Huckhagel et al.

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

(2020) 28:15
https://doi.org/10.1186/s13049-020-0712-5

ORIGINAL RESEARCH Open Access

Damage to the eye and optic nerve in

seriously traumatized patients with
concomitant head injury: analysis of 84,627
cases from the TraumaRegister DGU®
between 2002 and 2015
Torge Huckhagel1* , Jan Regelsberger1, Manfred Westphal1, Jakob Nüchtern2 and Rolf Lefering3

Abstract
Background: To determine the prevalence and characteristics of prechiasmatic visual system injuries (VSI) among
seriously injured patients with concomitant head trauma in Europe by means of a multinational trauma registry.
Methods: The TraumaRegister DGU® was searched for patients suffering from serious trauma with a Maximum
Abbreviated Injury Scale (AIS) ≥ 3 between 2002 and 2015 in Europe. After excluding cases without significant head injury
defined by an AIS ≥ 2, groups were built regarding the existence of a concomitant damage to the prechiasmatic optic
system comprising globe and optic nerve. Group comparisons were performed with respect to demographic, etiological,
clinical and outcome characteristics.
Results: 2.2% (1901/84,627) of seriously injured patients with concomitant head trauma presented with additional VSI.
These subjects tended to be younger (mean age 44.7 versus 50.9 years) and were more likely of male gender (74.8%
versus 70.0%) compared to their counterparts without VSI. The most frequent trauma etiologies were car accidents in
VSI patients (28.5%) and falls in the control group (43.2%). VSI cases were prone to additional soft tissue trauma of the
head, skull and orbit fractures as well as pneumocephalus. Primary treatment duration was significantly longer in the VSI
cohort (mean 23.3 versus 20.5 days) along with higher treatment costs and a larger proportion of patients with
moderate or severe impairment at hospital discharge despite there being a similar average injury severity at admission in
both groups.
Conclusions: A substantial proportion of patients with head injury suffers from additional VSI. The correlation between
VSI and prolonged hospitalization, increased direct treatment expenditures, and having a higher probability of
posttraumatic impairment demonstrates the substantial socioeconomic relevance of these types of injuries.
Keywords: Craniocerebral trauma, Epidemiology, Eye injuries, Optic nerve injuries

* Correspondence: torgehuckhagel@gmx.de
1
Department of Neurosurgery, University Medical Center
Hamburg-Eppendorf, Hamburg, Germany
Full list of author information is available at the end of the article

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Huckhagel et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2020) 28:15 Page 2 of 8

