel et méthode : Une enquête anonyme chez plus d’une centaine d’ophtalmologistes
trauma terms leads to misinterpreta-
206 confrontés à la description de trois cas cliniques différents de traumatisme oculaire, ainsi tion, rendering it impossible to des-
qu’une revue de la littérature internationale concernant la traumatologie oculaire ont été réa- cribe the injury to a colleague or pre-
lisées. Ce travail préliminaire a ensuite permis le mise au point de la Birmingham Eye Trauma sent the research results of a clinical
Terminology (BETT) à partir d’une approche clinique raisonnée. study.
Résultats : La classification élaborée pour la BETT réunit les critères suivants : 1) à chaque
With a lack of a standardized ter-
situation clinique correspond un terme précis et un seul ; 2) le globe oculaire pris dans sa
totalité sert de tissu de référence unique ; 3) la terminologie utilisée englobe tous les types de minology, ophthalmologists rely on
traumatismes oculaires mécaniques. using terms that have no clear defi-
Conclusion : La BETT permet une description et une classification simple, sans ambiguïté, nitions determined by factors such
cohérente, détaillée et complète pour tous les types de lésions traumatiques mécaniques du as place of training, place of prac-
globe oculaire. La BETT est déjà adoptée comme unique système de classification en trauma- tice, personal experience, peer pres-
tologie oculaire par plusieurs sociétés savantes et journaux avec comité de lecture. Elle devrait
sure, etc. This makes unbiased data
constituer la terminologie privilégiée pour classer les lésions oculaires en pratique courante.
comparison from various authors, or
Mots-clés : Lésion oculaire, traumatisme oculaire, traumatisme à globe fermé, traumatisme even by the same ophthalmologist
à globe ouvert. over time, unattainable. Medline
searches are also difficult to conduct
The Birmingham Eye Trauma Terminology system (BETT) since any eye injury term used as a
Purpose: To evaluate the international eye injury scene and design a standardized terminology keyword will identify articles that
for mechanical eye injuries.
Methods: Surveys of practicing ophthalmologists and an extensive review of the international
should not have come up and miss
ocular trauma literature. Development of the Birmingham Trauma Terminology (BETT) using others that should have been identi-
a logic-based approach. fied.
Results: BETT always uses the entire globe as the tissue of reference. Its well-defined terms Based on surveys conducted at
encompass all types of mechanical eye injury. A one-to-one relationship exists between terms different locations, an extensive re-
and clinical conditions.
view of major trauma-related articles
Conclusion: BETT provides an unambiguous, consistent, simple, and comprehensive system
to describe any type of mechanical globe trauma. Endorsed by several societies and peer- and textbooks published in several
reviewed journals as the standardized international language of ocular traumatology, BETT is countries, and personal experience,
expected to become the preferred terminology for categorizing eye injuries in daily clinical we developed a system (Birmingham
practice. Eye Trauma Terminology, BETT)
Key-words: Ocular injury, ocular trauma, closed globe injury, open globe injury. aimed at standardizing the terms
used to describe mechanical eye in-
juries.
Vol. 27, n° 2, 2004 Birmingham Eye Trauma Terminology

