Ocular Trauma During COVID-19 Pandemic: A Systematic Review and Meta-analysis : The Asia-Pacific Journal of Ophthalmology

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Review Article

Ocular Trauma During COVID-19 Pandemic: A Systematic Review and Meta-analysis

Liang, Huiyu MBBS*; Zhang, Meiqin MBBS*; Chen, Man MBBS*; Lin, Timothy P.H. MBChB; Lai, Mingying MD‡,§; Chen, Haoyu MD*

Author Information
Asia-Pacific Journal of Ophthalmology: September/October 2022 - Volume 11 - Issue 5 - p 481-487
doi: 10.1097/APO.0000000000000539
  • Open

Abstract

INTRODUCTION

The coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is one of the worst pandemics of humankind.1,2 As of January 10, 2022, more than 300 million confirmed cases have been reported worldwide.3 COVID-19 is a universal crisis globally, posing profound impacts to both public health and society. Governments worldwide have implemented a series of measures to contain COVID-19, such as suspension of schools, restriction of public activities, and even massive lockdowns. As a result, industrial, agricultural, and social activities have all been significantly altered.

Ocular trauma is one of the major causes of preventable vision loss in developed and developing countries. The causes of ocular trauma are closely related to industrial, agricultural, and social activities. For instance, occupational injuries and road traffic accidents were among the leading causes of ocular trauma.4,5 Occupational injuries can cause significant morbidity, especially in younger males. This age cohort is workers’ prime productive years, a time when injury can result in significant loss of wages and earning potential.6,7 It will also be a huge burden on the society and the family.

Like all other medical specialties, ophthalmology has witnessed significant changes and impacts brought by COVID-19 to its clinical practice.8,9 Trends in ophthalmic emergency department visits have changed during the COVID-19 pandemic due to the aberrancy in social activities.10 Nevertheless, there were discordant results from different studies evaluating ocular trauma during this pandemic. This study aimed to analyze the epidemiological and clinical characteristics of ocular trauma during the COVID-19 pandemic through a systematic literature review.

MATERIALS AND METHODS

A systematic search of the literature on PubMed, Web of Science, Scopus, China Biology Medicine, Wanfang Data, and China National Knowledge Infrastructure (CNKI) were conducted without limitation of language. The search terms included (“COVID-19” OR “novel coronavirus pneumonia”) AND (“ocular trauma” OR “eye injury” OR “eye trauma” OR “ocular injury”). The search period was between January 1, 2020, and September 20, 2021. Duplicate records were removed. The abstracts were screened, and the irrelevant records were excluded. The full texts of the remaining records were retrieved and reviewed, and the relevant articles were included. The references of the included articles were also screened. We only included original articles that reported eye injuries during the COVID-19 pandemic period. Reviews or commentaries which did not report original data or cases were excluded.

The enumeration data from different studies were added up and compared between the pre–COVID-19 and COVID-19 periods. The data from different studies were merged, and the odds ratio (OR) and its 95% confidence interval (CI) were computed using the R software (R Foundation for Statistical Computing).

RESULTS

Literature Search Results

A total of 691 articles were initially identified after following the aforementioned search strategy. After title and abstract screening, 48 studies were selected for full-text evaluation. Finally, 32 studies were included for analysis (Fig. 1).10–24 There were 31 studies in English and 1 in Chinese.

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FIGURE 1:
Results of systematic literature search strategy.

Incidence of Ocular Trauma

Among the 32 studies included, 13 evaluated the number of presentations to the ophthalmic emergency department and the incidence of ocular trauma cases (Table 1).