Background Management (Sektion NIS) of the German Trauma

Eye injuries are a significant global health problem with Society. Participating hospitals submit their data, which
a worldwide annual incidence of about 55 million people is pseudonymized, into a central database via a web-
impaired during their daily activities and 1.6 million based application. Overall completeness of data collec-
people with posttraumatic binocular blindness [1]. The tion has proven to be high, as laid down in the regularly
frequency of ocular trauma depends on numerous upcoming reports of the registry [9]. Scientific data ana-
factors including geographical, socioeconomic and also lysis is approved through a peer review procedure laid
seasonal circumstances [2–5]. In Germany, annual inci- down in the TR-DGU publication guideline. The partici-
dence rates of 302 and 30.5 per 100,000 inhabitants have pating hospitals are primarily located in Germany (90%),
been determined for mild and severe head trauma previ- but a growing number of hospitals in other countries are
ously [6, 7], but there is a general lack of information on contributing data as well. Currently, approximately 35,
the frequency of patients suffering from head and face 000 cases from almost 700 hospitals are entered into the
trauma with additional injury to the prechiasmatic visual database per year. A comprehensive list of all contribut-
system (VSI) which comprises of the globe and the optic ing institutions is available at the TR-DGU website
nerve. To the best of our knowledge, this is the first- (www.traumaregister-dgu.de). Participation in TR-DGU
time report aiming to determine the prevalence and is voluntary. For hospitals associated with TraumaNetz-
characteristics of VSI among seriously injured patients werk DGU®, however, the entry of at least a basic data
with concomitant moderate to severe head trauma in set is obligatory for reasons of quality assurance. After
the Central European setting by means of a large multi- identification of a total of 270,516 TR-DGU cases be-
national trauma registry. tween 2002 and 2015, all patients were assessed accord-
ing to our study protocol presented in detail in Fig. 1
Methods (flowchart _study population). Of note, all included pa-
All data analyzed in this survey were derived from the tients received serious injuries defined by a maximum
TraumaRegister DGU® (TR-DGU) upon receipt of an Abbreviated Injury Scale (AIS) score ≥ 3 and also a col-
authorization by the institutional review board in 2018. lateral head or face trauma with an AIS score ≥ 2. The
Data presentation follows the established guidelines for AIS forms a foundation for several trauma scores includ-
reporting observational studies outlined in the strength- ing the Injury Severity Score (ISS), which was first pub-
ening the reporting of observational studies in epidemi- lished in 1971 and underwent its last update in 2015
ology (STROBE) statement [8]. Moreover, the study fully (www.aaam.org; accessed 24 April, 2019) [10–12]. Non-
adheres to the publication guidelines of the TR-DGU European cases were excluded according to our aims to
and is registered as TR-DGU project 2018–014. The determine VSI epidemiology in the European setting. Pa-
TR-DGU of the German Trauma Society (Deutsche Ge- tients who died or were transferred to another institu-
sellschaft für Unfallchirurgie, DGU) was founded in tion within 48 h after hospital admission were also
1993. The aim of this multicenter database is a pseudo- excluded. This was done for two reasons: 1) Detection of
nymized and standardized documentation of severely in- VSI in individuals who died after a short time may be
jured patients. The TR-DGU collects data prospectively difficult and 2) Patients relocated at an early stage of
in four consecutive time phases from the site of the acci- treatment could otherwise be counted twice erroneously.
dent until discharge from hospital: A) Pre-hospital The resulting study population (n = 84,627) was subse-
phase, B) Emergency room and initial surgery, C) Inten- quently separated into two groups depending on the ex-
sive care unit and D) Discharge. The documentation in- istence of an additional VSI. VSI comprise injuries to the
cludes detailed information on demographics, injury globe and/or optic nerve and are represented by the fol-
pattern, comorbidities, pre- and in-hospital manage- lowing AIS 2005 codes currently utilized by the TR-
ment, course on intensive care unit, relevant laboratory DGU: 240499.1, 241,006.2, 241,200.2, 240,402.2 and 240,
findings including data on transfusion and outcome of 403.3 for eye injuries of different forms as well as 230,
each individual. Their inclusion criteria are admission to 202.2, 230,204.2 and 230,205.3 for traumatic optic neur-
hospital via emergency room with subsequent intensive opathy. Detailed information on the aforementioned
care unit (ICU) care or reaching the hospital alive, but codes is provided in supplement 1. VSI were detected by
with death occurring before ICU admission. The infra- a combined approach including neurological assessment
structure for documentation, data management, and data in all cases as well as cranial computed tomography in
analysis is provided by AUC - Academy for Trauma Sur- 91.8% of non-VSI and 93.4% of VSI patients. Both
gery (AUC - Akademie der Unfallchirurgie GmbH), a groups (VSI and control group) were compared with re-
company affiliated to the German Trauma Society. The gard to demographic and etiological characteristics as
scientific leadership is provided by the Committee on well as injury patterns, extent of the trauma measured
Emergency Medicine, Intensive Care and Trauma by the ISS, treatment duration, functional outcome in
Huckhagel et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2020) 28:15 Page 3 of 8

Table 1 Demographic characteristics as percentages with their related 95% confidence inter-
control group VSI group vals (CI) and central tendency measures with their asso-
male (%) 70.0 (CI 69.4–70.6) 74.8 (CI 70.8–79.0) ciated standard deviations (SD), where appropriate. All
mean / median age (years) 50.9 / 52.0 (SD 22.8) 44.7 / 45.0 (SD 21.4)
statistical calculations were performed using IBM SPSS
Statistics (version 24, International Business Machines
age ≤ 15 years (%) 4.5 (CI 4.3–4.6) 5.7 (CI 4.7–6.9)
Corporation, Armonk, NY, USA).
age 16–59 years (%) 56.6 (CI 56.1–57.1) 67.3 (CI 63.6–71.1)
age ≥ 60 years (%) 38.9 (CI 38.5–39.4) 27.0 (CI 24.7–29.4)
Gender and age distribution of head trauma patients ± concomitant Results
prechiasmatic visual system injury (VSI). CI 95% conficence interval, SD Prevalence of eye and optic nerve injuries in moderate to se-
standard deviation
vere head trauma patients 2.2% (CI 2.1–2.3%) of the total
terms of the Glasgow Outcome Scale Score (GOS) at the study population (n = 84,627) comprised of seriously injured
end of primary hospital treatment, and need for further patients with additional moderate to severe head trauma
inpatient care after primary hospital discharge [13]. suffered from accompanying VSI. The vast majority of the
Moreover, treatment expenditures were calculated for VSI cases showed ocular damage (87.0%; CI 82.9–91.3%)
both cohorts using the TR-DGU cost estimator imple- and only a minority presented with optic nerve trauma
mented by Lefering et al. [14]. The registry-based data (13.0%, CI 11.4–14.7%). One out of four patients with globe
material is outlined in a descriptive mode with primary injury presented with traumatic loss of an eye and more
focus on practical relevance, because the extensive sam- than 96% of traumatic optic neuropathies were unilateral.
ple size will easily render even clinically negligible differ- The detailed distribution of VSI is delineated in Fig. 2 (flow-
ences statistically significant. Frequencies are presented chart_distribution of visual system injuries).

