INTRODUCTION
Pediatric ocular trauma is an important cause of eye morbidity.[1] Epidemiology varies in different regions of the world. Though it accounts for 8–14% of total injuries in children,[2] it can be prevented in 90% of the cases.[1,2] There is a significant difference between the modes of traumatic injuries in children and adults, in children, the incidence mostly happens in recreational environments, and in adults, it is mostly due to occupational. Two percent to 14% of pediatric ocular trauma ends in visual impairment or blindness.[3,4,5] This study aims to determine the patterns of ocular trauma and analyze the mode of injury, its complications, and its visual prognosis after injury.
The major anticipated problems in pediatric ocular trauma even with good healing response are amblyopia, dense fibrous reaction, cataract, and also the lower success rate of keratoplasty due to excessive fibrin formation.[2,6]
METHODS
This study was a prospective observational case study conducted in the Department of Ophthalmology, in a tertiary care center for 1 year from January 2020 to January 2021, which included all children below the age of 12 years with a history of ocular trauma presented to the outpatient department or emergency department. All data were collected on a standardized proforma and entered into a dedicated database, after getting informed written consent from parents. The ethical committee approval has been obtained on 18.12.2020.
Data were collected on the demographic characteristics of patients in terms of age, sex, residential area (urban or rural), date and time of injury, mode of injury, place of injury, intervention is done, the course in the hospital, its complications, and final visual outcome. A detailed ocular examination including visual acuity, slit-lamp biomicroscopy, and fundus examination was done. In preschool children, visual acuity was evaluated using the Kay picture test and for the rest of the children, visual acuity was assessed using the Snellen chart. Ultrasound and radiography of eyes were obtained when needed. The ocular Trauma Score (OTS) has been calculated. They have been grouped between groups 1 to 5, group 1 was the poorest prognosis and group 5 was the best. The eye injuries were also classified using the international classification of ocular trauma, the Birmingham Eye Trauma Terminology System (BETTS) is to depict the Ocular injury terminology whether it is a closed globe or open globe injury.[7,8]
All patients were appropriately managed and followed up. Patients requiring surgical intervention were operated on, and these patients were followed up on day 1 postoperative period and subsequently until 6 months. The data were entered in an Excel sheet, and Snellen's visual acuity was converted to a Log MAR unit for statistical analysis. Mean and standard deviation were used to describe the continuous variables, whereas frequencies were used to describe the categorical and binary variables.
RESULTS
A total of 50 children presented to the Department of Ophthalmology with a history of ocular trauma during the study period. The patient demographics were shown in Table 1. Out of 50 children, children between 0 to 4 years of age were 13 (26%), 5 to 8 years of age were 13 (26%), and 9 to12 years of age were 24 (48%). The mean age of presentation was 7.43435. Of the total study population, 35 (70%) children were male and 15 (30%) were female. Forty-five (90%) children were from rural areas and 5 (10%) were from urban areas. The most common mode of injury was road traffic accidents and accidental falls, which were about 24% (n = 12 each). The next most common mode of injury was firecracker injury and it was about 14% (n = 7). Injury due to burns were about 6% (n = 3), foreign body 1% (n = 1), animal bite 4% (n = 2), and rare causes 13%, which include injury with goat horn, fingernail, bee sting, battery explosion, electric shock, and birth trauma. Figure 1 shows the various modes of pediatric ocular injury. Forty-five (90%) children were from rural areas and 5 (5%) were from urban areas. Forty-one (82%) children had uniocular and 9 (18%) children had binocular injuries.
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Table 1: Patient demographics
Figure 1: Chart showing various modes of pediatric ocular trauma
Ocular trauma has been classified as closed or open globe injury based on BETTS, which showed only 6% (3 patients) had open globe injury and 84% (42 patients) had closed globe injury, 10% (5 patients) had an adnexal injury, which was not classified in BETTS. Figure 2 shows the BETTS classification of ocular injuries.
Figure 2: BETTS classification of Ocular injury showing the closed globe injury being most common
Only 39 patients were assigned a score based on the ocular trauma score; for 11 patients, the score could not be assigned due to the absence of initial visual acuity and they have been grouped into five categories, group 1 had a poor prognosis and group 5 was good. Sixty-six percent (33 patients) have been grouped under group 5, which is the most common in our study. The Ocular Trauma Score is shown in Table 2.
Table 2: The Ocular Trauma Score (OTS) group
Out of the 50 children, 40 children were managed medically, and 10 children required surgical intervention. Of them, 2 had traumatic cataracts, 3 children had corneal tears for which tear repair was done, 3 patients had lid laceration suturing, 1 had retinal detachment and was referred to retina clinic, 1 patient had a medial blowout fracture with medial rectus entrapment and was referred to the plastic surgery department for muscle release. Figure 3 shows the various clinical presentations of pediatric ocular trauma.