TABLE 1 - Comparative Study of the Total Number of Ophthalmic Patients and Ocular Trauma Cases in Pre- and During COVID-19 Pandemic Periods
Date Ocular Trauma Cases Ophthalmic Emergency or Outpatient Cases Proportion of Ocular Trauma in Ophthalmic Emergency Cases
Author Country Study period COVID-19 Pre-COVID-19 COVID-19 Pre-COVID-19 COVID-19 / Pre-COVID-19 COVID-19 Pre-COVID-19 COVID-19 / Pre-COVID-19 COVID-19 Pre-COVID-19 COVID-19 / Pre-COVID-19
Ma10 China 68 days 2020/1/23-2020/3/31 2019/1/23-2019/3/31 1209 2444 49.5% 5978 12776 46.8% 20.2% 19.1% 105.7%
Shah13 India 110 243 45.3% 483 3106 15.6% 22.8% 7.8% 291.1%
Akova15 Turkey 3 months 2020/3/1-2020/5/31 2019/3/1-2019/5/31 821 1356 60.5% 1161 1855 62.6% 70.7% 73.1% 96.7%
Pellegrini16 Italy 1 month 2020/3/10-2020/4/10 2019/3/10-2019/4/10 112 354 31.6% 563 2269 24.8% 19.9% 15.6% 127.5%
Poyser17 Britain 1 month 2020/3/24-2020/4/23 2019/3/24-20194/23 124 220 56.4% 852 1818 46.9% 14.6% 12.1% 120.3%
Wu25 USA 1 month 2020/3/23-2020/4/20 2019/3/18-2019/4/15 62 87 71.3% 1058 1372 77.1% 5.9% 6.3% 92.4%
Salvetat 24 Italy 54 days 2020/3/10-2020/5/3 2019/3/10-2019/5/3 334 541 61.7% 851 1854 45.9% 39.2% 29.2% 134.5%
Halawa26 USA 1 year 2020/1/1-2020/12/31 2011/1/1-2019/12/31 4236 4959 85.4%
Agrawal18 India 128 days 2020/3/25-2020/7/31 2019/3/25-2019/7/31 71 171 41.5%
Kauser12 India 3 months 2020/4/1-2020/6/30 2019/4/1-2019/6/30 58 184 31.5% 876 7242 12.1% 6.6% 2.5% 260.6%
Stedman19 Britain 103 days 2020/3/23-2020/7/4 2019/3/23-2019/7/4 10 2 500%
Alqudah21 Jordan 2 months 2020/3/17- 2019/3/17- 10 34 288 11.8%
Hamroush27 Britan 1 weeks 2020/4/9-2020/4/15 293 837 35.0%
Total 7147 10561 67.7% 12149 33417 36.4% 23.9% 16.8% 142.4%

Eleven studies compared the incidence of ocular trauma during the COVID-19 pandemic with the control period, ranging from 3 months to 1 year. Among these studies, almost all (10/11) concluded that the incidence of ocular trauma decreased during the COVID-19 pandemic compared to the control period.10,12,13,15–18,25,26 One study described a 5-times increase in the number of ocular trauma cases during the pandemic compared to the control period,19 but the sample size was small. By merging the 11 articles, the total incidence of ocular trauma during the COVID-19 pandemic decreased to 67.7% of that in the control period (Table 1).

Six articles reported that the proportion of ocular trauma cases in ophthalmic emergency visits increased,10,12,13,16,17,24 while 2 articles reported that the proportion decreased.15,25 The pooled data showed that the proportion of ocular trauma cases in ophthalmologic emergency visits increased from 16.8% to 23.9% during the COVID-19 pandemic (OR, 95% CI: 1.46, 1.04–2.06) (Fig. 2).

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FIGURE 2:
Forest plot of the proportion of ocular trauma in ophthalmic emergency visits during COVID-19 and pre–COVID-19 periods. Events: ocular trauma; Total: ophthalmic emergency visits; OR: odds ratio; CI: confidence interval.

Pediatric Ocular Trauma

Table 2 summarized the studies which compared the incidence of pediatric ocular trauma cases prior to and during the COVID-19 pandemic. Six studies reported that the incidence of pediatric ocular injury cases declined during the pandemic period,12–16,28 accounting for only 54.3% of that in the control period.