Fig. 1 flowchart_study populationDescription of study inclusion and exclusion criteria. (M)AIS = (Maximum) Abbreviated Injury Scale. TR-DGU =
TraumaRegister DGU® of the German Trauma Society.
Huckhagel et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2020) 28:15 Page 4 of 8

Table 2 Etiology and mechanism of trauma whereas falls were more commonly seen in the control
control group VSI group cohort (43.2% versus 26.6%). Violent attacks including
traffic accident_car (%) 18.8 (CI 18.5–19.1) 28.5 (CI 26.2–31.1) stabbings and shootings were rarely encountered in both
traffic accident_motorbike (%) 9.1 (CI 8.9–9.3) 9.1 (CI 7.8–10.5)
groups, but generally affected VSI patients more fre-
quently. Penetrating trauma mechanisms accounted for
traffic accident_bicycle (%) 11.7 (CI 11.5–12.0) 11.3 (CI 9.8–12.9)
a slightly larger proportion of VSI compared to head in-
traffic accident_pedestrian (%) 7.7 (CI 7.5–7.9) 6.8 (CI 5.6–8.0) juries without involvement of the prechiasmatic optic
high fall > 3 m (%) 15.3 (CI 15.1–15.6) 12.7 (CI 11.2–14.4) system. Table 2 (table_etiology and mechanism of
low fall < 3 m (%) 27.9 (CI 27.5–28.3) 13.9 (CI 12.3–15.7) trauma) reveals in-depth data on trauma etiology and in-
punch (%) 3.0 (CI 2.8–3.1) 6.5 (CI 5.4–7.8) jury mechanisms for both groups.
shot (%) 0.3 (CI 0.3–0.4) 1.2 (CI 0.7–1.8)
Description of accompanying lesions
stab (%) 0.3 (CI 0.2–0.3) 0.8 (CI 0.4–1.3)
VSI patients suffered more frequently from associated
other reason (%) 5.9 (CI 5.8–6.1) 9.2 (CI 8.0–10.8) thoracoabdominal and limb injuries compared to their
blunt trauma (%) 97.8 (CI 97.1–98.5) 92.9 (CI 88.6–97.4) non-VSI counterparts, whereas similar frequencies could
penetrating trauma (%) 2.2 (CI 2.1–2.3) 7.1 (CI 5.9–8.4) be recorded for concomitant spine and pelvic trauma.
Comparison between head trauma cases ± additional prechiasmatic visual When comparing both groups with regard to intracra-
system injury (VSI) regarding trauma etiology and underlying mechanism. CI nial lesions, VSI cases showed larger proportions of pri-
95% confidence interval
mary pneumocephalus (4.1% versus 1.1%) and epidural
hematoma (12.7% versus 10.2%), but the frequencies of
Demographic comparison between head trauma patients brain contusion, global brain edema, pituitary and brain
with and without VSI stem injuries were distributed almost equally across both
VSI patients were more frequently male as compared to groups with pituitary and brain stem lesions being quite
the control group (74.8% versus 70.0%). We found that rare events. More superficially located damage to the
VSI patients were on average 6.2 years younger in com- head like soft tissue lacerations and skull fractures - es-
parison to the control group. Table 1 (table_demographic pecially orbit and Le Fort fractures - occurred much
characteristics) provides specific information on demo- more commonly in VSI patients compared to the control
graphic characteristics of both cohorts and includes a fur- group. Of note, subdural hematoma and intracerebral
ther differentiation into three distinct age categories. hemorrhage were more frequently seen in the control
group. Intracranial arteries and veins were injured only
Trauma etiology and injury mechanisms sporadically in VSI and non-VSI cases. Table 3 (table_
VSI resulted more frequently from car accidents com- concomitant lesions) delineates comprehensive data on
pared to the control group (28.5% versus 18.8%), accompanying involvement of other body regions as well

