Experts Seek to Update Globe-Adnexal Trauma Terminology

Ophthalmic surgeons performing an eye surgery
Ophthalmic surgeons performing an eye surgery at the hospital with a microscope – healthcare and medicine concepts
Ophthalmology society members support the existing nomenclature, but recommend adding terminology to account for the various mechanisms of trauma and location of the injury.

The Birmingham Eye Trauma Terminology (BETT) system is still applicable for clinicians to describe globe and adnexal trauma, survey results suggest. But, a new effort should be initiated to better capture and monitor traumatic injuries in both clinical and research settings, according to a report on the research published in JAMA Ophthalmology. The new terminology should account for the various mechanisms of trauma as well as the location of the injury within the eye.

The study was conducted by a subgroup to the International Globe and Adnexal Trauma Epidemiology Study (IGATES), the IGATES Terminology Consensus Group. The group first performed a literature review to reveal any constraints of the applied terminology. They then held teleconferences with selected steering committee members to design and oversee a survey using modified Delphi consensus methodology. The committee developed a 2-round, English-language online survey delivered with encrypted links to members of national and multinational specialist societies who were invited as unpaid contributors.

In the first round, 69 ophthalmologists with surgery experience or publications involving the globe and adnexa returned a 25-question survey from January 1 to March 31, 2021. Of these, 58 submitted second round, 7-question surveys between June 1 to July 31, 2021. Responses were anonymized, and consensus defined as 67% agreement. 

Overall, a majority of BETTs terms were still considered appropriate by 82% of experts. The benchmark 67% was also reached to favor nomenclature for globe and adnexal trauma, rather than ocular trauma. Moreover, 75% approved inclusion of mechanisms of injury: bite, burn, intraocular foreign body, blunt, sharp, and mixed.

“The term ocular trauma only related to trauma to the globe, and the question was refined in round 2, and 67% of respondents (39 of 58) agreed on the term globe and adnexal trauma.”

Respondents confirmed BETTs definitions are current for eye wall injuries, lamellar laceration, and penetrating or perforating trauma, as well as terms labeling closed- and open-globe injury. Those surveyed approved adding language for anterior or posterior location applied to globe rupture. Participants refined trauma zone descriptions — zone I: cornea and corneoscleral limbus, zone II: outside the limbus to 5 mm posterior to it, zone IIIa: 5 mm to 8 mm posterior to the limbus, and zone IIIb: more than 8 mm posterior to the limbus.

Most respondents (81%) agreed there should be language to differentiate corneal damage at the central or paracentral region. Inclusion of lens condition was suggested as an appropriate update by 80% of experts, and retinal involvement by 73%. Regarding severe nasolacrimal system trauma, all preferred injury to the canaliculi and/or nasolacrimal ducts, but they disagreed on specification of full-thickness lid injury, lacrimal gland, lacrimal sac, and punctum damage. 

A few non-BETTs inclusions did not achieve consensus in round 1, such as impact on intraocular pressure (IOP), and vitreous trauma. Respondents noted IOP cannot be taken in every presentation, and the aim toward an uncomplex classification system.

Globe luxation and avulsion were not addressed, representing a limitation of this study. Also, a small sample and inclusion criteria may have limited generalizability. Selection bias may have also occurred due to no certification available in globe and adnexal trauma. Revised terminology will need to correlate to International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD) codes, investigators report.

Disclosures: A study author has disclosed affiliations with a medical device company. Please see the original reference for complete disclosures. 


Hoskin AK, Fliotsos MJ, Rousselot A, et al. Globe and adnexal trauma terminology surveyJAMA Ophthalmol. Published online July 21, 2022. doi:10.1001/jamaophthalmol.2022.2594