Ocular Trauma in Children Below 16 Years’ Age admitted in a Tertiary Care Hospital

Objective: Ocular trauma is a leading cause of preventable blindness and is a serious public health concern. To describe the pattern and causes of ocular trauma in children below 16 years of age requiring hospitalization.
Methodology: A retrospective descriptive study was conducted in ophthalmology department of Hayatabad Medical Complex, Peshawar. Data of 658 patients admitted with ocular trauma during a period of three years, from January 2016 to December 2018 was reviewed and analyzed. The details of patients regarding age, gender, causes, types of injuries and outcomes were evaluated from the data.
Results: In our data majority were boys (63%). The mean age at admission was 6.4 years. Ocular trauma was noted more frequent in children between 5 and 10 years than those below or above age group. Most cases of trauma occurred at home (54 %) followed by playgrounds (22 %), roads and streets (20%), farms (3%) and schools (1%). Open globe injuries were reported more frequently than closed globe and adnexal injuries. Among the causes of injury, projectile objects constitute (22%), household objects (18%), blunt objects (16%) and others 44%. Open globe injuries with corneal laceration were the most common presentation causing severe visual impairment.
Conclusion: Most ocular injuries in children are preventable, therefore importance of health education, supervision at home and application of appropriate protective measures are necessary in order to reduce and avoid the incidence and severity of trauma.
Key words: Ocular trauma, children.

INTRODUCTION:

Non-fatal injuries are one of the leading causes of emergency hospitalizations with long term morbidity and burden for health systems around the world.1Ocular trauma is a leading cause of preventable blindness in any country and is a serious public health concern in developed and developing countries.2 In a research programme for the prevention of blindness, the World Health Organization (WHO) estimated that 55 million eye injuries occur yearly, of which 750 000 patients require hospitalization.3 Population based studies even in developed country like USA have reported eye injury as the third most common indication for hospitalization in emergency departments, and the National Society for the Prevention of Blindness estimates that up to 90% of all eye injuries are preventable, especially in the paediatric age group.(4–6)Ocular injuries accounts for approximately 8-14% of total injuries suffered by children. 7,8


1.Assistant Professor. Paediatric Ophthalmology, Deptt. of
Ophthalmology, Hayatabad Medical Complex (HMC), Peshawar2.
Junior Registrar, Deptt. of Ophthalmology, Hayatabad Medical
Complex (HMC), Peshawar3. Medical Officer, Gajju Khan Teaching
Hospital Swabi4. Post graduate Resident HMC Peshawar.


Correspondence. Dr. Afzal Qadir, Assistant. Professor. Paediatric
Ophthalmology, Deptt. of Ophthalmology, Hayatabad Medical
Complex (HMC), Peshawar House no 390, Street 27, Sector F 10.
Hayatabad, Peshawar drafzal74@yahoo.com Cell: 0333-9183098
03219128247


Received: April’2019 Accepted: June’2019


Most ocular injuries in children are preventable. The importance of health education, supervision at home and application of appropriate protective measures are necessary in order to avoid the incidence and severity of trauma.


Ocular trauma especially in children is an unpleasant event. Children are found more inquisitive than adult, hence they are exposed to violent environment in terms of place and causative objects. Children are more susceptible to ocular trauma because of their immature motor skills and curious nature.9Male gender is affected more than females for their adventurous and aggressive behaviour. Ocular injuries in paediatric patients have different patterns regarding nature of  trauma and cause of insult as compared to adult and have age-specific type of injuries. Children below 3 years of age mostly suffer handler-related injuries such as finger nails of parents, siblings or care takers while in older children injuries are mostly due to sharp pointing objects such as toys, sticks, pencils, needles, scissors, sports objects and stones etc. Children less than 3 years of age sustain fewer injuries because of close supervision by parents. 10Bringing the patient to the nearest available eye care facilities and rapid evaluation and assessment of severity along with early management must be provided earlier in order to avoid blindness causing complications. Paediatric eye injuries account for approximately 8-14% of total injuries and the most common type requiring hospitalization.11Ocular injuries are simply classified into three types: Open globe, closed globe, and adnexal injuries. Most common emergencies are due to open-globe injuries and require immediate interventions.12 The ignorance and lack of responsibility also leads to indirect damage to the eye resulting in loss of vision, This condition may result into poor visual outcome (dense amblyopia).13Even small trauma to an eye may lead to permanent visual impairment creating significant impact on future quality of life. The ensuing visual disability has significant emotional, psychological and socio economic impact on the individual person, family and to the society as a whole. Hence, awareness regarding eye injuries and its early specialized treatment can give good visual prognosis.12 Our study was aimed at describing the pattern of paediatric injuries in terms of age, place, causes and types of injury. The suggestions based on results would help in taking protective and precautionary measures at home and outside for kids to avoid blindness causing injuries.