Fig. 2 flowchart__distribution of visual system injuries. Composition of the study population with respect to different types of prechiasmatic
optic system lesions. VSI = visual system injury
Huckhagel et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2020) 28:15 Page 5 of 8

Table 3 Concomitant lesions medical expenses. 23.4% of globe injuries and 20.5% of
control group VSI group optic nerve injuries were treated surgically, but detailed
thorax (AIS > 1) (%) 43.9 (CI 43.4–44.3) 46.8 (CI 43.7–50.0) description of the utilized ophthalmosurgical and neuro-
abdomen (AIS > 1) (%) 11.9 (CI 11.6–12.1) 15.0 (CI 13.3–16.9)
surgical procedures is well beyond the scope of the TR-
DGU and therefore not provided.
spine (AIS > 1) (%) 25.1 (CI 24.7–25.4) 24.1 (CI 21.9–26.5)
pelvis (AIS > 1) (%) 13.1 (CI 12.9–13.4) 13.5 (CI 11.9–15.2) Outcome following primary treatment
upper extremity (AIS > 1) (%) 28.8 (CI 28.5–29.2) 33.9 (CI 31.4–36.7) The proportion of patients with mild to severe disability
lower extremity (AIS > 1) (%) 19.7 (CI 19.3–20.0) 23.4 (CI 21.3–25.7) (GOS 3–4) was larger in the VSI compared to the con-
pneumocephalus (%) 1.1 (CI 1.1–1.2) 4.1 (CI 3.2–5.1) trol group (45.1% versus 39.3%), whereas an almost
brain contusion (%) 25.2 (CI 24.8–25.5) 26.1 (CI 23.9–28.5)
equal percentage of cases with good recovery (GOS 5)
could be detected in both cohorts. VSI patients did not
global brain edema (%) 8.9 (CI 8.7–9.1) 9.4 (CI 8.0–10.8)
differ from non-VSI cases with respect to the need for
pituitary (%) 0.1 (CI 0.1–0.2) 0.3 (CI 0.1–0.6) further inpatient care (e.g. rehabilitation facility) follow-
brain stem (%) 2.1 (CI 2.0–2.2) 2.3 (CI 1.7–3.0) ing discharge from the hospital they were admitted to
soft tissue of the head (%) 22.7 (CI 22.4–23.0) 34.8 (CI 32.1–37.5) for primary treatment. Table 5 (table_outcome) displays
skull fractures (%) 41.5 (CI 41.0–41.9) 49.2 (CI 46.2–52.5) detailed information on GOS scores and hospital dis-
orbit fractures (%) 10.2 (CI 9.9–10.4) 31.6 (CI 29.5–33.7)
charge status for both groups.
a
Le Fort fractures (%) 7.0 (CI 6.8–7.2) 22.4 (CI 20.5–24.2)
Discussion
epidural hematoma (%) 10.2 (CI 9.9–10.4) 12.7 (CI 11.1–14.4) We primarily aimed to determine the prevalence and
subdural hematoma (%) 33.6 (CI 33.2–34.0) 23.7 (CI 21.5–26.0) characteristics of VSI in seriously injured patients with
subarachnoid hemorrhage (%) 27.3 (CI 27.0–27.7) 26.4 (CI 24.1–28.8) concomitant moderate to severe head trauma in Central
intracerebral hemorrhage %) 15.5 (CI 15.3–15.8) 13.4 (CI 11.7–15.1) Europe. According to the TR-DGU data presented in
external carotid artery (%) 0.0 (CI 0.0–0.0) 0.1 (CI 0.0–0.3)
this study, 2.2% of seriously traumatized patients with
significant head injury suffer from concomitant VSI with
internal carotid artery (%) 0.3 (CI 0.3–0.3) 0.7 (CI 0.4–1.2)
damage to the eye being much more frequent than optic
anterior cerebral artery (%) 0.1 (CI 0.0–0.1) 0.2 (CI 0.0–0.5) nerve trauma. Recent data published by Maegele et al.
middle cerebral artery (%) 0.2 (CI 0.2–0.3) 0.2 (CI 0.1–0.5) reveal an annual incidence of 10.1 moderate to severe
posterior cerebral artery (%) 0.1 (CI 0.1–0.1) 0.2 (CI 0.0–0.5) head trauma cases per 100,000 inhabitants of Germany,
vertebral artery (%) 0.2 (CI 0.2–0.2) 0.4 (CI 0.1–0.8) which would result in an estimated incidence of about
cerebral veins (%) 0.4 (CI 0.4–0.5) 0.8 (CI 0.5–1.4)
0.2 VSI per 100,000 people [15]. The incidence of ocular
trauma is known to be dependent on various factors like
Detailed exposition of associated lesions in head trauma patients ±
prechiasmatic visual system injury (VSI). a Without Le Fort fracture type 1. CI age, gender as well as socioeconomic and geographical
95% confidence interval background with a markedly higher risk of eye injuries
in developing countries compared to modern industrial
as damage to different extra- and intracranial structures societies [3, 16]. Legislative measures, education pro-
for both groups. grams, and the utilization of protection tools have been
able to reduce ophthalmic injury rates in children [17–
Injury severity and treatment characteristics 19]. Our finding of globe injury being more frequent
The median ISS was the same in both groups (22.0) in- than traumatic optic neuropathy is in line with previ-
dicating a comparable average burden of trauma for VSI ously published population-based studies [20, 21]. Gen-
and non-VSI cases, but the median number of intub- erally speaking, VSI patients tended to be younger and
ation and ICU days as well as total length of hospital were more frequently male compared to those without
stay varied significantly between both cohorts with a eye or optic nerve damage. Previous studies from other
general need for longer median total inpatient treatment world regions have revealed comparable results with re-
time in VSI patients (18.0 versus 15.0 days). In congru- spect to age susceptibility and gender distribution for
ence with that finding, estimated median primary care pediatric and adult eye trauma [5, 22–24]. The vulner-
treatment costs of VSI cases were considerably higher ability of adult males with regard to ophthalmic lesions
compared to head trauma patients without globe or may be related to the higher percentage of male em-
optic nerve injury (16,540.50 versus 13,266.00 Euro). ployees in the industrial and agriculture sectors, which
Table 4 (table_severity of injury and treatment duration) are known to be particularly prone to ocular injuries
gives specific information on injury severity measures, [25]. Trauma etiology was markedly different between
primary care treatment periods and calculated direct patients with versus patients without accompanying VSI.
Huckhagel et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2020) 28:15 Page 6 of 8