TABLE 2 - Comparative Study of Ocular Trauma Cases and Pediatric Ocular Trauma Cases Between COVID-19 Pandemic and Pre-COVID-19 Period Period (Number in brackets indicates percentage of total ocular trauma cases)
Pediatric Ocular Trauma Cases
Author Country Study Period COVID-19 Pandemic Pre-COVID-19 Period COVID-19 Pandemic/Pre-COVID-19 Period
Kauser6 India 3 mo 5 29 17.2%
Shah7 India 1 y 40 57 70.2%
Akova9 Turkey 3 mo 81 241 33.6%
Pellegrini10 Italy 1 mo 9 52 17.3%
Cavuoto8 America 6 mo 156 237 65.8%
Maria30 Austria 3 mo 110 123 89.4%
Total 401 739 54.3%

Four studies reported the proportion of pediatric eye injuries among total eye injuries, in which 3 studies (75%) reported a decline in the proportion of pediatric eye injuries during the COVID-19 pandemic.12,15,16 The pooled data showed that the proportion decreased from 17.7% to 12.3% during the COVID-19 pandemic, compared to the control period (OR, 95% CI: 0.72, 0.36–1.44) (Fig. 3).

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FIGURE 3:
Forest plot of the proportion of pediatric ocular trauma among all ocular trauma during COVID-19 and pre–COVID-19 periods. Events: pediatric ocular trauma; Total: total number of ocular trauma; OR: odds ratio; CI: confidence interval.

Category of Ocular Trauma

Five studies compared the incidence of domestic ocular trauma during the pandemic and the control period.12,16,18,19,25 The pooled results showed that the incidence of domestic ocular trauma remained at a similar level during the pandemic compared to the control period. Four studies reported that the proportion of domestic ocular trauma increased during the COVID-19 pandemic,12,16,18,25 while 1 study reported a reduction in such proportion.19 The merged data showed that the proportion of domestic ocular trauma cases increased from 16.8% to 43.1% during the COVID-19 pandemic, compared to the control period (OR, 95% CI: 3.42, 1.01–11.62) (Fig. 4A). Various case reports documented different domestic ocular trauma which occurred during the COVID-19 pandemic. There were 2 reported cases of metallic nail embedded in the left upper eyelid and corneal injury caused by gardening,29,30 respectively. Two studies reported 2 and 11 cases with ocular trauma due to resistance band–related exercises carried out at home,31,32 respectively. Bapaye et al33 described 2 cases of pediatric ocular trauma caused by bow and arrow at home due to imitation of TV dramas, and Alqudah et al21 reported 4 cases of open globe injury that occurred at home.

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FIGURE 4:
Forest plots of the proportion of domestic (A), sports-related (B) , and occupational (C) ocular trauma among all ocular trauma during COVID-19 and pre–COVID-19 periods. Events: domestic (A), sports-related (B), and occupational (C) ocular trauma; Total: total number of ocular trauma; OR: odds ratio; CI: confidence interval.

Four studies compared the incidence of ocular trauma caused by sports and outdoor activities during the COVID-19 pandemic and the control period. Among them, 3 (75%) reported a decrease in ocular trauma caused by sports and outdoor activities during the pandemic,12,16,25 but 1 reported that the incidence of sports-related eye injuries increased from 3 to 10 cases during the COVID-19 pandemic as compared to the control period.18 The pooled results of these 4 articles showed that the overall incidence of ocular injuries caused by sports and outdoor activities fell to 25.3% of the prepandemic period. The merged data also showed that the proportion of ocular trauma related to sports and outdoor activities decreased from 10.4% to 6.9% during the COVID-19 pandemic (OR, 95% CI: 0.64, 0.09–4.29) (Fig. 4B).

Two articles revealed that the incidence of occupational ocular trauma decreased during the COVD-19 pandemic, compared to the control period.18,25 The pooled results showed that the proportion of occupational ocular injuries decreased from 44.2% to 12.0% during the pandemic (OR, 95% CI: 0.10, 0.18–0.33) (Fig. 4C).