MATERIALS AND METHODS:

A retrospective descriptive study was conducted in ophthalmology department in Hayatabad Medical Complex, Peshawar. The data of 658 patients with 672 eyes admitted for ocular trauma during a period of three years, from January 2016 to December 2018 was reviewed and analysed. The details of patients regarding age, gender, causes and type of injuries were evaluated from the data. Children with age 16 years or below were included in study. Data consisted of only patients who presented or were referred to the hospital from all parts of Khyber Pakhtunkhwa and adjacent Tribal areas requiring hospital admission.

RESULTS:

Data of total 658 patients with 672 eyes, with bilateral involvement in 14 eyes was reviewed and analyzed. The minimum age affected was 7 months while the maximum age was 15 years and 11 months. Most of injuries were reported in boys (63%) as compared to girls. (Figure 1) Majority of injuries (61%) occurred in children age group between 6 and 10 years of age. (Table 1)





(Figure 1) Majority of injuries (61%) occurred in children age While analyzing the timings of seeking treatment, 85% eye injuries were reported within first 24 hours, 10 % within first week while remaining 5% eye injuries were reported after first week. Regarding the place of ocular trauma houses were among the most frequent causes followed by play grounds.



(Figure 2) Among the causes of injury, Projectile objects constitute( 22%), Household objects (18%), blunt objects (16%), sports objects(14%) and accidental fall (8 %), while rest of the injuries were caused by road traffic accidents, chemicals, burns, animal bite, assault etc.



(Table2) Open-globe injuries constitute 48% of cases where full thickness corneal, scleral, corneo-scleral lacerations were observed along with other ocular findings. While 4 % of open globe injuries were associated with intraocular or intra-orbital foreign bodies. Closedglobe injuries had 37% of cases that presented with hyphema ,cornea lFBs, partial thickness corneal tear, lens injuries, irido-dialysis and vitreous haemorrhage. While amongst the adnexal injuries lid lacerations were the most common findings.

???????

(Table 3) Open globe injuries and adnexal injuries needed early surgical treatment under general anaesthesia. While among the cases with blunt trauma, (58%) received conservative treatment with weekly first follow up. The remaining (42%) underwent surgery for early complications. 3% of eyes needed enucleation or evisceration as primary procedure due to presentation with either endophthalmitis or irreparable shattered globes.

DISCUSSION:

