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The Birmingham Eye Trauma Terminology - Extension from Lebanon (BETT-XL) classification: A multi-center validation in
Riwa Ibrahim1, Oulyana Arafat1, Romy Mansour1
1Department of Ophthalmology, Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, Byblos, Lebanon.
Background:
In modern warfare, ocular injuries frequently result in severe injuries that challenge existing classification systems. The standardized Birmingham Eye Trauma Terminology (BETT) does not adequately capture the extensive globe or periocular damage encountered in conflict settings. We aimed to develop an extension to BETT capable of classifying the full spectrum of injuries. We further sought to validate the extended framework using a real-world cohort from the 2024 pagers explosions in Lebanon.
Methods:
Phase I included a targeted literature review of severe ocular trauma cases unclassifiable on BETT, based on which experts practicing in conflict zones identified the gaps in and developed the BETT Extension from Lebanon (BETT-XL). In Phase II, we validated BETT-XL by applying it to a retrospective multicenter cohort of ocular injuries from the pager explosions. Data on examination on presentation, imaging, primary management, and intraoperative findings were collected. From available data, we classified the injuries using the BETT and BETT-XL systems.
Results:
The literature review identified the following injuries as unclassifiable in BETT: Traumatic Evisceration, Luxation, Avulsion, and Traumatic Exenteration. We addressed the first three gaps by incorporating three novel subcategories in BETT-XL, and by adding Traumatic Exenteration to a previous modification of BETT that incorporated periocular injuries. The validation cohort included ninety-three patients with pager-related ophthalmic trauma. Closed Globe injuries were present in 36.6% and 22.6% of right and left eyes respectively. Per BETT, Open Globe injuries were present in 19.4% and 25.8% of eyes. An additional 24.7% and 34.4% of severely injured eyes were unclassifiable in BETT, and were presented under the BETT-XL category of Traumatic Evisceration.
Conclusion:
BETT-XL provides an evidence-based extension that incorporates previously unclassifiable, severe ocular injuries. This enables a more comprehensive characterization of modern conflict-related ocular injuries. Further prospective studies can be done to validate it across diverse conflict-affected settings and to document inter-rater reliability and prognostic utility. These results also highlight the devastating impact of blasts on vision, and the necessity of conflict medicine preparedness in care systems, starting with updated classification systems.
