ZDRAV VESTN 2002; 71: II-179

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Review article/Pregledni prispevek

THE BIRMINGHAM EYE TRAUMA TERMINOLOGY SYSTEM (BETT)

BIRMINGHAMSKI TERMINOLOKI SISTEM OESNIH POKODB (BETT) Ferenc Kuhn1, 2, Viktoria Mester2, 3, Robert Morris1, Clark D. Witherspoon1
1

United States Eye Injury Registry, Birmingham, Alabama, U. S. A. 2 Department of Ophthalmology, University of Pcs, Hungary 3 Mafraq Hospital, Abu Dhabi, U. A. E.

Arrived 2002-02-28, accepted 2002-03-14; ZDRAV VESTN 2002; 71: Supl. II: 179

Key words: ocular trauma; classification Abstract Background. To analyze the currently used ocular trauma terms and design a comprehensive yet simple new system. Methods. Extensive survey of the recent international ophthalmic literature. Results. A new system to describe globe injuries was designed in which the tissue of reference is always the globe itself. All injury types are unambiguously defined and are part of an overall classification. Early results show that the proposal has been welcomed by practitioners and researchers alike; the system has also been officially endorsed by several national and international organizations. Conclusions. BETT has a good chance of replacing the individual interpretation associated with the current terminology, thereby providing a standardized basis for epidemiologic and clinical practice and research.

Kljune besede: pokodbe oesa; klasifikacija Izvleek Izhodia. Analiza uporabe terminologije oesnih pokodb in izdelava vseobsgajoega a enostavnega sistema poimenovanja. Metode. Izrpen pregled literature v mednarodnih oftalmolokih revijah. Rezultati. Razvit je bil nov sistem poimenovanja oesnih pokodb pri katerem je referenni organ vedno oko. Vse vrste pokodb so nedvoumno definirane in uvrene v klasifikacijo. Odmevi kaejo, da je bil predlog klasifikacije v svetu iroko sprejet, tako med raziskovalci kot tudi med klininimi oftalmologi; sistem terminologije so sprejela tudi najpomembneja mednarodna strokovna telesa v oftalmologiji. Zakljuki. BETT ima dobre monosti, da zamenja tradicionalni nain poimenovanja oesnih pokodb in tako zagotovi standardizirano osnovo za epidemioloke in klinine tudije.

Introduction
Without a standardized terminology of eye injury types, it is impossible to design projects such as the development of the ocular trauma score; clinical trials in the field of ocular trauma cannot be planned and the communication between ophthalmologists remains ambiguous. Multiple literature examples demonstrate the lack of definitions, with obvious implications. For example, Blunt injury: If the consequences are blunt, it is a contusion (closed globe injury) (1). If the inflicting object is blunt, it is either a contusion or a rupture (open globe injury) (2). To add to the confusion, the two terms have even been thrown together as contusion rupture (3). Since the word blunt is ambiguous and contusion and rupture have vastly different implications, it is best to eliminate blunt from our eye injury vocabulary. Blunt nonpenetrating globe inju-

ry (3): Do sharp nonpenetrating injuries also occur? Blunt penetrating trauma (4): Arent all penetrating injuries sharp? Sharp laceration (5): Is there a laceration that is blunt? Blunt rupture (6): Is there a rupture that is sharp?

Development of standardized classification of ocular trauma terminology

An unambiguous system in ocular traumatology must satisfy the following three criteria. 1. Each term has a unique definition. Currently, it is exceptional that definitions in publications are provided at all or that their use is enforced (7). 2. No term can be applied for two different injury types. Unfortunately, numerous examples show that the same term (perfo-

Opomba urednika: Terminologija, ki je predstavljena v lanku je mednarodno sprejeta in uveljavljena, zato jo je potrebno uporabljati tudi v Sloveniji. Predvsem opozarja na razliko med izrazom: perforativna rana, ki je po BETT penetrantna rana. Perforativna rana je po BETT tista, ki smo jo doslej imenovali dvojna perforativna rana.

