Ocular trauma in the pediatric age group: a systematic review

Abstract

Background

Ocular traumas are the leading cause of acquired unilateral blindness in the pediatric age group. The aim of this study is to determine the incidence of pediatric ocular injuries, the etiological factors that cause them, and to make some preventive recommendations.

Methods

This was a retrospective observational study of pediatric ocular trauma (age < 18 years) presented to the pediatric emergency unit of our tertiary university hospital between January 2016 and December 2020. Demographic data such as age, gender, season, duration of admission, trauma etiology, and type of injury were recorded. Patients with missing medical records were excluded from the study.

Results

Two hundred two patients aged a mean of 107.4 ± 40.7 months including 87 females (43.07%) and 115 males (56.93%) were included in the study. Most of the patients (n = 135, 66.83%) were in the 7–11 years of age group. The vast majority of the study population lived in the urban area (n = 119, 58.91%). Most injuries were seen in the summer (n = 108, 53.47%). 59.41% of all patients had closed globe injuries. Hyphema (32.5%) and endophthalmitis (26.6%) were the most common in closed globe injuries. Of the open globe injuries, 39 were penetrating (47.5%), 12 were perforated (14.6%), and 23 were intraocular foreign body injuries (28%). It was determined that the places where the injury occurred were mostly in situations where family control was reduced, such as weddings, holidays, and playgrounds (80.69%). The most common causes of injury were toy guns (35.15%), stones (28.71%), and fireworks (16.34%).

Conclusion

This analysis is the first study to provide data on childhood ocular trauma in Aksaray. Most of the childhood ocular injuries can be prevented with simple precautions. For this purpose, effective and preventive strategies should be developed such as raising public awareness, providing parental control, and early intervention.

Background

Ocular traumas are the leading cause of acquired unilateral blindness in the pediatric age group [1]. It is devastating trauma in the pediatric age group and is an important cause of morbidity in children. Worldwide, ocular trauma admissions in children account for 8 to 14% of total emergency trauma admissions, and the incidence of severe visual impairment or blindness ranges from 2 to 14% [2,3,4]. Eye injuries are both a significant socioeconomic burden and an important cause of morbidity that causes parents to worry about their children [5]. Most eye injuries can be prevented with simple protective measures [6].

Ocular injuries are usually caused by sharp objects, toys, wooden sticks, pencils, various sports activities, and stones in children [4]. Traumas are generally classified into two types as globe and adnexal. The most common emergency admission is with open globe injuries and require urgent intervention [7].

The incidence of childhood ocular traumas varies from region to region and also varies with demographic data such as age and gender. While many studies have been conducted on ocular trauma in developed countries, the incidence of eye injuries in developing countries is not well known [4, 8, 9]. This study is aimed to determine the incidence of pediatric ocular injuries, the etiological factors that cause it, and to make some preventive recommendations.

Methods

Study design

This retrospective observational study was conducted in the pediatric emergency department of a tertiary hospital in Aksaray, Turkey. In the period between January 2016 and December 2020, the medical records of patients admitted to the emergency department were retrospectively reviewed. The study was conducted in compliance with the principles of the Declaration of Helsinki and approved by the regional ethical committee (2020/03–49).

All patients were referred to an ophthalmologist and treated appropriately. Patients requiring interventions such as open globe injuries repair, foreign body removal, and vitrectomy were transferred to the ophthalmology department to be operated.

Study population and setting

The following patients were included in the study: (1) under 18 years of age and (2) those diagnosed with ocular trauma. The following patients were excluded: (1) over 18 years old, (2) those with multiple trauma, and (3) missing data.

Gender (female, male), age (0–5, 6–12, and 13–18), residence area (rural, urban), season (spring, summer, autumn, winter), duration of admission (0–8, 8–24, < 24 h), etiology of trauma (toy gun, firework, wooden stick, stone, sharp object, trauma), and type of ınjury (open globe injury—closed globe injury and its subtypes) were recorded.

Statistical analysis

The SPSS 20 (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.) package program was used to evaluate the data. Data were summarized as mean ± standard deviation for continuous variables and frequencies (percentiles) for categorical variables. Descriptive statistics for this retrospective observational study are given in tables.

