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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 19  |  Issue : 4  |  Page : 259-267

To study the epidemiological and clinical profile of ocular trauma at a tertiary health-care facility


1 Department of Ophthalmology, Adesh Institute of Medical Sciences and Research, Bathinda, Punjab, India
2 Department of Ophthalmology, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India

Date of Submission05-Mar-2018
Date of Acceptance27-Jul-2018
Date of Web Publication20-Dec-2018

Correspondence Address:
Ekta Syal
Department of Ophthalmolgy, Adesh Institute of Medical Sciences and Research, Bathinda, Punjab 151001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/DJO.DJO_14_18

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  Abstract 


Aim To study the profile of ocular trauma and to find out its risk factors.
Settings and design This is a prospective hospital-based study that included patients of ocular trauma presenting to the Department of Ophthalmology and Emergency, Guru Gobind Singh Medical College and Hospital, Faridkot, India during the period from May 2015 to November 2016.
Patients and methods The study included patients with recent history of trauma (<7 days). Complete demographic data, history of trauma, and detailed ocular examination were done. Statistical analysis used the statistical package for the social sciences software.
Results A total of 200 patients were studied. Men had twofold higher rates of injury than women. The predominant age group was between 21 and 30 years with a mean age of 29.87±12.46 years. Daily laborers were most frequently involved in trauma (n=64; 32%). The workplace trauma was the most common mode accounting for 27.5% of the cases and was most commonly sustained by laborers (50.90%). Metallic objects were responsible in 28.5% followed by vegetative matter (11%). Mechanical trauma was present in 94.5% while 5.5% suffered from chemical trauma. In 94.5% cases with mechanical trauma, 60.5% sustained closed globe injuries and 26% had open globe injuries. Contusions and penetrating injuries were the most common in closed and open globe injuries, respectively. Corneoscleral perforation was the most common clinical presentation in 50 patients. Forty-two percent of patients required only medical management and 58% required surgical management with the most frequent being corneal/scleral perforation repair.
Conclusion Workplace-related eye injuries were noted in a significant number of cases. Strict implementation of health education and preventive strategies especially at the workplace will help to decrease the occurrence of ocular injuries.

Keywords: closed globe, ocular trauma, prevention, workplace


How to cite this article:
Syal E, Dhawan M, Singh SP. To study the epidemiological and clinical profile of ocular trauma at a tertiary health-care facility. Delta J Ophthalmol 2018;19:259-67

How to cite this URL:
Syal E, Dhawan M, Singh SP. To study the epidemiological and clinical profile of ocular trauma at a tertiary health-care facility. Delta J Ophthalmol [serial online] 2018 [cited 2021 Dec 3];19:259-67. Available from: http://www.djo.eg.net/text.asp?2018/19/4/259/248080




  Introduction Top


Ocular trauma is a preventable public health problem throughout the world [1]. It is a major cause of preventable monocular blindness and visual impairment throughout the world [2]. Each year 55 million eye injuries occur in the world that restrict victims’ activities for at least 1 day. Nineteen million have at least unilateral permanent reduction of vision and 1.6 million are blinded by their injury [3]. Studies indicate that one out of every five adults have a history of ocular trauma [4]. In the pediatric group, these rates are 12–38%, making ocular trauma the most avoidable cause of childhood blindness [5]. Despite having major socioeconomic impact, less data on the magnitude and risk factors are available especially in developing countries like India [4],[6].

This study was conducted to determine the causative agents and risk factors for ocular injuries and to outline the protective measures for the patients.


  Patients and methods Top


This study was conducted in the Department of Ophthalmology at Guru Gobind Singh Medical College & Hospital, Faridkot, India, from May 2015 to November 2016. It was a prospective study consisting of 200 ocular trauma patients attending the emergency room, outdoor, and admitted inpatients. The study was neither age nor sex specific. A written informed consent form was signed by the patients and their relatives. The study was approved by the Local Ethical Committee of the Institution.

Inclusion criteria

Patients with a recent history of trauma (<7 days).

Exclusion criteria

Included patients with a history of trauma more than 7days, pre-existing diseases like glaucoma and previously operated eyes and cases where clinical findings appeared to be of nontraumatic nature.