Figure 3: Shows the various clinical presentations of pediatric ocular trauma. (a) Corneal lamellar laceration, (b) Firecracker injury, (c and d) Pre and post op picture of lid laceration (e and f) Pre and post op picture of lid laceration
Table 3 shows the initial and follow-up visual acuity. It shows that the follow-up visual acuity was good in the age group 9–12 years compared to the 0–4 and 5–8 years.
Table 3: Initial and follow-up visual acuity
DISCUSSION
Ocular injury is one of the common causes of acquired blindness in children. Children form a special high-risk group for ocular trauma due to their behavior, attitude, inquisitiveness, and playfulness. Several unique problems arise in the evaluation and management of pediatric ocular trauma. Difficulty in getting an appropriate history due to the child's fear, poor cooperation during the examination, and often requiring general anesthesia are the drawbacks. The consequences of childhood injury are harmful as it leads to permanent blindness and visual handicap and adds to the economic burden of society. It also affects the psychological, social, and emotional development of a child.
According to the American Academy of Pediatrics (APP), 66% of all ocular injuries occur in patients 16 years of age or younger, with the highest prevalence between 9 and 11 years of age.[9] In our study, children aged 9–12 years (48%) were most commonly affected followed by the age group 0–4 years, and 5–8 were equally involved (26% each). Seventy percent of the involved population are boys, which probably reflects the boy's nature of being more adventurous and their tendency to play outdoors. A high male-to-female ratio has been observed in our study as compared to the other studies published.[10,11,12]
Singh et al. and Saxena et al. noted the incidence of pediatric ocular trauma in the central Indian population as 12.8% and 20.8%, respectively.[13,14] Maurya et al. described that 30.35% of ocular trauma occurred in the pediatric age group.[15]
Our study shows the incidence of ocular trauma to be more common in rural than in urban areas, which is similar to Singh et al.[13]
Ocular trauma in children accounts for 8% to 14% of the total injuries.[1] Childhood injury is different from adult ocular trauma in terms of the objects involved in causing the injury, evaluation, and management protocols.[16,17] The majority of ocular injuries in children are preventable by taking minor precautions and identification of risk factors for ocular injury.[14,16,18,19,20]
The epidemiological profile of pediatric ocular injuries varies from country to country and state-wise in the same country. Eye trauma is the most common in developing countries than in developed countries.[21] The nature of the injury and visual outcome is different between developing and developed countries due to vast differences in social, demographic, and cultural factors.
There is a wide spectrum of modes of injury in pediatric ocular trauma compared to adult trauma. The following are some of the few highlights.
A 5-year-old female child had an injury with a thorn in the right eye and had a corneal tear, for which corneal suturing was done. Later, she developed a post-traumatic cataract for which cataract surgery was done and the child regained 6/12 vision following surgery. According to a study conducted by AlMahmoud et al.,[22] the main cause of vision limitation in thorn injury was corneal involvement (81%).
Similarly, an 11-year-old boy had traumatic retinal detachment due to assault by his brother while playing, the child was referred to the vitreoretinal clinic promptly and another 9-year-old child had a corneal tear in the right eye due to a battery explosion while playing and corneal repair was done.
A 7-year-old male child had a category 3 dog bite and had avulsion laceration in the right lower eyelid involving full-thickness lid margin with canalicular injury, for which lid suturing with canalicular reconstruction was done and another 9-year-old female patient had a category 3 dog bite and had a left upper eyelid laceration, wound wash given, Inj. ARV was given, and stay suturing was done. In a study conducted by Savar et al., 66% of the ocular injury caused by dog bites resulted in canalicular injury.[23]
A 9-year-old male child had left eye isolated medial rectus palsy following an accidental fall, Computed Tomography (CT) facial bone showed left medial rectus entrapment and the child was referred to the plastic surgery department for muscle release.
Two children have got traumatic optic neuropathy following accidental falls and RTA, for which Inj. methylprednisolone was given for 3 days followed by oral prednisolone for 11 days. The inability of children to self-assess the visual symptoms after the traumatic injury can lead to misdiagnosis and a poor prognosis, which can prevent the early diagnosis.[24]
Regarding the visual outcome, 45 children had good visual outcomes, 1 child had 1/60 vision, 1 had the vision of counting fingers close to face, 1 had the perception of light, and 1 landed up with no PL and no child was blinded bilaterally.
Timely referral and prompt management can help prevent blindness from ocular trauma. Follow-up plays a vital role in identifying the secondary complications earlier. It is a prerequisite to educate the children, parents, and teachers concerning ocular health and hygiene to minimize eye injuries.