This study described the patterns of eye injuries in children who presented to the Ophthalmology department of Hayatabad Medical Complex, a teaching hospital in Peshawar that provides health facilities to adjacent districts of Khyber Pakhtunkhwa as well. The unilateral blindness in children is rare but ocular trauma is the commonest cause of acquired unilateral blindness. 15The children are more prone to get eye injuries due to their immature motor skills and immature common sense. 16 Ocular injuries were more frequent (82 %) in age-group between 6and 16 years than below 6 years (18 %) which is similar to other studies like MacEwen where it was 84% of ocular injuries in 5-14 years agegroup.( 17,18,19) Children of this age group are more susceptible to injuries than younger age-groups, because of their independent, adventurous and aggressive behaviour in many unsupervised activities, making them more vulnerable. While children of age-group below 5 years are most of the time under supervision of parents and less active in physical activities as compared to other age groups. So, younger age-groups are more susceptible to handler-related injuries like fingernails of siblings, mother, or caretakers.18Overall, there was disproportionately large number of boys in the study population with male to female proportion of 63:37. In one local study there were 166 male (76.85 %) while female were 50 (23.15 %).20 This owing to more adventurous and aggressive behaviour of boys compared to girls for getting more and severe ocular injuries. The strong associations of ocular trauma with younger age, male gender have been consistently documented in other studies.21 Ocular injuries were more commonly domestic (54%), followed by playground (22 %) which are very much similar to MacEwen C(51%) and Desai T et al., (45.62%).(11,16 )Similarly the injuries due to knife and scissors occurred in home and were the commonest (17.59 %) and the injuries occurring due to fire cracker and vegetable matter outside home were also common 16.20% and 13.89 % respectively.20 Home is the common place of injuries both for preschool and school-going children, for the amount of time is spent more at home. Early treatment acquisition is very important for good visual outcome and in our study 85% of patients reported within 24 hours, 10 % within first week which was contradictory with few studies like in Desai T et al.16 where around 70% presented after 24 hours. Malik R et al. 22 found 47.50% visit within 24 hours and 30.50% in more than 48 hours. It appears to be due to improved infrastructure like transport, availability of specialized hospitals in remote area, and increasing awareness in parents and society at large. Those visited late were due to poor parenthood, carelessness, poverty, extremely remote area, and fear factor in children. In our study, projectile objects caused more number of eye injuries (22%), by household injuries (18%),blunt objects (16%) and sports (14%) which are more common in older age-groups (6-16 years). Due to low socioeconomic status and lack of supervision on part of parents accidental fall, burns and animal bite injuries were more common in younger age-group (>6 years). Similarly, in sports injuries, cricket ball and bat injuries are more common to gilli-danda and bow-arrow injuries nowadays even in rural areas. One study showed that vegetative material (branches of trees, thorns) and wooden sticks as the common causative agents.23  Adnexal, closed globe and open globe injuries had different incidences of 15 % , 37%, and 48% respectively, which are different from other studies like Desai T et al.16where incidence of adnexal and closed globe injuries were 27% and 32% respectively. In a study that looked at the medical records of 481 children of up to 16 years who had sustained ocular trauma, about 51% injuries were of open-globe type and 37.6% were closedglobe injuries.24,25While Open globe injuries incidence varies in different studies in different countries.16,17 All patients treated were admitted at our hospital. Eyes with traumatic cataract were treated surgically with posterior chamber intraocular lens (PCIOL) implantation. Eyes with lacerated adnexa and globe were surgically repaired under general anaesthesia. 4 % eyes had Intra-ocular foreign bodies that were removed with vitrectomy by vitreoretinal surgeons. 3 % of eyes needed enucleation or evisceration with implants due to either irreparable shattered globes or endophthalmitis. Endophthalmitis following retention of intraocular foreign body for prolonged time is extremely serious, and may lead to severe loss of vision.26In a global survey the reported incidence of endophthalmitis after penetrating ocular trauma was 13.5%.27 Post-traumatic eye complications caused is facial expression amblyopia, and blindness that affect quality of life. Therefore, it is very important for the health care providers and the parents to be aware of the ocular traumas and its consequences, risk factors and causative objects at home and in surroundings and to take preventive measures to avoid trauma. Moreover, in addition to describe patterns of trauma, further studies are required on visual outcome and long term complications of traumatic eyes.

CONCLUSION:

Most of the eye injuries in paediatric age group occur below 10 years, due to aggressive and curious behaviour prevailing at this period of life, particularly in male gender. Risk factors such as playing with stones, sticks and other sharp pointed objects should be identified and discouraged. Provision of pictorial educational materials to parents and at schools in order to distract the attention from aggressive behaviour are very much advised. Moreover, seeking treatments in time is helpful for better outcome and avoid complications in traumatic eyes.

