Download Pattern of ocular injury in Pediatric Population in western India

Research article
Pattern of ocular injury in Pediatric Population in western India
Tejas Desai*, Chinmayi Vyas**, Suhani Desai**, Shiv Malli**
*
Assoc. Professor , Resident Doctor**, Department of Ophthalmology,Nagari Eye Research Foundation Trust,
Smt. NHL Municipal Medical College, Ahmedabad.
ABSTRACT
Aim: To analyze the pattern of ocular trauma,
causative agents and to find the correlation between
time of intervention & visual outcome in pediatric
population referred to a tertiary eye care center in
western India.
Method and Results: Prospective observational
study, in which pediatric patients having ocular trauma
between April 2011 - April 2012 referred to our
hospital were enrolled. These children underwent
detailed ophthalmic examination and intervention as
required. Demographic data, mechanism, cause of
injury and visual outcome were recorded with details
of anterior and posterior segment evaluation. Follow
up period: up to 6 months. 217 children (218 eyes)
were enrolled. Age ranged from 4months to 15 years
(mean ± SD, 3.8±2.3 years; male: female ratio(2.08:1);
mean time between injury to treatment(1day ± 2.12
hours).Out of all, trauma occurred at
home
(45.65%,n=99), school (31.15%,n=68) and Road
Traffic Accidents (23.18%,n=50).Most common
modes of injury-wooden-stick, RTA, pencils/pens,
broken eye glasses, cricket-ball, and hand of adult and
fire-crackers. Injuries were classified as open globe
(41.93%), adnexal (31.33%) and closed globe
(26.72%).
Conclusion: Most patients presented with a delay of
24 hours during which substantial damage was done.
Thus, emphasizing the need to educate parents and to
improve rural health care system to provide better
facilities and a better transport system to reduce the
duration between injury & treatment.
INTRODUCTION
Ocular trauma is an important and yet preventable
cause of visual morbidity especially among pediatric
population in developing countries. The visual
outcome of ocular trauma depend on many factors
namely the etiology, severity and most importantly on
the duration from injury to intervention.1
Trauma is a significant cause of monocular blindness.
Western population-based surveys have shown
incidence of monocular blindness due to trauma
ranging from 20%–50% and of bilateral blindness
from 3.2%–5%1,3. These Hospital-based studies also
indicate that about two-thirds of those affected are
males, predominantly children and young adults.
Injuries with sticks, stones, cricket ball, and metallic
objects are the most common.3,4 The use of traditional
eye medicine like instilling honey, rose water is
common and its use potentially worsens otherwise
minor conditions and delays treatment for serious
injury.2
Ocular injury occurs in three forms: open globe,
closed globe, and adnexal injuries. Open globe injuries
are one of the most common emergencies in
ophthalmologic clinics and require immediate
operation.3
Children are not aware of the consequences of eye
injury and often report the injury after substantial
damage has already occurred. This leads to delayed
medical and surgical intervention and ultimately poor
visual outcome. Identifying the cause of injuries
among children may help in determining the most
effective measures to prevent visual loss.3 Pediatric
ocular trauma has a significant impact on the future
quality of life as children are exposed to a major risk
of amblyopia.4
Thus, A trauma to the eye however small may lead to
permanent visual impairment. Patient education
regarding the eye injury and its prompt management
can lead to better visual outcome.
The purpose of this study was to analyze the pattern of
ocular trauma, causative agents and to find the
correlation between time of intervention & visual
outcome in pediatric ocular trauma at C.H.Nagri
Municipal Eye Hospital, Ahmedabad.
MATERIAL AND METHOD
In this prospective observational study of all pediatric
patients having ocular trauma between from April
2011 to April 2012 referred to C.H. Nagri Municipal
eye hospital were enrolled. Patients were either
referred to us from other eye care centers in the state
or attended our emergency/outpatient department
directly.