Complete history and examination of patients were done. History included demographic data, namely age, sex, residence (rural/urban), occupation, literacy status, past ocular history in the context of ophthalmic surgery or trauma and ailment to the eye. Medical history included history of diabetes mellitus and hypertension which could affect the vision.

Examination included slit lamp examination, dilated fundus examination with and indirect ophthalmoscope and 90 D lens wherever possible. Gonioscopy and intraocular pressure (IOP) measurement were done only in closed globe injuries. In eyes with corneal edema and hyphema, gonioscopy was done at the next follow-up. B-scan ultrasonography (NIDEK Inc., Fremont, California, USA) was done in cases of opaque media where the fundus examination was not possible. Orbital radiography: anteroposterior and lateral views were done to rule out fractures and intraocular foreign body. Computed tomographic scan was done in cases of optic nerve injury to detect any optic canal fracture. The injuries were further classified into:
  1. Mechanical.
  2. Nonmechanical: chemical/radiation/thermal.


Mechanical injuries were classified according to the ocular trauma classification system (OTCS) [7] ([Table 1]). Since OTCS was only for mechanical globe injuries and did not include isolated adnexal injuries (lid and orbit), the isolated injuries of lids and orbit were classified under a new category of adnexal injuries, but the combined injuries of globe and adnexa were included under globe injuries. The open and closed globe injuries were divided into three zones as per the OTCS ([Table 1]). Chemical injuries were classified according to the Roper-Hall Classification System [8] ([Table 2]).
Table 1 Ocular trauma classification system for mechanical ocular injuries

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Table 2 Roper-Hall classification of chemical injuries

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Following examination and classification, the patients were managed either medically or surgically. Due to the complex nature of ocular trauma, some patients required more than one surgery. Complete data, so collected, were analyzed with statistical package for the social sciences (version 16.0; SPSS Inc., Chicago, Illinois, USA). Frequency analysis was performed by the χ2 test. A P value less than 0.05 were considered statistically significant.


  Results Top


The study enrolled 200 patients which included 141 men and 59 women with an male : female ratio of 2.4 : 1. The mean age was 29.87±12.46 years. The pediatric age group (age, <16 years) constituted 15.5% of cases. Seventy-six percent of the patients presented within 24 h of trauma followed by 17% of the patients presenting late after 48 h. Of all patients, 50.5% were illiterate followed by 31.5% who were matric pass (10th class) and only 7.0% of the patients were graduates showing an increased incidence of trauma in illiterates.

Daily laborers were most commonly involved in trauma (64 cases=32%), followed by housewives (37 cases=18.5%) then by farmers and students accounting for 35 cases (17.5%) each. The occupation of the patients was found to be statistically correlated with the sex of patients (χ2 test, 55.761; P=0.0004) showing that the highest frequency of men involved were daily laborers and women were housewives ([Figure 1]).
Figure 1 Correlation of occupation of patients with sex showing most men involved as daily laborers and women as housewives.

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Regarding the mode of injury, the workplace was the most common location of trauma accounting for 27.5% of the cases followed by road traffic accidents in 23.5% of the patients. Trauma due to assault was present in 22.5% of the patients and trauma at domestic setup was present in 14.5% of the patients. Only 12% of the patients sustained injuries during sports/leisure activity.

The mode of trauma was found to be significantly correlated to the sex of patients showing that men were commonly involved in workplace trauma (52 cases=36.87%) and women in domestic injuries (24 cases=40.67%) ([Figure 2]). The most frequent workplace trauma was sustained by laborers, that is, in metal and construction workers (50.90%) followed by farmers (32.73%), and factory workers (16.36%).
Figure 2 Correlation of mode of injury with sex of patients showing preponderance of workplace trauma in men and domestic trauma in women.

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Sports/leisure activities (61.29%) were the most common mode of trauma in children, followed by domestic trauma (22.58%) and road traffic accidents (16.12%). The study enrolled 142 rural patients and 58 urban patients and the geographical residential location was found to be significantly correlated with the mode of injury (χ2 test, 29.6135; P<0.00001) with higher frequency of road traffic accidents in urban areas (61.70 vs. 38.29%) and work-related injuries in rural areas (81.81 vs. 18.18%).