METHODS Designing and testing the new BETT


terminology system (BETT)
Surveys The system we have designed is
Based on the results of the surveys based on a logical, systematic ap-
Over 100 ophthalmologists from and literature reviews, we designed proach. It is a compromise that is
different backgrounds were asked a system we considered as simple, both meaningful and useful for the
to anonymously indicate how they logical, and comprehensive. We clinician and is applicable in re-
would classify three cases of me- conducted tests over a 3-year pe- search. It was widely accepted as a
chanical eye injury (table I). We riod, polling ophthalmologists from user-friendly solution to the pro-
wanted to find out whether the ra- a large number of countries from blem when we tested it at several
ther straightforward case reports several continents to determine international meetings.
we presented would be termed whether the obvious compromise
identically by the responders. within the system was acceptable.
The goal was to design a practical
system, one that would be used in DISCUSSION
clinical practice as well as in re-
Literature review
search, rather than a sterile, purely The development and clinical ap-
We analyzed over 120 major arti- academic system based on seman- plication of any management stra-
cles and 11 books dedicated solely tics. For this reason, we did not use tegy for a certain type of eye injury
to the topic of eye injuries. Our goal the traditional interpretation of the is based on a critical evaluation of
was to try to identify whether defi- term laceration. It originally means prior treatment options on as large
nitions were included in the publi- A linear or jagged tear resulting a number of cases as possible. It is
cations for the terms used and from overstretching of the skin and fundamental that the type of injury
whether identical injuries were des- underlying tissues [1], whereas in analyzed for making clinically
cribed using the same term. We BETT it describes a wound that was relevant conclusions be unambi-
also wanted to determine whether caused by a sharp, as opposed to a guously defined.
the authors were consistent in the blunt, object. Unfortunately, the analysis of
usage of the their own terms. the literature shows that this is not 207
the case. As the many examples
shown in table II demonstrate, the
RESULTS injury types are often labeled arbi-
Table I
Survey results: eye injury types as defi- Surveys
ned by over 100 responding ophthal-
mologists (in %)*. Even though several ophthalmolo-
gists had been working together
Case Case Case for considerable length of time,
Injury type
1 2 3
their answers varied widely, and it A.
Penetrating 65 76 24 was very rare to find identical res-
Perforating 47 29 ponses (table I).
Rupture 47 59
Blunt rupture 6 88 Literature review
Laceration 6 47 24 We found that virtually no publica-
Full-thickness 41 65 tion provides a definition of the
wound terms it uses. The reader therefore
Open globe injury 76 88 remains uncertain whether interpre-
tation of the type of injury is identical B.
* The numbers do not add to 100 because
multiple answers were allowed. to that intended by the authors. Fur-
Case 1: a patient presents with a history of thermore, inconsistencies are com-
a large nail hitting the eye. A scleral wound
of 10mm in length is seen with uveal pro- mon even within the same publica-
lapse. There is a small vitreous hemorrhage tion: different terms may be used to
but no vitreous prolapse or retinal defect is report the same injury in the title,
seen. Case 2: a patient presents with a his- Figure 1 : Corneal penetrating injury. A. The
tory of falling into bushes. A small thorn is abstract, and body of the article. The
reference tissue is the cornea. This is a pene-
still visible poking out from the cornea. Des- situation is all the more confusing tration into the cornea, therefore a closed-
cemets membrane seems intact. Case 3: a
patient presents with a history of falling because of authors trying to use in- globe injury. B. The reference tissue is the
onto a couch. A corneoscleral wound of dividually invented terms such as globe. This is a penetration through the cor-
12mm is seen with retinal prolapse. blunt penetrating trauma (table II). nea, therefore an open-globe injury.
F. Kuhn et coll. J. Fr. Ophtalmol.

trarily. One can rarely be sure by globe: is there a full-thickness breach transfers its kinetic energy without
reading the articles (book chap- of the eyewall? For this, one must creation of a full-thickness wound.
ters) title or abstract what types define what makes up the wall of Within the open-globe category,
of injuries are discussed. In an the eye. Although books on ana- the key issue is to differentiate
ideally designed terminology sys- tomy and pathology usually in- between ruptures and lacerations.
tem, several criteria must be met clude the choroid and the retina as The underlying cause of a rupture
and BETT was designed with these part of the eyewall, this is imprac- is elevated intraocular pressure
criteria in mind. tical for the practicing ophthalmo- that is the result of energy transfer
First, there has to be an unambi- logist. Even if the retina is not in- from a blunt object. Consequently,
guous definition for each term. jured, trauma involving the total the injury occurs through an in-
This means that no term can des- width of the sclera technically side-out mechanism, and fre-
cribe more than a single clinical means that the inside of the eye quently there is loss of the globes
condition and, conversely, no clini- has been violated; furthermore, in contents: tissue prolapse/extru-
cal condition can be described by many cases it is not possible to de- sion. The wound is not necessarily
more than a single term. at the impact site but commonly at
termine whether there is accompa-
Second, the reference tissue the locus minoris resistentiae. A
nying choroidal and retinal injury,
must always be determined. If the typical example is an eye after ca-
much less whether these are in-
reference tissue is in question, a taract surgery: if hit by a blunt ob-
term such as “corneal penetrating deed full-thickness injuries. An ject such as a fist, the wound is
injury” cannot be unambiguously open-globe injury in BETT thus most likely to form at the original
tied to a single injury type: one means that there is a full-thickness surgical incision rather than at the
must know whether “corneal” is wound of the sclera and/or cornea point of impact.
the tissue in question or the loca- (eyewall), regardless of the pre- In case of a laceration, a sharp
tion of the injury (fig. 1). sence or absence of choroidal or object is the culprit. A laceration
Third, all terms must be part of retinal involvement. always occurs at the impact site by
a comprehensive system, which Within the closed-globe category an outside-in mechanism and is
provides an overview so that the (no injury to the eyewall), a distinc- usually caused by a sharp object.
208 ophthalmologist can easily deter- tion had to be made based on The object typically enters the in-
mine in which category the en- whether a lamellar (partial-thic- side of the eye, temporarily or per-
countered injury belongs. kness) laceration has occurred or manently (retained intraocular fo-
The primary task is to determine the trauma is a contusion. A contu- reign body). Lacerations, however,
whether an injury is open or closed sion is caused by a blunt object that may involve different injuries,

Table II
Selected examples to demonstrate the confusion in lack of a standardized system to describe mechanical eye injuries.