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Children with history of any pre-existing diseases like
congenital anomalies, glaucoma or any non-traumatic
cause were excluded from the study. The demographic
data of each child included the age of the child; sex;
activity; place; date of trauma; time before seeking
medical care. Other details included the cause, nature
and circumstance of injury. A thorough ophthalmic
examination which included presenting visual acuity
measurement by Snellen’s chart, slit lamp examination
to evaluate anterior segment injuries with fundus
evaluation was done by indirect ophthalmoscopy and
slit lamp bio-microscopy. In hazy media
ultrasonography and in some cases ultrasound biomicroscopy was done to evaluate the eye status.
Intraocular pressure was measured in all eyes except in
open globe injuries. Gonioscopy to visualize the angle
of the anterior chamber was done in closed globe
injuries where angle recession was suspected.
All the patients were followed up at monthly intervals
for initial six months. The initial visual acuity and
final visual acuity after 6 months follow-up were
recorded. Open globe injury with lid tear or any
adnexal involvement was classified as open globe
injury only.
injury corneal tear was found in 33(15.2%), sclera tear
in 12(5.52%) globe rupture due to penetrating
corneal/sclera wound with extensive uveal tissue
prolapsed was seen in 10(4.06%). More severe open
globe injury presented with retained Intra ocular
foreign body with penetrating corneal/ sclera/ globe
rupture was seen in 9(4.14%) and open globe injury
with intraocular infection in the form of
endophthalmitis was found in 27( 12.44%) cases who
presented to us with a delay of 24 to 48 hrs from the
time of injury
Injury with blunt objects caused coup counter-coup
effect. Out of 59 (27.18%) patients with closed globe
injury presented to us, lens damage was seen in
16(7.37%), hyphema in 18(8.29%), angle recession in
6(2.76%), retinal detachment in 8 (3.68%), vitreous
hemorrhage in 11(5.06%) and optic nerve avulsion
1(0.46%).
Ocular adnexal injury was caused by either sharp
instruments or severe thrust by blunt object in
67(30.87%) of cases. They presented with lid tear in
34(15.66%) cases, conjunctival tear in 7(3.22%),
canalicular tear with lid tear in 18(8.29%) and
miscellaneous in 8(3.68%) cases.
OBSERVATIONS AND RESULTS:
We enrolled 217 children (218 eyes, 1 child bilaterally
involved) in the age group of 4 months to 15 yrs
(3.8±2.3 years) with a history of ocular trauma. There
were 145 boys and 72 girls (M: F=2.08:1) in the study.
The mean time between injury to treatment was 24 ±
2.12 hours. 47.46% children belonged to the urban
population and 52.53% children belonged to the rural
population.
Table: 2 Correlations between the Type of Ocular
In our study population three varieties of ocular
trauma was seen. Blunt injury causing closed globe
injury, where as injury with sharp objects caused
either open globe injury or ocular adnexal injuries.
Table 1: Pattern of Ocular Injury
Sr.
no
1
2
3
TYPE OF INJURY
PERCENTAGE
open globe injury
closed globe
adnexal injury
91(41.93%)
59(26.72%)
67(31.33%)
Most of the open globe injuries were caused by injury
with sharp objects. Out of 91 patients with open globe
Injury and Age Group
AGE OF
OPEN
PATIENTS
GLOBE
0-5 yrs
25
6-10 yrs
32
10yrs
34
CLOSED
GLOBE
08
29
22
ADNEXA
L
11
28
28
Majority of children had suffered the injury during day
time especially when parents were at work. Most of
the children had suffered ocular trauma while playing
in the house or at school.
Table: 3 Timing And Place Of Injury
Timing of injury
Morning
Mid-day
Evening
Night
Place of injury:
Home
School
Street
Playground
Patients
25 (11.52%)
88 (40.55%)
83 (38.24% )
21 (9.66%)
99(45.62%)
68(31.33%)
20 (9.66%)
30(13.82%)
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Table: 4 Types of Objects Causing Ocular Injuries
OBJECT
Wooden stick:
AMOUNT OF
INJURY
33(15.20%)
Due to Fall
21(9.67%)
Broken Eye glasses
19(8.75%)
Stone
11(5.06%)
Metallic wire/sharp instrument
24(11.05%)
Hand of other person:
17(7.83%)
Pencil:
14(6.45%)
Animal Horn
4(1.84%)
Cricket ball
33(15.20%)
Fire crackers:
13(5.99%)
Road traffic accidents
28(12.90%)
Majority of the patients suffering ocular trauma
presented at our institute after 24 hours of insult. We
found two major reasons for delayed presentation on
eliciting history that Children did not report the injury
to their parents out of fear and parents did not visit
hospital because of the lack of awareness regarding the
serious consequences of an eye injury leading to
blindness. In 92% of cases no adults were present at
the time of injury.