Metallic objects (28.5%) were the most frequent material involved, followed by vegetative matter (11%). The chemicals responsible for causing trauma were pesticide, lime, cement, and cleanser in 5.5% of the patients ([Figure 3]).
Figure 3 Distribution of various objects causing trauma.

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The spectrum of injuries showed that corneoscleral perforation was the most common presentation in 50 patients, followed by subconjunctival hemorrhage, hyphema, etc. ([Figure 4]). The posterior segment involvement showed traumatic optic neuropathy, retinal detachment ([Figure 5]), and Berlin’s edema. The adnexal injuries included lid laceration in 27 patients and orbital fracture in three patients ([Table 3]).
Figure 4 Subconjunctival hemorrhage and total hyphema.

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Figure 5 B-scan ultrasonography showing retinal detachment.

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Table 3 Distribution of ocular findings

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Mechanical trauma was sustained by 94.5% of the cases while 5.5% of the patients suffered from chemical trauma. Mechanical injuries were classified and zonal distribution was done according to OTCS ([Table 4]). Eleven out of 200 patients sustained chemical injuries in which four patients had grade 2 injuries, one case had grade 1 whereas grades 3 and 4 shared an equal number of three patients each (using the Roper-Hall Classification System).
Table 4 Type and zonal distribution of mechanical injuries according to ocular trauma classification system

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The patients were either managed medically or surgically. Out of 200 patients, 42% of the patients required only medical management, while 58% required surgical management. Out of 116 (58%) patients requiring surgical intervention, 93 cases (46.5%/58%) required only a single surgery and 23 cases (11.5%/58%) needed more than one surgery due to multiple tissue involvement. The spectrum of surgeries included corneal/scleral perforation repair and lid reconstruction, etc. ([Figure 6] and [Figure 7]). Due to the complex nature of ocular injuries, multiple surgeries were done in some patients ([Figure 8]).
Figure 6 Central corneal perforation and repaired cornea.

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Figure 7 Preoperative and postoperative image of lid laceration.

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Figure 8 Spectrum of surgical procedures done.

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  Discussion Top


Ocular trauma is a major public health problem and demands immediate and comprehensive care. Epidemiological profile of ocular trauma varies with greater incidence in developing than developed countries [9]. More studies are required to define the target population for prevention and to determine the prognostic factors at presentation.

The present study suggested the correlation of age and sex with the susceptibility to ocular trauma. The mean age for ocular injury in this study was 29.87±12.46 years, which is in accordance with most other studies in which a mean age of ∼30 years has been reported [6],[10]. This is likely due to work-related injuries that contributed to the largest portion of injuries (27.5%). This feature is of great importance as this is the most economically productive age group and has important consequences on finances of household and society [11].

Consistent with other studies [12],[13], the current study observed male dominance of ocular trauma with a male : female ratio of about 2.4 : 1. This male preponderance is thought to be related to occupational exposure, participation in dangerous sports and hobbies, alcohol use, and risk-taking behavior.

Children below 16 years of age were more susceptible to ocular injuries while playing (61.29%), which could be due to unsupervised and risky sports. This was consistent with the study by Grieshaber and Stegmann [14] who observed that most injuries occurred during playing in the streets and roads (66%). Vats et al. [9] also concluded that there is a need for supervision of the activities by parents.

In the current series, a large proportion of patients sustaining trauma were from rural areas (74%) which could be due to illiteracy and ignorance and also due to exposure to occupation without preventive measures. This was consistent with the study done by McCarty et al. [6] in which 51.7% of the cases were of rural origin.

Various causes and places of ocular trauma have been reported over the course of the 20th century. Similar to other studies [6],[10] workplace was found to be the most common place of trauma accounting for 27.5% of the patients in the present study. A study by McCarty et al. [6] found factory workers and manual daily laborers to be a high-risk population for ocular trauma similar to the present study, which could be explained by involvement of unskilled and semiskilled workers and lack of any eye protection. This is the target population for emphasizing recommendations for safety measures as most of the injuries can be prevented by appropriate use of ocular protection.

