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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. 37 NHL Journal of Medical Sciences/July 2013/Vol.2/Issue 2 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%) 38 NHL Journal of Medical Sciences/July 2013/Vol.2/Issue 2 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%). 39 NHL Journal of Medical Sciences/July 2013/Vol.2/Issue 2 100.00% 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 REFERENCES problem of amblyopia 12,13. However, from our study 1. MacEwen CJ, Baines PS, Desai P. Eye injuries in children: the current picture. Br J Ophthalmol. 1999;83(8):933–936. we found that besides nature of injury, late 2. Lewallen S, Courtright P. Blindness in Africa: present situation presentation (>24hrs after ocular injury) resulted in a and future needs. Br J Ophthalmol. 2001;85(8):897–903. 3. MacEwen CJ. Ocular injuries.J R CollSurgEdinb. 1999;44(5): poor visual outcome. 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 was responsible for the poor visual outcome in these children. Thus, indicating that either negligence or ignorance on part of the parents was the most important factor in eye injuries in children. More than 60% children remained legally blind even after prompt management. Thus, suggesting that prevention is superior to treatment in pediatric ocular trauma.Thus, Education of both parents and children about the grave consequences of different types of ocular trauma and the need to seek prompt opinion of an ophthalmologist can decrease burden of childhood blindness due to trauma. Good training in how to deal with different types of ocular trauma is important for resident ophthalmologists which would go a long way in salvaging the vision of a child. Our data support the need for improving rural health services by providing them with facilities and equipment which is necessary for urgent management of ocular trauma. 317–323. 4. 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