100.00%
75.30%
70.42%
61.70%
38.29%
29.57%
25.70%
50.00%
0.00%
1st 24 hrs
24 to 48 hrs more than 48
hrs
URBAN
RURAL
Fig.1 Time Interval between the Time of Injury to
Hospitalization.
At the end of 6 months 60% remained legally blind.
Out of 217 children visual outcome was ≥0.48
logMAR in 40.09%, <0.48logMAR in 19.81%,
Counting finger close to face (CFCF) to <1 logMAR
in 9.72%; perception of light (PL) to <CFCF in
12.90%; and no perception of light (NPL) in 1.38 % of
cases.
At presentation
69
87
24
43
At the End of 6 months
67 57
55
28
3 3
Fig.2 Visual outcome (No. Eyes)
Patients reported within 24hr of eye injury showed
better visual outcome as compared to more than 24hrs
of presentation.
DISCUSSION
Our study was a hospital-based study among children
attending the ophthalmology department C.H.Nagri
Eye Hospital. Its results showed that the percentage of
pediatric ocular trauma among patients attending the
ophthalmology department during a period of 1 year
was 3.7%. This is in agreement with Dandona et al5
from south India who found a rate of ocular trauma of
3.97% in their study.
Our study showed that about 61.28% of pediatric
ocular trauma occurred in children aged 1-10years.
Younger
children
have
common
physical
vulnerability, lack of coordination, and limited ability
to avoid or escape from danger. Also children show
curiosity and a desire to explore, which may expose
them to serious hazards. Abraham et al6 found that
one-third of the injuries occurred in those less than the
age of 20 years. Niiranen and Raivio et al7 found that
children with ocular trauma represented 34.5% of all
eye injuries and 3% of all patients treated. ElMekawey et al8 found that pediatric ocular trauma
constituted 37.1% of all ocular emergencies in a 5year study in Egypt.
Our study showed that a higher frequency of ocular
trauma occurred at home (45.62%), followed by
school (31.33%), play ground (13.82%), and finally
the street (9.66%). This agrees with Kaimbo et al9 who
stated that street and home-related injuries accounted
for 54% of all ocular injuries. Wooden stick was the
cause of injury in 15.20% of patients, followed by
cricket
ball
(15.2%).
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100.00%
86.53%
80.00%
60.00%
40.00%
25.30%
20.00%
22.89%
9.61%
<24 hrs
21.14% 22.28%
15.66%
0
0 1.80%
> 24 hrs
0.00%
≥0.48 logMAR
<0.48 logMAR- <1 logMAR -CFCF
1logmar
<CFCF– PL+
NPL
Fig.3 Correlations between the Visual Outcome and Time of Intervention.
ABBREVIATIONS
Counting finger close to face – CFCF
This is in contrast to other studies done in African
PL +: perception of light present
countries which stated that 25% of ocular injuries in
No perception of light- NPL
children are from gunshots, 24.2% from tools, and
logMAR- log of Minimum Angle of Resolution
21.8% from assault which reflect the cultural and
DISCLOSURE
10,
socio-economical differences between the countries.
This paper was present in the annual conference of the
14
Niiranen and Raivio7 noted that despite therapeutic
international ocular trauma society 2012 (ISOTCONadvances, visual prognosis in children is still worse
2012) as an E-POSTER.
than adults due to the nature of the injuries and the
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CONCLUSION
Our study showed that Almost 70% children presented
to us 24 hrs after the injury. During these crucial hours
substantial damage to the ocular structures had already
taken place. This delayed presentation to the hospital
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