Same term used to characterize Perforating Injury with entrance wound [4] Injury with both entrance
two different clinical conditions and exit wounds [5]
Same injury (with entrance Double penetrating [6] Double perforating [7] Perforating [8]
and exit wounds) described
by different terms
Single term used to describe Rupture [9] = Penetrating = Perforating
all injury types
Penetrating [10] = Rupture = Perforating
Individually developed terms Blunt nonpenetrating globe Is there a sharp nonpenetrating Is this a contusion?
injury [11] injury?
Blunt penetrating trauma [12] Is this a rupture? Is this a contusion?
Sharp laceration [13] Is there a blunt laceration?
Blunt rupture [14] Is there a sharp rupture?
Posterior penetrating trauma Is the penetration occurring Is the penetration so deep as to
[15] posteriorly? reach the posterior of the eye?
Closed rupture [16] Contusion? Occult rupture?
Blunt trauma Contusion [17] Rupture [18]
Contusion rupture [16] Which? Both?
Vol. 27, n° 2, 2004 Birmingham Eye Trauma Terminology

based on whether the object also To avoid ambiguity, BETTs key ture; an object may result in a pos-
causes an exit wound or whether element is its consistency: the terior impact site that is technically
foreign material is retained inside reference tissue is always the globe not an exit wound but behaves as
the globe. In the simplest case, as a whole. The term corneal pene- one in terms of the potential for
only a single (entrance) wound is trating injury in BETT describes a pe- extensive reparative proliferation.
present: this is a penetrating injury. netrating injury with the cornea as Individual decisions by the ophthal-
If an exit wound is also present, a the single wounds location (fig. 1b). mologist therefore still have to be
perforating injury is encountered The individual definitions are listed made in rare cases, but BETT provi-
(a through-and-through injury). An and explained in table III; the overall des a platform that standardizes the
intraocular foreign body injury is system is shown on (fig. 2). description of eye injury types regar-
distinguished (it is technically a pe- BETT is not perfect. There are in- dless of the ophthalmologists natio-
netrating injury) because of its spe- juries of a mixed nature: certain ob- nality, place of practice, or training.
cial management and prognostic jects such as an air-gun pellet can BETT has been essential in deve-
implications. penetrate the eye and cause rup- loping projects such as the Ocular

Table III
Definitions in BETT*.

Term Definition Remarks


Eyewall Sclera and cornea Though technically the wall of the eye has not one
but three tunics (coats) posterior to the limbus, for
clinical purposes it is best to restrict the term eyewall
to the rigid structures of the sclera and cornea
Closed-globe injury The eyewall does not have a full thickness wound Rarely, a contusion and a lamellar laceration coexist*
Lamellar laceration The eyewall has a partial thickness wound
Contusion There is no wound The energy transfer from object to globe causes 209
damage inside the eyewall
Open-globe injury The eyewall has a full thickness wound The cornea and/or the sclera sustained a through-
and-through injury. Depending on the objects
characteristics and the injury circumstances, ruptures
and lacerations are distinguished. The choroid and
the retina may be intact, prolapsed, or damaged.
Rupture Full thickness wound of the eyewall, caused by a The eye is a ball filled with incompressible liquid.
blunt object. The impact results in a momentary A blunt object with sufficient momentum creates
increase in IOP and an inside-out injury mechanism energy transfer over a large surface area, greatly
increasing IOP. The eyewall gives way at its weakest
point, which may or may not be at the impact site.
The actual wound is produced by an inside-out
force; consequently, tissue herniation is very
frequent and can be substantial.
Laceration Full-thickness wound of the eyewall, usually caused Further classification is based on whether an exit
by a sharp object. The wound occurs at the impact wound or an IOFB is also present. Occasionally,
site through an outside-in mechanism an object may create a posterior (exit) wound while
remaining, at least partially, intraocular (IOFB)*
Penetrating injury Single laceration of the eyewall, usually caused by a No exit wound has occurred. If more than one
sharp object entrance wound is present, each must have been
caused by a different agent
Intraocular foreign Retained foreign objects causing entrance An IOFB is technically a penetrating injury but is
body injury lacerations grouped separately because of different clinical
implications (treatment modality, timing,
endophthalmitis rate, etc.)
Perforating injury Two full-thickness lacerations (entrance + exit) Both wounds must have been caused by the same
of the eyewall, usually caused by a sharp object agent
or missile
* Rarely, the injury is so atypical that characterization is very difficult; the clinician should use his or her best judgment, based on the information
provided here. IOP, intraocular pressure; IOFB, intraocular foreign body.
F. Kuhn et coll. J. Fr. Ophtalmol.

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