II-18 rating) is used to describe two distinctly different clinical entities: an injury with a single [entrance] wound (8) or one with both entrance and exit wounds (9). 3. No injury is described by different terms. Unfortunately, numerous examples show the opposite: an injury with both entrance and exit wounds is referred to as double penetrating, (10) doubleperforating, (11) and perforating; (12) or the same injury is alternatively referred to either as penetrating or as perforating even within the same article (13). Birmingham Eye Trauma Terminology (BETT) satisfies all criteria by: providing a clear definition for all injury types (Tab. 1).

ZDRAV VESTN 2002; 71: SUPPL II

Tab. 1. Terms and definitions in BETT.* Tab. 1. Izrazoslovje in definicije BETT.*

Term Izraz Definition and explanation Definicija in razlaga Sclera and cornea. Belonica in roenica. Though technically the eyewall has three coats posterior to the limbus, for clinical and practical purposes violation of only the most external structure is taken into consideration. eprav ima stena oesa za limbusom tri plasti, je tu miljena zunanja stena (belonica). No full-thickness wound of eyewall. Ni rane skozi vso debelino oesne stene. Full-thickness wound of the eyewall. Prisotna je rana skozi vso debelino oesne stene. There is no (full-thickness) wound. Ni rane skozi vso debelino oesne stene. The injury is either due to direct energy delivery by the object (e. g., choroidal rupture) or to the changes in the shape of the globe (e. g., angle recession). Pokodba je bodisi posledica direktnega prenosa energije objekta na oko (npr. ruptura ilnice) ali pa ta povzroi spremembo oblike zrkla (npr. recesija zakotja). Partial-thickness wound of the eyewall. Rana, ki sega delno v oesno steno. Full-thickness wound of the eyewall, caused by a blunt object. Rana, ki sega skozi vso debelino oesne stene, povzroena s topim predmetom. Since the eye is filled with incompressible liquid, the impact results in momentary increase of the IOP. The eyewall yields at its weakest point (at the impact site or elsewhere; example: an old cataract wound dehisces even though the impact occurred elsewhere); the actual wound is produced by an inside-out mechanism. Ker je oko napolnjeno z nestisljivo tekoino, udarec povzroi trenutno poveanje IOP. Stena se predre na najibkejem mestu (bodisi na mestu udarca ali drugje; npr. stara rane po operaciji katarakte se lahko odpre kljub temu, da je udarec na drugem mestu); rana nastane zaradi pritiska od znotraj navzven. Full-thickness wound of the eyewall, caused by a sharp object. Raztrganina skozi vse plasti oesa, ki jo povzroi oster predmet. The wound occurs at the impact site by an outside-in mechanism. Rana nastane na mestu udarca zaradi vpliva predmeta od zunaj. Entrance wound. Prisotna je vstopna rana. If more than one wound is present, each must have been caused by a different agent. e je prisotnih ve vstopnih ran, je bila vsaka povzroena z drugim predmetom. Retained foreign object/s. Prisoten/ni tujek/i v oesu. Technically a penetrating injury, but grouped separately because of different clinical implications. Gre za penetrantno pokodbo, vendar za loeno skupino zaradi razlinih klininih implikacij. Entrance and exit wounds. Prisotna je vstopna in izstopna rana. Both wounds caused by the same agent. Obe rani sta povzroeni z istim predmetom.

Closed globe injury Zaprta pokodba oesa Open globe injury Odprta pokodba oesa Contusion Udarnina