1. World Health Organization. Injuries and violence – the facts. Geneva: World Health Organization; 2010.
2. May DR, Kuhn FP, Morris RE, Witherspoon CD, Danis RP, Matthews GP et al. The epidemiology of serious eye injuries from the United States Eye Injury Registry. Graefes Arch ClinExpOphthalmol 2000;238:153–7.
3. Négrel AD, Thylefors B. The global impact of eye injuries. Ophthalmic Epidemiol 1998;5:143–69.
4. Abbott J, Shah P. The epidemiology and etiology of pediatric ocular trauma. SurvOphthalmol 2013;58 476–85.
5. Pollard KA, Xiang H, Smith GA. Pediatric eye injuries treated in US emergency departments, 1990-2009. ClinPediatr (Phila) 2012;51 374–81.
6. Cao H, Li L, Zhang M. Epidemiology of patients hospitalized for ocular trauma in the Chaoshan region of China, 2001-2010. PLoS One 2012;7:e48377.
7. Scribano PV, Nance M, Reilly P et al. Pediatric non-powder firearm injuries: Outcomes in an urban paediatric setting. Pediatircs. 1997; 100: E5.
8. Takvam JA, Midelfart A. Survey of eye injuries in Norwegian children. ActaOphthalmol. 1993; 71:500-05.
9. Adhikari NK. Ocular trauma among children in western Nepal: Agents of trauma and visual outcome. Nep J Ophthal. 2010; 2:164-165
10. Natarajan S. Ocular trauma, an evolving subspecialty. Ind J Ophthal 2013; 61:539-541.
11. Kaur A, Agrawal A. Paediatric ocular trauma. CurrSci 2005;89.
12. Desai T, Vyas C, Desai S, Malli S. Pattern of ocular injuries in paediatric population in western India. NHL J Med Sci 2013;2:37- 40
13. Bukhari S, Mahar PS, Qidwaiq, Bhutto 1A, Memon AS. Ocular trauma in children, Pak J Ophtamol. 2011;27(4):208-13.
14. Le Q, chen Y, Wang X, Hang J: Analysis of meical expenditure and socio economic status in patients with ocular chemical burns in East China, A prospective Sucy. BMC Public Health. 2012;12:409.
15. Ghafoor A, Waseem M. Khan SA. Frequency of ocular trauma in children. PTMHS. 2016;10(1):222- 3
16. Desai T, Vyas C, Desai S, Malli S. Pattern of ocular injuries in paediatric population in western India. NHL J Med Sci 2013;2:37- 40
17. .MacEwen CJ, Baines PS, Desai P. Eye injuries in children: The current picture. Br J Ophthalmol 1999;83:933-6
18. Dulal S, Ale JB, Sapkota YD. Profile of pediatric ocular trauma in mid western hilly region of Nepal. Nepal J Ophthalmol 2012;4:134-7
19. Al-Bdour MD, Azab MA. Childhood eye injuries in North Jordan. IntOphthalmol 1998;22:269-73
20. Sultan MN, Javed EA, Nawaz M. Profile of Ocular Trauma in Patients Under the Age of Sixteen Years in Allied Hospital, Faisalabad. APMC 2016;10(4):228- 232
21. Wong TY, Tielsch JM: A population based study on the incidence of severe ocular trauma in Singapore. AM J Ophthalmol. 1999;128:345-51.
22. Malik R, Rahil N, Husssain M, Wajid A, Zaman M, et al.Frequency and visual outcome of anterior segment involved in accidental ocular trauma in children.J Postgradu Med Inst. 2011;95:44-8
23. Sadia Bukhari, P S Mahar, UmairQidwai, Israr Ahmed Bhutto, Abdul Sami Memon. Ocular Trauma in Children. Pak J Ophthalmol 2011, Vol. 27 No. 4
24. Demissie BS, Demissie ES. Patterns of eye diseases in children visiting a tertiary teaching hospital in south western Ethiopia. Ethiop J Health Sc. 2014; 24:69-74
25. Liu X, Liu Y, Liu z. Determination of visual prognosis in children with open globeinjuries. Eye (London). 2014; 28:852-856
26. Azad RV, Kumar N, Sharma YR, Vohra R. Role of prophylactic scleral buckling in the management of retained intraocular foreign bodies. Clin Experiment Ophthalmol 2004; 32: 58-61
27. El-Asrar AM, Al-Amro SA, Khan NM, Kangave D. Visual outcome and prognostic factors after vitrectomy for posterior segment foreign bodies. Eur J Ophthalmol 2000; 10: 304-11