An article showed that only 3 cases of ocular trauma caused by road traffic accidents were documented during the COVID-19 pandemic, compared with 16 in the control period.18 Among all ocular trauma cases, the proportion of ocular trauma caused by traffic accidents decreased from 9.3% in the control period to 4.2% during the pandemic (OR, 95% CI: 0.43, 0.12–1.52).

Ocular Trauma Related to COVID-19 Preventive Measures

Five studies compared the incidence of chemical eye injury during the pandemic and the control period. Among them, 3 reported that the incidence of chemical eye injury decreased during the pandemic compared with the control period.12,17,18 The pooled results showed that the incidence of chemical eye injury during the pandemic decreased to 56.1% of that in the control period. However, the proportion of chemical eye injury increased during the pandemic compared to the control period when all ocular trauma were analyzed (OR, 95% CI: 1.33, 0.78–2.27, Fig. 5). Martin et al20 reported that although no significant differences in the incidence and proportion of chemical injuries in children were documented during the pandemic compared to the control period (from 98 cases to 80 cases, accounting for 4% to 5% of all ophthalmic emergencies), chemical eye injuries related to alcohol-based sanitizers increased from 1 case to 16 cases. Wasser et al23 reported that the incidence of pediatric chemical injuries in 2019 was 36, which increased to 72 cases during the pandemic. More importantly, a significant increase in chemical injuries related to alcohol-based sanitizers was observed. During the pandemic, 9 cases of children aged below 10 were documented, compared to 0 in 2019. In addition, 3 studies reported ocular trauma caused by the improper use of alcohol-based sanitizers during the pandemic. Sonam et al22 mentioned 2 cases of toxic keratopathy in children aged under 5 years. One article reported alcohol-based-sanitizers–related ocular trauma in two 3-year-old girls.34 The cause of the injury was that the children stepped on the pedal to obtain the disinfectant, and the alcohol sprayed into their eyes. Sunny et al35 described a 32-year-old woman who accidentally made the portable disinfectant spray on her right eye.

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FIGURE 5:
Forest plot of the proportion of chemical eye injury among all ocular trauma during COVID-19 and pre–COVID-19 periods. Events: chemical eye injury; Total: total number of ocular trauma; OR: odds ratio; CI: confidence interval.

Ma et al10 reported that the number of cases of photokeratitis during the lockdown period was higher than that in the control period (141 cases vs 53 cases), and the proportion of photokeratitis cases in nonmechanical injuries significantly increased from 46.9% to 81.0% in comparison with the control pandemic (χ2=36.437, P<0.001). In addition, 2 studies reported 7 cases and 3 cases of electric ophthalmia caused by improper use of ultraviolet disinfection, respectively.36,37

A study also documented ocular trauma secondary to the inappropriate use of masks.38 Seven patients were injured by metal nasal wires or other hard and sharp parts of masks, and 2 patients were injured by elastic masks.

DISCUSSION

By summarizing the current literature, we found that the overall incidence of ocular trauma during the pandemic decreased to 67.7% of that in the control period. Various potential reasons could account for such observation. Firstly, COVID-19 changed many human activities, including industrial, agricultural, and social activities, which are all risk factors of ocular trauma.10 In addition, large-scale lockdowns imposed by many governments may limit some patients with mild ocular trauma from medical contact, hence resulting in an apparent reduction in the incidence of ocular injuries. This is further aggravated by the negative financial impact brought by COVID-19 to the general population, which may deter patients from seeking medical care unless the nature of the ocular injuries was urgent or severe.12 However, there were inconsistencies in the literature. Stedman et al19 reported 10 cases of serious ocular trauma (4 globe ruptures, 4 full-thickness lid lacerations, and 2 intraocular foreign bodies).There was a 5-times increase in the incidence of ocular trauma in Royal Hallamshire Hospital Sheffield in the UK during the pandemic compared with the control period, in which the incidence of ocular trauma related to falls and house decoration increased significantly. This inconsistency was accounted for by the authors due to the increased time people spent at home in compliance with extended lockdown periods, during which they engaged in home improvement–related projects and the elderly individuals were limited at home. Such alteration in daily activities, therefore, led to increased ocular trauma related to domestic renovation. Elderly individuals were regarded as high-risk population of eye injuries due to falling at home and their risk of fall increased as their time at home raised. Moreover, eye injuries constitute a huge cost to the individual, health care system, and society. Therefore, family members should strengthen their care for the elderly to avoid falls during the COVID-19 pandemic.7

