FP254 : Newly Proposed Expanded Betts Classification of Mechanical Ocular Trauma.

Dr. Ankita Mulchandani, M17408, Dr.Kashyap Patel, Dr. Parth J Rana, Dr. Anand Tibdewal, Dr. Mehul Ashvin Kumar Shah


Presentng Author: Dr. Ankita Mulchandani

Co-Authors:           Dr. Mehul Shah

                                Dr. Anand Tibdewal

                                Dr. Parth Rana

Affiliations all authors:

1.Drashti Netralaya, Dahod, Gujarat, India

Address of corresponding author:

Drashti Netralaya,

Chakalia Road.



Ph: 00-91-2673-251100 Fax: 00-91-2673-251100

Email: omtrust@rdiffmail.com

  • No financial support received from any company or institution
  • This study is not presented at any conference or meeting
  • Authors do not have any financial interest in any aspect of this study



To reinforce the Birmingham Eye Trauma Terminology (BETT) according to current needs.

Design: Prospective cohort study.

Participants: 4271 eyes of 4200 mechanical eye injury patients from Tertiary Eye Care Centre, Western Central India.


All the patients were presented to the Out-Patient department between January 2005 and December 2014, and were examined and categorised based on the BETT. Cases which did not comply with the BETT system of classification were placed in additional categories, and documented for and type of injury.

Main Outcome Measures:

The types of injury that were difficult to classify according to BETT, had to be placed in newly created categories, and followed up with documentation of figures for number and percentage of patients in the same.


Of 4721 eyes that suffered mechanical injuries, 1060 (22.4%) eyes could not be classified with BETTS. These include 368 globe injuries (7%) associated with orbital/ocular adnexa injury; 692 eyes (14.6%) with ocular surface foreign body (OSFB) or ocular wall foreign body (IMFB); 77(1.6%) eyes  with contusion, 9(0.19) eyes  with lamellar laceration associated OSFB or OWFB, 29 eyes (0.6%) with globe rupture associated OSFB, OWFB or intraocular foreign body (IOFB), and 60 eyes (1.4%) with laceration associated OSFB or OWFB.

Conclusion: BETT needs modification. Suggestions have been made for the same.

Key Words: BETTS, Reinforcement, Ocular trauma


Birmingham Eye Trauma Terminology (BETT) is an ideal ocular trauma terminology system for several reasons:  Clarifies the issue of reference, Provides a clear definition for each injury type ,Places each injury types within the framework of a comprehensive system.1

As a consequence, the BETT is widely accepted by ophthalmologists for almost one decade, and is extensively used in articles, conferences and books. In the present study however, some difficulties were encountered in application of the BETT system to classify some instances of mechanical eye injuries, because of non-specificity.

Ocular trauma classification and score are also not free from controversy, and have been challenged by several authors.2,3,4 BETTS classification needs looking into. Some authors have proposed and published newer classification systems to complement the existing BETTS.2,3,4 The present study, validates the newly created classification categories.

Materials and Methods

The present study is prospective cohort study involved all mechanical ocular trauma patients presented to the outdoor at the selected centre, between January 2005 and December 2014. The cases ranged from trivial to severe ocular injury. All patients who consented to inclusion were enrolled in the project, with the exception of life threatening poly trauma cases. Details of all enrolled patients (fresh as well as follow-up), were documented in World Eye Injury registry forms.

Patients were thoroughly examined according to standard protocol, for ocular adnexa and anterior/posterior segment findings. The information was recorded in pre-tested online format, and all eyes classified according to BETTS, which is the accepted standardised international classification of ocular trauma. Some eye injuries which were difficult to classify in this manner, were documented for type and number, and classified in supplemented categories. The documented data was exported to MS Excel spreadsheets and analysed statistically using SPSS version 22.

The entire research procedure and design complies with stipulated ethical guidelines, and adheres to the legal requirements of India, and the tenets of the Declaration of Helsinki.


A total of 4200 mechanical eye injury patients (numbering 4271 eyes) were registered during the 9-year study period, at the OP departments of the hospitals being studied. According to BETT, eye injury cases numbering 2608 (55.4%) and 1047 (22.1%) fell in the closed globe injury category and open globe injury categories respectively. However, of the total mechanical injuries, 368 eyes (7%) with merely orbital or ocular adnexa injuries, and 692 (14.6%) ocular surface and ocular wall foreign body injuries, could not be classified in either of the mentioned categories. In a broader perspective, 1060 (22.33%) eye injury cases could not be classified according to BETTS (Fig.1).

