How Well Do Ocular Trauma Scores Predict Vision After Open Globe Injury? A Systematic Review and Meta-Analysis

Abstract

Topic: This systematic review and meta-analysis evaluate the predictive accuracy of ocular trauma scoring systems, particularly the Ocular Trauma Score (OTS) and Pediatric Ocular Trauma Score (POTS), for estimating final visual outcomes after open-globe injuries (OGIs).

Clinical relevance: OGIs are vision-threatening injuries with significant global morbidity. In children, amblyopia risk and age-related limitations in visual assessment complicate prognostication. Although OTS and POTS are commonly used for counseling and triage, their accurancy and applicability in pediatric patients remains uncertain.

Methods: A comprehensive search of PubMed, EMBASE, the Virtual Health Library (VHL), and Latin American and Caribbean Health Sciences Literature (LILACS) databases (through September 2024) identified observational studies (n≥10 patients/eyes) reporting both predicted and actual visual outcomes after OGI. Adult and pediatric data were summarized descriptively, while meta-analyses were restricted to pediatric studies evaluating OTS and POTS. Pooled correlations, concordance (Cohen's κ), and subgroup analyses were sconducted using random-effects models in R. Certainty of evidence for each outcome was assessed using the GRADE framework. The protocol was registered in PROSPERO (CRD42024591115; Version 2.0, October 26, 2025).

Results: Forty-seven studies (n=12,515) were included. Male predominance was observed in both pediatric (83%) and adult (69%) cohorts. Globe rupture was the most common pediatric injury (23%), whereas intraocular foreign body-related injuries were more frequent in adults (29%). Zone I injuries predominated (>50%), and traumatic cataract was the leading complication in both groups. Pooled pediatric analyses demonstrated a moderate to strong correlation between higher OTS/POTS scores and improved visual outcomes (Spearman r = 0.60-0.65; Pearson r = 0.93), reflecting subgroup analyses based on the statistical methods used in the original pediatric studies. Concordance between predicted categories (no light perception; light perception/hand motion; counting fingers-1/200; 20/200-20/50; ≥20/40) and observed final outcomes showed moderate agreement (Cohen's κ = 0.48, 95% CI: 0.38-0.59) with substantial heterogeneity (I² = 96%). The certainty of evidence for both correlation and concordance was moderate (GRADE) due to imprecision and methodological variability.

Conclusions: With moderate certainty of evidence, OTS and POTS demonstrate a meaningful correlation with final visual outcomes; however, agreement between predicted and observed outcome categories remains only moderate and heterogeneous, underscoring limitations in categorical prognostication. These findings support cautious clinical use of existing trauma scores and underscore the need for refined, pediatric-specific models that incorporate amblyopia risk and real-world care factors.

Keywords: Ocular Trauma Score; Open Globe Injuries; Pediatric Ocular Trauma; Trauma Scoring Systems; Visual Prognosis.