CONCLUSION
Our study concludes that ocular trauma serves as a major ocular morbidity in the pediatric age group. While confirming the various other study results of male predominance, and the most common age group affected, we also noted the higher prevalence of road traffic accidents and higher presentation of closed globe injury instead of open globe injury in pediatric trauma as a flip-side. Visually-threatening injuries occurred in both assault and unintentional trauma in younger children while being more common in assault and self-inflicted injuries in older age groups. The ocular trauma score served as a useful tool in predicting the anticipated visual outcome. Also, timely management served as essential in preventing vision-threatening complications.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Brophy M, Sinclair SA, Hostetler SG, Xiang H. Pediatric eye injury-related hospitalizations in the United States Pediatrics. 2006;117:e1263–71
2. American Academy of Ophthalmolgy. Pediatric Ophthalmology and Strabismus. 2005;6 San Francisco AAO
3. MacEwen CJ, Baines PS, Desai P. Eye injuries in children: The current picture Br J Ophthalmol. 1999;83:933–6
4. Moreira CA Jr, Debert-Ribeiro M, Belfort R Jr. Epidemiological study of eye injuries in Brazilian children Arch of Ophthalmol. 1988;106:781–4
5. Poon AS, Ng JS, Lam DS, Fan DS, Leung AT. Epidemiology of severe childhood eye injuries that required hospitalisation Hong Kong Med J. 1998;4:371–4
6. Farjo AA, Rhee DJ, Soong HK, Meyer RF, Sugar A. Iris-sutured posterior chamber intraocular lens implantation during penetrating keratoplasty Cornea. 2004;23:18–28
7. Kuhn F, Maisiak R, Mann L, Mester V, Morris R, Witherspoon CD. The
ocular trauma score (OTS) Ophthalmol Clin North Am. 2002;15:163–5
8. Pieramici DJ, Sternberg P Jr, Aaberg TM, Bridges WZ Jr, Capone A Jr, Cardillo JA, et al A system for classifying mechanical injuries of the eye (globe). The ocular trauma classification group Am J Ophthalmol. 1997;123:820–31
9. Coody D, Banks JM, Yetman RJ, Musgrove K. Eye trauma in children: Epidemiology, management, and prevention J Pediatr Health Care. 1997;11:182–8
10. Niiranen M, Raivio I. Eye injuries in children Br J Ophthalmol.. 1981;65:436–8
11. Al-Bdour MD, Azab MA. Childhood eye injury in North Jordan Int Ophthalmol. 1998;22:269–73
12. Singh DV, Sharma YK, Azad RV, Talwar D, Rajpal. Profile of ocular trauma at tertiary eye centre JK Science. 2005;7:16–21
13. Singh S, Sharma B, Kumar K, Dubey A, Ahirwar K. Epidemiology, clinical profile and factors, predicting final visual outcome of
pediatric ocular trauma in a tertiary eye care center of Central India Int J Ophthalmol. 2017;65:1192–7
14. Saxena R, Sinha R, Purohit A, Dada T, Vajpayee RB, Azad RV. Pattern of
pediatric ocular trauma in India Indian J Pediatr. 2002;69:863–7
15. Maurya RP, Srivastav T, Singh VP, Mishra CP, Al-Mujaini A. The epidemiology of ocular trauma in Northern India: A teaching hospital study Oman J Ophthalmol. 2019;12:78–83
16. Agarwal R, Rao G, Naigaonkar R, Ou X, Desai S. Prognostic factors for vision outcome after surgical repair of open globe injuries Indian J Ophthalmol. 2011;59:465–70
17. Shah A, Blackhall K, Ker K, Patel D. Educational interventions for the prevention of eye injuries Cochrane Database Syst Rev. 2009;2009:CD006527
18. Philip SS, Hoskin AK. Children's protective eyewear: The challenges and thewayforward Med J Aust. 2014;201:87–8
19. Hoskin AK, Philip SS, Yardley AM, Mackey DA. Eye injury prevention for the pediatric population Asia Pac J Ophthalmol. 2016;5:202–11
20. Shoja MR, Miratashi AM.
Pediatric ocular trauma Acta Med Iran. 2006;44:125–30
21. Salvin JH. Systematic approach to
pediatric ocular trauma Curr Opin Ophthalmol. 2007;18:366–72
22. AlMahmoud T, Elhanan M, Abu-Zidan FM. Eye injuries caused by date palm thorns and leaves Saudi J Ophthalmol. 2020;34:13–7
23. Savar A, Kirszrot J, Rubin PA. Canalicular involvement in dog bite related eyelid lacerations Ophthalmic Plast Reconstr Surg. 2008;24:296–8
24. Chen M, Jiang Y, Zhang J, Li N. Clinical treatment of traumatic optic neuropathy in children: Summary of 29 cases Exp Ther Med. 2018;16:3562–6
