The first step in the SPIKES protocol is setting up the interview [8]. One can mentally review the dialogue approach to broach the subject and be prepared for difficult questions. Negative feelings and feelings of frustration and responsibility may come up and are normal. However, it is ultimately your responsibility to communicate the prognosis to the patient. The key to setting up a good interview is arranging for privacy, involving significant others, having a place to sit down, and maintaining good eye contact.

The second step is to assess the patient’s perception and the third step is obtaining the patient’s invitation [8]. These steps are important when discussing the patient’s condition because they may have misperceptions about their condition and they may not want to know their prognosis. Obtaining permission is important because the patient may not be in the mindset for discussion. You can start using open-ended questions to ascertain the patient’s level of understanding and willingness to discuss the issue further. You can also provide a warning of bad news so that the patient can be prepared, and it is important to avoid medical jargon so that the patient can comprehend.

Step four involves giving the medical information to the patient [8]. The discussion of medical conditions can be improved if the conversation starts at the level of comprehension of the patient. For example, the vitreous can be explained as a “clear jelly” inside the eye. The use of analogies may be useful in certain situations. For example, if the patient has a severe dry eye due to trauma resulting in corneal surface irregularity, the surface can be compared to concrete rather than marble. It is important to confirm an understanding before proceeding to avoid miscommunication. Allow the patient to express questions and emotions. It is imperative to be supportive and empathetic of the patient’s emotions as part of the fifth step of the protocol [8]. At the end of this session, the diagnosis and plan should be summarized so that both doctor and patient are all on the same page. Needless to say, any discussions should be documented in detail in the chart.

Numerous retrospective studies have been conducted to assess prognostic factors in predicting visual outcomes after ocular trauma. The most widely used system is the Ocular trauma score (OTS) system suggested by Kuhn et al. (Table 1.2). The OTS is based on an analysis of about 2500 eye injuries and calculated by assigned raw points to six variables: initial visual acuity, globe rupture, endophthalmitis, perforating injury, retinal detachment, and relative afferent pupillary defect (RAPD) [9]. The scores are then stratified into five categories that give the probabilities of attaining a range of visual acuities post-injury (Table 1.3) [9].