28. World Health Organization. Injuries and violence – the facts. Geneva: World Health Organization; 2010.
29. May DR, Kuhn FP, Morris RE, Witherspoon CD, Danis RP, Matthews GP et al. The epidemiology of serious eye injuries from the United States Eye Injury Registry. Graefes Arch ClinExpOphthalmol 2000;238:153–7.
30. Négrel AD, Thylefors B. The global impact of eye injuries. Ophthalmic Epidemiol 1998;5:143–69.
31. Abbott J, Shah P. The epidemiology and etiology of pediatric ocular trauma. SurvOphthalmol 2013;58 476–85.
32. Pollard KA, Xiang H, Smith GA. Pediatric eye injuries treated in US emergency departments, 1990-2009. ClinPediatr (Phila) 2012;51 374–81.
33. Cao H, Li L, Zhang M. Epidemiology of patients hospitalized for ocular trauma in the Chaoshan region of China, 2001-2010. PLoS One 2012;7:e48377.
34. Scribano PV, Nance M, Reilly P et al. Pediatric non-powder firearm injuries: Outcomes in an urban paediatric setting. Pediatircs. 1997; 100: E5.
35. Takvam JA, Midelfart A. Survey of eye injuries in Norwegian children. Acta Ophthalmol. 1993; 71:500-05.
36. Adhikari NK. Ocular trauma among children in western Nepal: Agents of trauma and visual outcome. Nep J Ophthal. 2010; 2:164-165
37. Natarajan S. Ocular trauma, an evolving subspecialty. Ind J Ophthal 2013; 61:539-541.
38. Kaur A, Agrawal A. Paediatric ocular trauma. CurrSci 2005;89.
39. Desai T, Vyas C, Desai S, Malli S. Pattern of ocular injuries in paediatric population in western India. NHL J Med Sci 2013;2:37-40
40. Bukhari S, Mahar PS, Qidwaiq, Bhutto 1A, Memon AS. Ocular trauma in children, Pak J Ophtamol. 2011;27(4):208-13.
41. Le Q, chen Y, Wang X, Hang J: Analysis of meical expenditure and socio economic status in patients with ocular chemical burns in East China, A prospective Sucy. BMC Public Health. 2012;12:409.
42. Ghafoor A, Waseem M. Khan SA. Frequency of ocular trauma in children. PTMHS. 2016;10(1):222- 3
43. Desai T, Vyas C, Desai S, Malli S. Pattern of ocular injuries in paediatric population in western India. NHL J Med Sci 2013;2:37- 40
44. MacEwen CJ, Baines PS, Desai P. Eye injuries in children: The current picture. Br J Ophthalmol 1999;83:933-6
45. Dulal S, Ale JB, Sapkota YD. Profile of pediatric ocular trauma in mid western hilly region of Nepal. Nepal J Ophthalmol 2012;4:134-7
46. Al-Bdour MD, Azab MA. Childhood eye injuries in North Jordan. IntOphthalmol 1998;22:269-73
47. Sultan MN, Javed EA, Nawaz M. Profile of Ocular Trauma in Patients Under the Age of Sixteen Years in Allied Hospital, Faisalabad. APMC 2016;10(4):228- 232
48. Wong TY, Tielsch JM: A population based study on the incidence of severe ocular trauma in Singapore. AM J Ophthalmol. 1999;128:345-51.
49. Malik R, Rahil N, Husssain M, Wajid A, Zaman M, et al. Frequency and visual outcome of anterior segment involved in accidental ocular trauma in children.J Postgradu Med Inst. 2011;95:44-8
50. Sadia Bukhari, P S Mahar, UmairQidwai, Israr Ahmed Bhutto, Abdul Sami Memon. Ocular Trauma in Children. Pak J Ophthalmol 2011, Vol. 27 No. 4
51. Demissie BS, Demissie ES. Patterns of eye diseases in children visiting a tertiary teaching hospital in south western Ethiopia. Ethiop J Health Sc. 2014; 24:69-74
52. Liu X, Liu Y, Liu z. Determination of visual prognosis in children with open globeinjuries. Eye (London). 2014; 28:852-856
53. Azad RV, Kumar N, Sharma YR, Vohra R. Role of prophylactic scleral buckling in the management of retained intraocular foreign bodies. Clin Experiment Ophthalmol 2004; 32: 58-61
54. El-Asrar AM, Al-Amro SA, Khan NM, Kangave D. Visual outcome and prognostic factors after vitrectomy for posterior segment foreign bodies. Eur J Ophthalmol 2000; 10: 304-11