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Patients with open globe injuries experience best visual acuity outcomes when ophthalmologists can perform rapid surgical closure within 24 hours of injury. A UNC Department of Ophthalmology faculty and a team comprised of two medical students and an ophthalmology resident has found that rapid surgical closure of open globe injuries may be delayed by hospitals that transfer patients, many of which have ophthalmology coverage or a closer-by Level I Trauma Center. In the August 2022 (Vol. 16) issue of Clinical Ophthalmology, study authors* examined time-to-surgery and visual outcomes in patients with open globe injuries who experienced a lapse in time-to-surgery when transferred to the emergency department (ED) of a flagship Level 1 Trauma Center for triage and surgery. Investigative results showed that transferred patients who exceeded the optimal window for surgical intervention due to inter-hospital transfer experienced significantly poorer final visual acuities on average than those who presented directly post-injury to the tertiary care center and received timely surgical intervention. 

In this retrospective cohort study, investigators reviewed medical records of open globe injury patients (n = 238) who were triaged and surgically treated at UNC Medical Center (UNCMC)’s ED over 15 years (January 2005 – December 2020). Patient demographics, time of injury, final clinical outcomes, time to surgical intervention, and transfer history were extracted from UNCMC’s trauma registry for analysis. The study divided patients into two cohorts: 1) Non-transferred patients who presented at UNCMC’s ED directly post-injury for triage and surgical intervention; and 2) Patients who were transferred to UNCMC for triage and surgical intervention after initial presentation post-injury at a close-proximity hospital.

From its records analysis, the UNC Ophthalmology research team found that inter-hospital transfer leads to an almost four-hour delay for surgical intervention to repair open globe injuries. As a result, the time-to-surgery experienced by transferred ocular trauma patients produced poorer final visual acuities than in non-transferred study counterparts. By comparison to non-transfer patients, patients transferred from a same-state hospital to a tertiary care center for open globe surgical repair experienced longer delays between presentation at the hospital ED of origin and surgery, as well as between injury and arrival at the treating facility where treated.

In this study, UNC Ophthalmology researchers addressed the ongoing debate in managing open globe injuries when ED best practices are affected by and significant delays in surgical intervention occur due to same-state, inter-hospital transfers. This study found that many same-state hospitals chose to transfer open globe injury cases to the flagship Level 1 Trauma Center, which treats trauma cases that are wide-ranging in severity.  The UNC Ophthalmology research team acknowledges their study is limited by evaluation of records from a singular Level 1 Trauma Center, high variability among open globe cases, as well as whether ocular trauma score (OTS) is a confounding variable on injury outcomes. They conclude a multi-center, higher-powered study accounting for these limitations is warranted to better understand the relationship between final visual acuity, transfer history, time-to-surgery and OTS trauma outcomes for inter-hospital transfers from a same-state hospital to a tertiary care center.

Lead faculty study author and UNC Associate Professor of Ophthalmology, David Fleischman, MD, FACS, noted: “This study highlights the need for us to understand comfort levels for handling ocular trauma within the community. Ophthalmologists are trained for this during residency, but these skills dissipate over time, especially if handling trauma is not frequently performed.”

The study’s first author and third-year (M3) UNC School of Medicine student Elise Fernandez adds: “Our study clearly shows that transferring a patient for their surgery will add hours until they receive definitive care. Those are hours where the patient may cough, sneeze, rub their eye, or other events that may worsen the patient’s outcomes.”


* Authors: Fernandez EO, Miller HM, Pham VQ, Fleischman D.

To read an online synopsis and analysis of this study, go to: Medical Dialogues.