Table 4 Severity of injury and treatment duration

control group VSI group
mean / median ISS 23.5 / 22.0 (SD 11.0) 25.1 / 22.0 (SD 10.9)
preclinical GCS ≤ 8 (%) 31.2 (CI 30.8–31.6) 30.3 (CI 27.7–33.3)
preclinical shock (RR sys ≤ 90 mmHg) (%) 10.4 (CI 10.2–10.7) 14.1 (CI 12.2–16.2)
mean / median intubation time (days) 5.8 / 1.0 (SD 9.9) 7.0 / 2.0 (SD 11.0)
mean / median ICU treatment duration (days) 10.0 / 5.0 (SD 12.4) 11.7 / 6.0 (SD 13.8)
mean / median hospital stay (days) 20.5 / 15.0 (SD 19.7) 23.3 / 18.0 (SD 19.9)
mean / median calculated treatment costs (Euro) 21,083.1 / 13,266.0 (SD 21,611.2) 24,511.5 / 16,540.5 (SD 23,825.6)
Severity of injury, duration of primary treatment and estimated medical expenses of head trauma cases ± accompanying injury of the prechiasmatic visual system
(VSI). CI 95% confidence interval, GCS Glasgow Coma Scale, ICU intensive care unit, ISS Injury Severity Score, SD standard deviation