The present study observed a male preponderance at workplace trauma and road traffic accidents and women at domestic trauma showing a significant correlation which is similar to the results found in the study by Oum et al. [15]. This difference is probably due to the fact that men spend more time outdoors.

In the current series, metal fragments/nails were the leading agents that cause eye injury among all injuries which was in accordance with previous reports [16],[17]. The local work tasks included grinding, welding, hammering, drilling, carpentry, metal cutting, and nailing which involve high-powered tools that generate metal fragments/nails at high velocities and often have devastating effects on the eye. In contrast to this, a study by Mishra et al. [18] reported wooden stick as an offending agent for ocular injury which could be due to the fact that the study was conducted in a rural area.

In the present study, 5.5% of the cases were due to chemical injuries in which lime predominated acids due to the common use of lime by workers in rural areas which was consistent with the reports by Saini and Sharma [19].

In the present study, 78% of the patients reported within 24 h of trauma. This is important as regard prognosis as instituting early treatment will result in better prognosis whereas even minor injury may prove blinding if treatment is delayed.

Closed globe injuries were found to be more common accounting for 60.5% of the cases in the current study. In a Korean study by Oum et al. [15], the prevalence of closed globe injury was six times higher than open globe injury.

Contusions were the most common among closed globe injuries (46%/60.5%) and penetrating injuries were the most common in open globe injuries (23%, 26%). These results were consistent with the study by Karaman et al. [20] where contusion and penetrating injury were the most common in closed and open globe injuries (58.6, 67.3% and 19.6, 32.7%), respectively. Sixteen (8.0%) cases had isolated injuries of the ocular adnexa and orbital wall fractures, thus demonstrating that there is a wide spectrum of presentation of ocular trauma.

Anterior segment was the most frequently involved with the cornea being the most common structure involved (26.5%), which could be due to its anterior position and exposure to environment thus making it highly susceptible to trauma. Isolated posterior segment trauma was detected in 10% of the patients manifesting as optic nerve involvement, Berlin’s edema, Purtscher’s retinopathy, and retinal hemorrhages. Combined injuries of adnexa and globe were found in 30 patients showing that ocular trauma had a wide spectrum of presentations and requires a multidisciplinary approach.

Young age, illiteracy, rural background, delayed presentation, open wound, and injury to lens capsule are more likely to develop endophthalmitis after trauma as reported previously [21]. Similarly, in the present study all three cases were illiterate and of rural background with open wound and presenting late after 48 h.

In the present study, 3.0% of the eyes developed retinal detachment over a period of 3 months. Retinal detachment was more common in open globe trauma than closed globe injury. This can be explained by a higher incidence of vitreous disturbance, incarceration, and resultant traction in open globe injuries. Blood in vitreous in the presence of scleral wound leads to fibrovascular proliferation and tractional retinal detachment [22].

In the present, study, patients were either managed medically or surgically. Corneoscleral perforation repair and eyelid reconstruction were the most common procedures performed. A study by Lee and Oh [23] reported that surgical procedures of ocular trauma in emergency included mainly primary closure of eyelid and face wounds and corneal sutures.

Due to the complex pattern of trauma, multiple surgeries were required in 11.5% of the patients, in the present study. The most common second surgery was cataract extraction with or without intraocular lens implantation in 7.5% of the cases due to the development of post-traumatic cataract. Seven patients needed vitrectomy and three underwent scleral buckle surgery for retinal detachment. Similar results were seen in the study of Oum et al. [15] in which 9.6% of the cases required multiple surgeries.


  Conclusion Top


Ocular trauma is a grave cause of ocular morbidity and mortality. Prevention is always better than cure, so appropriate preventive measures should be used at potentially hazardous places. Prompt transfer to a good eye facility, early investigations, and management are key features to prevent permanent visual loss. The results of this study suggest the need to explore strategies to minimize ocular trauma as a priority. The target population which includes young, illiterate, and those working in mechanical jobs should be focused upon and given preventive measures and timely visit to ophthalmologists. Resources should be mobilized to provide quality ocular emergency care. Certain legislative directives for the protection of laborers and factory workers should be implemented. A joint effort by the industry and agricultural experts with the health professional is the need of the hour to determine the region and work-specific eye protection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


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