Children are a special population, and the occurrence of pediatric ocular trauma warrants special attention. The pooled number of pediatric ocular trauma cases decreased during the pandemic. The merged proportion of pediatric ocular trauma cases among the total ocular trauma cases decreased. This may be related to the suspension of classes, which prohibited children from sports and recreational activities.14 Their exposure to risk factors was subsequently reduced. Parents also had more time to supervise their children due to lockdowns, thereby potentially reducing the risk of misadventure.

We further analyzed the category of ocular trauma reported in the literature. The results showed that the proportion of occupational, sports-related, and traffic-related ocular trauma decreased, while the proportion of domestic ocular injuries increased during the pandemic. The change in the category of ocular trauma may be attributed to the alterations of social activities caused by pandemic-control policies such as massive lockdowns and the implementation of work-from-home strategies worldwide.

During the COVID-19 pandemic, many measures were implemented to prevent and curb the transmission of the coronavirus, such as the use of alcohol-based sanitizers, ultraviolet lamps, and masks.39 These measures may cause ocular injuries by accident. Keeping hands clean is a simple, effective, and economical measure of infection control. Alcohol-based sanitizers were placed in many public places for hand disinfection. There was a significant increase in alcohol-based-sanitizer–related eye chemical injuries, many of which involved children.22,23,34,35 It is likely that most alcohol-based sanitizers were installed at the waist height of an adult in public, which approximated a child’s eye level and rendered children prone to ocular chemical injuries when these alcohol-based sanitizers were activated in close proximity to them. To prevent ocular chemical injuries, guardians ought to maintain a high level of vigilance to prevent inadvertent ocular exposure of children to such devices. Meanwhile, manufacturers of alcohol-based sanitizers should consider design modifications for such devices to minimize the said risk. In addition, we observed an increase in photokeratitis caused by ultraviolet disinfection. The public ought to be better informed and educated on the proper use of UV germicidal lamps in order to prevent such accidents.10

During the pandemic, masks, as a preventive measure, are widely used to combat the spread of coronavirus.40 The correct use of masks can effectively prevent us from infection. However, with the increase in the use of masks, ocular trauma secondary to improper use of masks has been documented.38,41 Therefore, public education on the proper donning of masks should be emphasized, in particular to empower vulnerable groups such as the elderly and children.

In conclusion, during the COVID-19 pandemic,the total incidence of ocular trauma decreased. People were more likely to suffer from ocular trauma while at home. The incidence of pediatric ocular trauma and sports and outdoor activities–related ocular trauma decreased. Significant variations in the spectrum of ocular trauma during the pandemic should nonetheless be noted by frontline ophthalmologists, in particular ocular trauma related to pandemic-control strategies. Epidemic prevention and control measures such as alcohol-based sanitizers, ultraviolet disinfection, and masks may also cause eye damage. Adequate education should be offered to the general public to prevent them from ocular trauma secondary to improper implementation of pandemic preventive measures.

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Keywords:

COVID-19; ocular trauma; epidemiology; meta-analysis; systematic review

Copyright © 2022 Asia-Pacific Academy of Ophthalmology. Published by Wolters Kluwer Health, Inc. on behalf of the Asia-Pacific Academy of Ophthalmology.