In general, VSI resulted more commonly from car colli- previously, especially in the case of posterior and/or lat-
sions and non-VSI trauma arose more frequently from eral extension of the fracture [28, 29]. Of note, final vis-
falls. Injuries due to violent attacks were exceptionally ual prognosis is reported to be worse in severe eye
rare, but were more frequently seen in the VSI cohort. trauma with associated orbit fracture [30]. Moreover,
The literature reveals heterogeneous information on eye frontal bone fractures are known to be closely related to
trauma causes. Past surveys reported on a majority of posttraumatic pneumocephalus, which was also seen
occupation-related eye injuries [21, 23], whereas Qi et al. more commonly in VSI patients in our study [31]. Des-
identified firecrackers and traffic accidents as primary pite similar global burden of injuries in both cohorts,
causes of ocular trauma leading to hospitalization in a VSI exhibited longer average ICU and total hospital stay
large Chinese cohort study comprising 5799 patients as well as higher primary care treatment expenses. The
[26]. Falls were determined to be the leading cause of median treatment duration of 18 days in VSI patients is
corneal and scleral ruptures in geriatric patients corre- slightly longer than the average hospitalization time of
sponding to another study from Hong Kong [27]. The pediatric eye trauma patients reported by Karim-Zade
discrepancies concerning our results may be explained et al., which might be explained by the associated ser-
by the present TR-DGU inclusion criterion of hospital iousness of the injuries in the TR-DGU derived cases
admission via emergency room with subsequent ICU [32]. More than one out of five VSI patients underwent
care which deviates from the typical patient population surgery targeting the globe or optic nerve damage, but
at tertiary eye referral centers without concomitant life- detailed information on specific procedures is unfortu-
threatening injuries. Our registry-based data reveal more nately not obtainable from the registry database. There
frequent soft tissue lesions and skull fractures including is a growing body of evidence concerning the benefits of
orbit and Le Fort fractures in VSI cases compared to early surgical interventions such as globe repositioning
head trauma patients without prechiasmatic visual im- and repair, removal of intraocular foreign bodies as well
pairment. A correlation between ocular injuries and as supporting intravitreal antibiotics and preventive vi-
orbit fractures has been detected by several authors trectomy following open globe trauma [3, 33–38].

Table 5 Outcome
control group VSI group
a
GOS_1 _death > 48 h (%) 10.1 (CI 9.9–10.4) 4.7 (CI 3.8–5.9)
GOS_2_persistent vegetative state (%) 3.3 (CI 3.1–3.4) 3.0 (CI 2.3–3.9)
GOS_3_severe disability (%) 13.1 (CI 12.8–13.3) 16.1 (CI 14.3–18.1)
GOS_4_moderate disability (%) 26.2 (CI 25.8–26.5) 29.0 (CI 26.7–31.6)
GOS_5_good recovery (%) 47.4 (CI 46.9–47.8) 47.1 (CI 43.9–50.3)
discharge_home (%) 42.2 (CI 41.8–42.6) 43.8 (CI 40.8–46.9)
discharge_rehabilitation (%) 30.8 (CI 30.4–31.2) 32.9 (CI 30.4–35.5)
discharge_hospital (%) 13.7 (CI 13.4–13.9) 15.2 (CI 13.5–17.1)
discharge_death or other (%) 13.3 (CI 13.1–13.6) 8.1 (CI 6.9–9.5)
Description of functional outcome for head trauma patients ± prechiasmatic visual system injury (VSI) by means of Glasgow Outcome Scale Score (GOS) and need
for further medical attention following primary care discharge. a Individuals dying later than 48 h following hospital admission. Patients perishing within 48 h after
admission were excluded from the analysis according to the study exclusion criteria
Huckhagel et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2020) 28:15 Page 7 of 8

