Bloodshot: Ocular lacerations from gunshot wounds

The word “bloodshot” is defined as red and inflamed by swelling of blood vessels, or subconjunctival hemorrhage. The term was coined in the 1550s and derived from bloodshotten—from the noun “blood” and the old past participle of “shoot,” a verb.* Many different ocular pathologies may result in conjunctival injection, or a bloodshot eye. The differential runs the gamut from allergies, dry eye, contact lens overwear, and viral or bacterial conjunctivitis, to more serious eye conditions, such as uveitis or glaucoma.

Keeping an eye out for complications

Gunshot wounds account for 6 percent of all ocular injuries reported to the U.S. Eye Injury Registry Database. These injuries often occur unintentionally at home and more commonly in young, minority men. The exposed surface of the eye accounts for 0.1 percent of the frontal surface area of the body; however, the projectile-related damage is 50 times greater than what one would expect based upon surface area alone. Nearly 30 percent of all facial and cranial gunshot wound victims present with ocular injuries, and, of those, more than 50 percent lead to permanent visual dysfunction.

Management of ocular gunshot wounds requires the fundamentals of wound care similar to gunshot wounds in other areas of the body, such as routine tetanus prophylaxis. However, as a result of the complex and delicate anatomy of this area, special challenges arise. Broad-spectrum antibiotics are administered more liberally in an effort to prevent posttraumatic endophthalmitis, a devastating complication of an open-globe injury. Patients with ocular lacerations undergoing wound closure greater than 24 hours, injuries occurring in a rural setting, having a retained intraocular foreign body, intraocular tissue prolapse, large wound size, and ruptured lens capsule are conditions associated with a higher risk of endophthalmitis.

Another rare but significant complication of open-globe injuries is sympathetic ophthalmia, which is estimated to develop in less than 1 percent of cases. It is an incompletely understood autoimmune phenomenon initiated by the exposure of previously sequestered ocular self-antigens from the injured eye that results in a bilateral, diffuse, granulomatous non-necrotizing panuveitis and vision loss in the uninjured, or sympathizing, eye. This condition has been reported as early as five days and up to 56 years later. The overwhelming majority occur within three months to a year. Initial treatment is with systemic corticosteroids, immunomodulatory therapy, topical corticosteroids, topical cycloplegics, and occasionally intravitreal corticosteroid injections.

Enucleation of the traumatized (exciting) eye within 14 days should be considered in patients with severely disorganized eyes that have no discernible visual function to prevent the development of sympathetic ophthalmia in the other eye. Enucleation of the exciting eye offers no benefit once the disease process of sympathetic ophthalmia has started.

Incidence and outcomes

To examine the occurrence of ocular lacerations resulting from gunshot wounds, the National Trauma Data Bank® (NTDB®) research admission year 2017 medical records were searched using the International Classification of Diseases, Tenth Revision Clinical Modification codes. Specifically searched were records that contained one of 192 nonwar-related E codes for penetrating injury and one of the following diagnosis codes:

  • S05.20XA (ocular laceration and rupture with prolapse or loss of intraocular tissue, unspecified eye)
  • S05.21XA (ocular laceration and rupture with prolapse or loss of intraocular tissue, right eye)
  • S05.22XA (ocular laceration and rupture with prolapse or loss of intraocular tissue, left eye)
  • S05.30XA (ocular laceration without prolapse or loss of intraocular tissue, unspecified eye)
  • S05.31XA (ocular laceration without prolapse or loss of intraocular tissue, right eye)
  • S05.32XA (ocular laceration without prolapse or loss of intraocular tissue, left eye)

A total of 405 records were found, 337 of which contained a discharge status, including 194 patients discharged to home, 83 to acute care/rehab, 12 to skilled nursing facilities, and six to law enforcement; 42 died (see Figure 1). Of these patients, 67 percent were male, on average 35.2 years old, had an average hospital length of stay of 10 days, had an intensive care unit length of stay of 7.9 days, had an average injury severity score of 17.0, and were on the ventilator for an average of 6.4 days. Of those patients tested for alcohol, 30 percent (82 of 268) tested positive.

Figure 1. Hospital Discharge Status

Figure 1. Hospital Discharge Status

The eye is an organ that is roughly the size of a large marble, yet at least seven different ophthalmologic specialties are focused on its care. While taking an overnight red-eye airline flight and reading a computer screen until landing may result in bloodshot eyes, a good night’s rest and some artificial tears will resolve that malady. However, a gunshot wound that results in an ocular laceration has a significant chance of resulting in permanent vision loss.

Throughout the year, we highlight these data through brief reports that are published monthly in the Bulletin. If you are interested in obtaining Trauma Quality Programs (TQP) data for your own analysis, or your trauma center is interested in participating in the TQP, e-mail us at traumaquality@facs.org or find more information on the ACS website.

Acknowledgment

Statistical support for this column was provided by Ryan Murphy, Data Analyst, NTDB.


*Online Etymology Dictionary. Bloodshot definition. Available at: www.etymonline.com/word/bloodshot. Accessed July 25, 2019.

Erickson BP, Feng PW, Ko MJ, Modi YS, Johnson TE. Gun-related eye injuries: A primer. Surv Ophthalmol. Available at: www.clinicalkey.com/#!/content/playContent/1-s2.0-S0039625718301644?returnurl=null&referrer=null. Accessed July 25, 2019.

Read RW, Acharya N, Levinson RD, et al. Noninfectious Ocular Inflammatory Diseases. In: Intraocular Inflammation and Uveitis. 2018–2019 Edition. San Francisco, CA: American Academy of Ophthalmology; 2018:111-182.

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