April 2019


Presentation Spotlight
Linking eye trauma and falls among the elderly

by Vanessa Caceres EyeWorld Contributing Writer

58-year-old male with right partial thickness upper and lower lid lacerations, with microperforation of canalicular system, secondary to assault
Source: Jared Weed, MD

10-year-old with pencil thrown in the eye
Source: Tarika Thareja, MD


Some eye trauma hospitalization trends that a recent study tracked may not surprise physicians.
However, what may be surprising is the increasing role of patient falls for many of these hospitalizations.
A study1 in JAMA Ophthalmology focused on changes in the incidence of eye trauma hospitalizations in the U.S. between 2001 and 2014. Mustafa Iftikhar, MD, and a team of researchers led by Syed Mahmood Ali Shah, MD, used the National Inpatient Sample (NIS), which they said is the largest publicly available all-payer inpatient database in the U.S. The database is sponsored by the U.S. government as part of the Healthcare Cost and Utilization Project and includes as much as 96% of the U.S. population, according to the study.
Researchers examined diagnoses and procedures for each hospitalization record and used ICD-9-CM codes to identify patients with a primary or secondary diagnosis of eye trauma.

Looking at the numbers

The study found an estimated 939,608 patients with eye trauma were hospitalized in the U.S. between 2001 and 2014. Of these, 17.1% had a primary diagnosis of eye trauma, while 82.9% had it as a secondary diagnosis. Comparing 2001 to 2014, total eye trauma increased from 18.3 per 100,000 population to 22.0 per 100,000 population, respectively. “This was because of the increase in eye trauma as a secondary diagnosis, which rose 31% from 14.5 to 19.0 per 100,000 population in the study period,” the researchers wrote. At the same time, eye trauma as a primary diagnosis decreased, albeit marginally (from 3.9 to 3.0 per 100,000 population).
The most frequent diagnoses for eye trauma as a primary diagnosis included orbital fracture (39.9%), ocular laceration (21.3%), and eyelid laceration (7.7%). When eye trauma was a secondary diagnosis, the most frequent diagnoses were contusion of the eye and adnexa (37.8%), orbital floor fracture (24.2%), and superficial injury of the eye and adnexa (13.2%).
When eye trauma was the primary diagnosis, the main causes were falls (25.3%) and assault (24.7%), while eye trauma as a secondary diagnosis was associated with falls (35.2%) and auto crashes (26.6%).
Among the falls, 67.3% occurred in older patients. By contrast, in children, unintentional injuries caused by objects and machinery made up the largest chunk of primary diagnosis cases (30.1%). Among all patients, the elderly composed the largest overall age group. Most of the patients (59.3%) were male, had a lower income, were publicly insured through Medicare or Medicaid, and were from the South (36.7%).

Focusing on falls

Among the study’s findings, the connection with falls was of particular concern to the researchers. “Falls continue to occur in high-risk populations, which I think calls for a reexamination of our existing prevention strategies,” Dr. Shah said. “A fall is considered a ‘never event’ in hospitals, and it’s time that we make it a never event outside the hospitals as well.”
Ophthalmologists should proactively identify patients at risk for falls, Dr. Shah said. Those at higher risk can be referred for low vision services, something that Howard R. Krauss, MD, often does. It’s also important to address fall risk with any family members present at the exam, Drs. Shah and Krauss said.
Dr. Krauss will make a note in the electronic medical record about patients who are at risk for falls, so the primary care doctor can follow up accordingly. He also sees patients at risk for falls who need further neurological assessment, particularly because he specializes in neuro-ophthalmology.
One challenge, according to Dr. Krauss, is that ophthalmologists may not always get a sense of who is at a higher risk for falls during an exam, due to the short amount of time with a patient. However, staff members may have valuable insight based on how a patient walks to and from the waiting area and exam room. Another challenge is with patients receiving certain treatments, for example, those with age-related macular degeneration who return to a practice for regular injections. Eye doctors may not always have the time to assess or ask how these patients are managing their vision loss in terms of preventing falls, Dr. Krauss said.
Ophthalmologists should take a more global view on preventing falls by working with physicians across specialties to recognize at-risk patients, Dr. Shah said.
Although there is a tendency nowadays to put off second eye cataract surgery, John S. Jarstad, MD, thinks that getting that second eye operation sooner rather than later could help lessen fall risk, even in borderline cases.

Beyond the falls

The study results bring attention to other eye trauma pearls that ophthalmologists should share with patients, according to sources. First, parents should be educated about the use of protective eyewear in children, including sports-related eye protection, Dr. Shah said.
Dr. Jarstad agreed. “I try to emphasize wearing eye protection with polycarbonate lenses,” he said.
Second, anyone training to use a gun should remember the cardinal rule of never aiming at another person, Dr. Jarstad said. This could help avoid eye trauma, not to mention serious injury or death.

About the doctors
John S. Jarstad, MD
Associate professor
Director of cataract and refractive surgery
University of Missouri School of Medicine
Columbia, Missouri

Howard R. Krauss, MD
Clinical professor of ophthalmology and neurosurgery
John Wayne Cancer Institute,
Pacific Neuroscience Institute
Providence Saint John’s Health Center
Santa Monica, California

Syed Mahmood Ali Shah, MD
Associate professor of ophthalmology
University of Pittsburgh School
of Medicine Pittsburgh

Contact information
: jarstadj@health.missouri.edu
Krauss: hkrauss@pacificneuro.org
Shah: sms@syeds.org


1. Iftikhar M, et al. Changes in the incidence of eye trauma hospitalizations in the United States from 2001 through 2014. JAMA Ophthalmol. 2019;137:48–56.

Financial interests
Jarstad: None
Krauss: None
Shah: None

Eye trauma stats1

• Two million to 2.4 million cases of eye trauma occur each year.
• Of those cases, about 1 million have permanent significant visual impairment.
• Twenty-seven percent or more of serious eye injuries in the U.S. lead to legal blindness.
• A primary diagnosis of eye trauma decreased from 2001 to 2014, but secondary diagnoses of eye trauma increased.
• A rise in the secondary diagnosis of eye trauma was linked to an increasing frequency of falls among those age 65 or older.
• A primary diagnosis of eye trauma was more common in children and teens, African Americans and Hispanics, uninsured patients, and those receiving Medicaid.

Linking eye trauma and falls among the elderly Linking eye trauma and falls among the elderly
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