Patients with VSI showed increased disability rates at complementary approach of clinical and radiological
hospital discharge compared to those without visual dys- examination provides a substantial increase in the detec-
function. Taking into account the young average age of tion rate of damages to the prechiasmatic visual system.
the VSI patients and the great importance of good vision
for most professional activities, one can easily imagine Conclusion
the profound socioeconomic significance of these lesions A substantial number of seriously injured patients with
beyond individual misfortune. On a global scale, Negrel head trauma suffers from additional VSI. Through the
et al. reported on approximately 1.6 million people with provided data concerning characteristic trauma mecha-
injury-related blindness and an additional 2.3 million nisms and injury patterns, clinicians may be able to bet-
cases of trauma-related bilateral low vision [1]. One limi- ter identify and focus on patients at higher risk for
tation of this study is the lack of information on the type ocular and optic nerve lesions, which may eventually im-
of ocular injury. The TR-DGU is a registry aiming to prove visual outcomes in these cases. The correlation
standardize documentation of severely injured patients between VSI and higher probability of posttraumatic
and is not explicitly dedicated to eye injuries. Therefore, functional impairment demonstrates the urgent need for
well-established prognostic scores and specific termin- more effective preventive measures as well as improve-
ology like the Ocular Trauma Score and the Birmingham ment of the current therapeutic methods used to treat
Eye Trauma Terminology are not obtainable from the these injuries in order to reduce their detrimental im-
underlying database [39, 40]. Moreover, TR-DGU data pact at both the individual and also societal level.
collection terminates at hospital discharge, which im-
pedes presentation of long-term functional outcome. All Supplementary information
admitted patients are initially examined by specialized Supplementary information accompanies this paper at https://doi.org/10.
1186/s13049-020-0712-5.
trauma surgeons and not primarily by ophthalmologists,
which could potentially lead to systematic underreport- Additional file 1.
ing of minor ocular injuries. Furthermore, the propor-
tion of patients undergoing dedicated contrast-enhanced Abbreviations
vascular imaging is not reported, which may constitute a AIS: Abbreviated Injury Scale; CI: 95% confidence interval; GCS: Glasgow
source of error regarding the detection of accompanying Coma Scale; GOS: Glasgow Outcome Scale; ICU: Intensive care unit; ISS: Injury
Severity Score; SD: Standard deviation; TR-DGU: TraumaRegister DGU® of the
cerebrovascular injuries. Additionally, patients directly German Trauma Society; VSI: Prechiasmatic visual system injury comprising
transferred to specialized neurosurgical and/or ophthal- globe and optic nerve
mological care without trauma team activation upon ad-
Acknowledgements
mission do not meet the inclusion criteria of the registry We are very grateful for the methodological support provided by the review
and therefore constitute a case selection bias. In the board of the TraumaRegister DGU® of the German Trauma Society.
early phase of data collection a potential bias resulting
Authors’ contributions
from a disproportionate high rate of contributing max- TH conceived the study. TH and RL collected data. TH and RL analyzed data.
imum care hospitals cannot be excluded, but one should All authors contributed to the manuscript and approved the final text prior
keep in mind that patients with head injuries tend to be to submission.
more likely referred to large trauma centers with neuro-
Funding
surgical service. The possible bias is therefore limited by The authors received no specific funding for this work.
the inclusion criteria. The major strengths of this survey
include its multinational origin, having a large number Availability of data and materials
All epidemiological data presented in this study were retrieved from the
(more than 84.6 thousand) of head trauma cases, and TraumaRegister DGU® of the German Trauma Society. The datasets are
having a comprehensive evaluation of basic demograph- available from the registry on reasonable request.
ics, trauma etiology, associated injuries, treatment course
Ethics approval and consent to participate
and costs as well as neurologic outcome with respect to The present study is in agreement with the publication guidelines of the
present or absent additional VSI. There is a high data TraumaRegister DGU® of the German Trauma Society and received the
representativity and generalizability for Germany due to registration ID 2018–014 upon approval by the institutional review board.

a nationwide coverage of contributing hospitals of differ- Consent for publication

ent levels of care. Completeness and quality of data have Not applicable.
been shown to meet high standards, as laid down in the
Competing interests
official annual reports of the registry [9]. In addition, The authors declare that they have no competing interests.
more than 90% of individuals of both groups underwent
emergency cranial computed tomography, which is the Author details
1
Department of Neurosurgery, University Medical Center
preferred imaging tool for the detection of bony skull Hamburg-Eppendorf, Hamburg, Germany. 2Department of Trauma, Hand and
and facial lesions as well as acute hemorrhages. The Reconstructive Surgery, University Medical Center Hamburg-Eppendorf,
Huckhagel et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2020) 28:15 Page 8 of 8

Hamburg, Germany. 3Institute for Research in Operative Medicine (IFOM), 24. Puodžiuvienė E, Jokūbauskienė G, Vieversytė M, Asselineau K. A five-year
University of Witten/Herdecke, Cologne, Germany. retrospective study of the epidemiological characteristics and visual
outcomes of pediatric ocular trauma. BMC Ophthalmol. 2018;18:10.
Received: 3 October 2019 Accepted: 21 February 2020 25. Gobba F, Dall’Olio E, Modenese A, De Maria M, Campi L, Cavallini G. Work-
related eye injuries: a relevant health problem. Main Epidemiological Data
from a Highly-Industrialized Area of Northern Italy. Int J Environ Res Public
Health. 2017;14:604.
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