Discussion
The key to BETTs logic is to understand that all terms relate to the whole eyeball as the tissue of reference. Standardizing injury types also has far-reaching prognostic implications (see Chapter 3). For instance: Many variables characterize an object (e.g., aerodynamics, kinetic energy) (14). The most important, kinetic energy (E), is determined by the mass (m) and the velocity (v); E = 1/2 mv2. Blunt objects need higher kinetic energy to enter the eye (rupture) and are thus capable of inflicting more damage than sharp objects (laceration). Even when the blunt object causes a closed globe injury (contusion), the visual consequences can be more devastating (e.g., choroidal rupture at the fovea) than in eyes with an open globe trauma (e. g., retinal tear). While in BETT, a penetrating corneal injury is unambiguously an open globe injury with a corneal wound, the same term had two potential meanings before: an injury penetrating into the cornea (i. e., a partial-thickness corneal wound: a closed globe injury) or an injury penetrating into the globe (i. e., a full-thickness corneal wound: an open globe injury). When the tissue of reference changes, the terminology must reflect that; e. g.: The intra-ocular foreign body must possess certain energy to perforate the eyes protective wall, the tissue of reference is obviously the sclera/cornea. If the object penetrates either of these tissues, it does not become intraocular but remains intrascleral/corneal. Perforation means that the object entered the tissue on one side and left it on the other side. BETT (15) has been endorsed by several organizations such as the: American Academy of Ophthalmology; International Society of Ocular Trauma; Retina Society; United States Eye Injury Registry and its 25 international affiliates; Vitreous Society; and the World Eye Injury Registry. BETT it is mandated by several journals such as: Graefes Archives; Journal of Eye Trauma; Klinische Monatsbltter; and Ophthalmology. It is desirable for BETT to also become the language of everyday clinical practice.

Lamellar laceration Lamelarna raztrganina Rupture Ruptura

Laceration Raztrganina

Penetrating injury Penetrantna pokodba

References
1. Joseph E, Zak R, Smith S, Best W, Gamelli R, Dries D. Predictors of blinding or serious eye injury in blunt trauma. J Eye Trauma 1992; 33: 1924. 2. Russell S, Olsen K, Folk J. Predictors of scleral rupture and the role of vitrectomy in severe blunt ocular trauma. Am J Ophthalmol 1988; 105: 253 7. 3. Liggett PE, Gauderman WJ, Moreira CM, Barlow W, Green RL, Ryan SJ. Pars plana vitrectomy for acute retinal detachment in penetrating ocular injuries. Arch Ophthalmol 1990; 108: 17248. 4. Meredith TA, Gordon PA. Pars plana vitrectomy for severe penetrating injury with posterior segment involvement. Am J Ophthalmol 1987; 103: 54954. 5. De Juan E, Sternberg P Jr., Michels RG. Penetrating ocular injuries. Ophthalmology 1983; 90: 131822. 6. Klystra JA, Lamkin JC, Runyan DK. Clinical predictors of scleral rupture after blunt ocular trauma. Am J Ophthalmology 1993; 115: 5305. 7. Alfaro V, Liggett P. Vitrectomy in the management of the injured globe. In: Philadelphia: Lippincott Raven, 1998. Perforating injury Perforativna pokodba

* Some injuries remain difficult to classify. For instance, an intravitreal pellet is technically an IOFB injury. However, since this is a blunt object that requires a huge impact force if they enter, not just contuse, the eye, there is an element of rupture involved. In such situations, the ophthalmologist should either describe the injury as mixed (i. e., rupture with an IOFB) or select the most serious type of the mechanisms involved.

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8. Punnonen E, Laatikainen L. Prognosis of perforating eye injuries with intraocular foreign bodies. Acta Ophthalmol 1989; 66: 48391. 9. Ramsay RC, Knobloch WH. Ocular perforation following retrobulbar anesthesia for retinal detachment surgery. Am J Ophthalmol 1978; 86: 614. 10. Ramsay RC, Cantrill HL, Knobloch WH. Vitrectomy for double penetrating ocular injuries. Am J Ophthalmology 1985; 100: 5869. 11. Topping TM, Abrams GW, Machemer R. Experimental double-perforating injury of the posterior segment in rabbit eyes. Arch Ophthalmol 1979; 97: 73542. 12. Hutton WL, Fuller DG. Factors influencing final visual results in severely injured eyes. Am J Ophthalmology 1984; 97: 71522. 13. Hassett P, Kelleher C. The epidemiology of occupational penetrating eye injuries in Ireland. Occup Med 1994; 44: 20911. 14. Dziemian A, Mendelson J, Lindsey D. Comparison of the wounding characteristics of some commonly encountered bullets. J Trauma 1961; 1: 34153. 15. Kuhn F, Morris R, Witherspoon CD, Heimann K, Jeffers J, Treister G. A standardized classification of ocular trauma terminology. Ophthalmology 1996; 103: 2403.