Newer categories were created as part of this study, and the above mentioned injuries were grouped accordingly (Fig.2).

Of the 2608 (55.4%) with closed globe injury, 1333 exhibited closed globe contusion, and 1273 showed lamellar laceration. 548 (12%) of eye injuries with ocular surface foreign body (OSFB), and 144 (3.5%) with ocular wall foreign body (OWFB), could not be classified, and such cases accounted for 14.5% of all mechanical eye injuries. In addition, 77 eyes with contusion and 9 with lamellar laceration associated OSFB or OWFB (constituting 1.6% and 0.19% of all closed globe injuries), failed to get categorised (Fig-1).

Of the 803 eyes with open globe injuries, rupture and laceration cases numbered 244 (5%) and 803(16.5%) respectively. The number of cases with globe rupture associated OSFB, OWFB or intraocular foreign body (IOFB) was 29, accounting for 0.6% of the gross total, 1.4% of mechanical eye injury category, 3.6% of the total open globe injuries, and 11% of all rupture injuries.

Of 803 eyes with laceration, 728 (5%) were of the penetrating type, 25 (0.5%) were cases of IOFB, and 50 (1%) showed perforation. Within the laceration group, 60 eyes were associated with OSFB or OWFB, equivalent to 1.27% of the total mechanical eye injury category, 7.4% of the total open globe injuries, and 10.6% of all laceration injuries.


Undoubtedly, BETT is the language of everyday ophthalmic clinical practice, and is endorsed by several ophthalmic organisations, journals and ophthalmologists. In the present study, it helped in eliminating many ambiguities while communicating in the domain of ocular traumatology. 5-7 However, according to some authors, BETT is not perfect, and needs to be developed and modified further in order to be the ideal system.8

BETT is believed to lay down standardised terminology for mechanical eye injuries5, but in practice, this system of terminology considers the entire optic globe as the tissue of reference, and remains concerned only with mechanical eyeball injuries. Consequently, certain injuries resist classification based on the BETT system, and in the present investigation, this group constituted 11% of the total mechanical eye injuries. Although some proportion of orbital and ocular adnexa associated globe injuries can be classified as globe injury according to the BETT system, this description is incomplete and misses out some vital information. Furthermore, some mechanical eye injuries with only orbital and ocular adnexa injuries, do not fit into any category; this group constitutes nearly 7% of all mechanical eye injuries in the present investigation. In a study of hospitalised ocular injuries among persons from a low socioeconomic background, Chen et al observed that the three foremost types of ocular injuries seeking hospitalisation, included orbital floor fracture, open wound of eyeball, and open wound of ocular adnexa.9 Another study on paediatric eye injury-related hospitalisations in the United States, reveals that open wounds of the adnexa and orbital floor fractures represented almost two-thirds of hospitalisations for adolescents aged 15 to 17 years (61.6%), as well as young adults aged 18 to 20 years (62.9%).10 In his study on the nature, incidence, and impact of eye injuries among US military personnel, Andreotti et al noted that 85% of hospitalisations were diagnosed as either orbital floor fractures (30%), contusions (28%), or open wounds to ocular adnexa and orbit (27%).11

In clinical practice, although the eyeball is more important than orbital or/ocular adnexa, mechanical injuries in the latter region could well be described if classified by listing the injured region by a definition of the anatomy of that region.

Foreign body injury, especially IOFB, is an important type of eye injury commonly seen in clinical practice. In the present study, following BETT guidelines, IOFB cases were grouped separately, because of their special management and prognostic implications, although technically, IOFB is a penetrating injury.1 OSFB and OWFB injuries are equally important components of globe injury, forming nearly 12% of all globe injuries. The percentage would rise several fold if the number of outpatients is increased.

An examination of the clinical and epidemiological profiles of ocular emergencies in a reference emergency centre, indicated that ocular surface foreign body was the most frequent occurrence, totalling 863 (58%) cases in all.12 Yet another investigation identified that corneal foreign bodies (usually iron in nature) are the most common hazard faced by workers involved in welding, grinding and hammering activities in factories.13 Such professions also pre-dispose workers to ocular adnexa associated foreign body injuries, such as eyelid foreign body, orbital foreign body and so on.14 It follows therefore, that  foreign body injury should be grouped separately, giving more details with the help of anatomical definitions.

Finally, it is proposed that, as a complement to BETT (Fig.1), as advised by Kuhn et al, injuries that are difficult to categorise may be described as “mixed”.1 In fact, many mechanical eye injuries overlap, and can be described accordingly., e.g., rupture with an IOFB, penetrating with eyelid injury, and contusion with OSFB and OWFB. 15,16 It is hoped that more ophthalmic experts get together to offer better alternatives and suggestions, in order to lend perfection to the BETT system.

Conclusion: Addition of certain categories for classification of mechanical eye injuries would succeed in improving the present system of terminology, and can encompass all those cases of eye injury that are hitherto, not being accommodated by the existing standard BETTS.

  1. Kuhn F, Morris R, Witherspoon CD. Birmingham Eye Trauma Terminology (BETT): terminology and classification of mechanical eye injuries. Ophthalmol Clin North Am 15:139-43
  2. Shah MA, Shah SM, Chaudhry AH, Pannu S.(2015) Traumatic cataracts in children: Visual outcome. World J Ophthalmol 5: 80-5
  3. Agrawal R, Shah M, Mireskandari K, Yong GK (2013)Controversies in ocular trauma classification and management: review International Ophthalmology Int Ophthalmol. 33:435-45.
  4. Shah M, Shah S, Upadhyay P, Agrawal R.(2013)Controversies in traumatic cataract classification and management: a review. Can J Ophthalmol.48:251-8.
  5. Shah M, Shah S, Shah S, Prasad V, Parikh A.(2011) Visual recovery and predictors of visual prognosis after managing traumatic cataracts in 555 patients. Indian J Ophthalmol. 59:217-22.
  6. Onakpoya OH, Adeoye A, Adeoti CO Ajite K.(2010) Epidemiology of ocular trauma among the elderly in a developing country. Ophthalmic Epidemiol. 17:315-20.
  7. Mansouri MR, Hosseini M, Mohebi M, Alipour F, Mehrdad R.(2010)Work-related eye injury: the main cause of ocular trauma in Iran. Eur J Ophthalmol. 20:770-5.
  8. Kuhn F, Morris R, Witherspoon CD, Mester V.(2004) The Birmingham Eye Trauma Terminology system (BETT). J Fr Ophtalmol. 27:206-10.
  9. Chen G, Sinclair SA, Smith GA, Ranbom L, Xiang H.(2006) Hospitalized ocular injuries among persons with low socioeconomic status: a medicaid enrollees-based study. Ophthalmic Epidemiol. 13:199-207.
  10. Brophy M, Sinclair SA, Hostetler SG, Xiang H.(2006) Pediatric eye injury-related hospitalizations in the United States. Paediatrics. 117:1263-71.
  11. Andreotti G, Lange JL, Brundage JF.(2001) The nature, incidence, and impact of eye injuries among US military personnel: implications for prevention. Arch Ophthalmol.119:1693-7.
  12. Cecchetti DF, Cecchetti SA, Nardy AC, Carvalho SC, Rodrigues Mde L, Rocha EM.(2008) A clinical and epidemiological profile of ocular emergencies in a reference emergency centre. Arq Bras Oftalmol. 71:635-8.
  13. Aziz MA, Rahman MA.(2004) Corneal foreign body–an occupational hazard. Mymensingh Med J. 13:174-6.
  14. Santos Tde S, Melo AR, Moraes HH, and Almeida Júnior P, Dourado E. (2010) Impacted foreign bodies in orbital region: review of nine cases. Arq Bras Oftalmol. 73:438-42.
  15. Larque-Daza AB, Peralta-Calvo J, Lopez-Andrade J.(2010) Epidemiology of open-globe trauma in the southeast of Spain. Eur J Ophthalmol. 20:578-83.
  16. Chen KJ, Sun MH, Hou CH, Chen TL.(2008) Retained large nail with perforating injury of the eye. Graefes Arch Clin Exp Ophthalmol. 246:213-5

FP241 : Visual Outcome of Surgical Management in Severely Traumatized Eyes Presenting with Nolightperception
FP1630 : Characteristics for Early Predictors of Traumatic Glaucoma After Closed Globe Injury

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