Results

Eye trauma was present in 212 (0.72%) out of a total of 27,896 children admitted to the emergency department for trauma. Data of 7 patients were deficient. Three patients did not accept treatment to go to another hospital. Data of 202 patients were analyzed. The mean age at admission was 107.4 ± 40.7 months. Children aged 7–11 years (66.83%) were most frequently affected, followed by children aged 0–6 (19.31%). One hundred fifteen patients (56.93%) were males. Most of the patients (57.43%) presented within 8–24 h after trauma. It was determined that there were more frequent admissions from the urban area (58.91%). The frequency of admission was highest in summer and lowest in autumn. Patients mainly arrived at the emergency department between 16:00 and 24:00, the busiest hours. The demographic characteristics and data of the patients are shown in Table 1.

Table 1 Descriptive information of the patient sample

Ocular ınjury details

There were unilateral injuries in 178 children (88.1%) and bilateral injuries in 24 children (11.9%). Injuries were classified as 82 patients with open globe injury (40.59%) and 120 patients with closed globe injury (59.41%). Perforating open globe injury of the cornea (n = 25, 30.48%) was the most common injury. In closed globe injuries, hyphema (n = 39, 32.50%) was the most common injury, followed by endophthalmitis (n = 32, 26.6%). Other closed globe injuries were determined as foreign body, corneal abrasion, and dislocated lens. It was determined that ocular traumas were mostly seen in places where family control was reduced, such as weddings, holidays, and playgrounds (80.69%). Toy gun (n: 71, 35.15%) was the most common cause, followed by stones (n: 58, 28.71%) and fireworks (n: 33, 16.34%). Details of ocular traumas and injury characteristics are shown in Table 2 and Figs. 1, 2, and 3.

Table 2 Ocular traumas and injury characteristics

Fig. 1

Types of closed globe ınjury

Fig. 2

Types of open globe ınjury

Fig. 3

Causes of ınjury

All of the patients were referred to an ophthalmologist. Despite the treatment, 5 of the patients ended with monocular blindness, and the remaining patients were discharged with recovery.

Dıscussıon

Our study was started with the aim of increasing awareness and lack of current data on pediatric ophthalmologic trauma in Turkey. This is the first study evaluating ocular trauma in the pediatric age group in our region.

Many epidemiological studies have reported that ocular trauma is more common in men than women [10,11,12,13,14]. Although the rate of ocular trauma in the patient group of our study differed between the pediatric and adolescent groups, it was more common in males, generally 1.3:1.

Ocular traumas constitute 5% of all cases in developed countries and approximately 12.9% in developing countries [15]. Although the incidence was not reported in a study by Dandona et al., they reported that ocular trauma constituted 4.2–7% of all childhood blindness [16]. In our study, the incidence of pediatric ocular trauma was found to be 0.72%; the pediatric ocular trauma-related blindness rate was found to be 2.47% in a 1-year period. The differences in the incidence of ocular trauma in the pediatric population may be due to the overuse of emergency services in our country and the lower incidence. In addition, sociocultural differences may be another factor contributing to this difference.

In a study, it was reported that most of the children presenting with ocular trauma resided in urban areas (70%) [10]. Although our hospital accepts patients from every region of the city and rural areas; it has been determined that the admissions are mostly from the city center and in places and times where parental supervision is reduced. It should not be ignored that the differences in the rural and urban populations may be due to the conditions that restrict access to treatment in rural areas.

We found that children aged 7–11 years (66.83%) were most affected, followed by those aged 0–6 years (19.31%). In a study conducted in Kuwait, the average age was 7.8 years; in our study, the average age was 8.9 years, similarly. In a case series conducted in Denmark, the mean age was 13 years [12]. They stated that this may be due to the fact that the 13–18 age group is more frequently engaged in individual entertainment, games, and activities.

In this study, we determined that toys were the main cause of ocular injury in the 0–6 age group, as in studies conducted in other countries. Pencils were the main cause in 7–12 age group; sports activities were the main cause in 13–18 age group. In our study, similar to previous studies, 33% of the injuries were caused by active fireworks [17]. In another study, despite the fireworks regulation law, it has been reported that eye injuries are on the rise, especially in relation to the increased use of fireworks during festivals [18]. Similarly, in our study, injuries related to the use of fireworks in weddings and celebrations, which increased in the summer months, were more common. Safety glasses should be worn during risky activities. Sharp objects such as pens, scissors, needles, knives, and household chemicals such as acid should be out of the reach of children. Strict laws and family and community education are urgently needed to stop injuries related to fireworks.

As a result of our study, contrary to studies conducted in developing countries, open globe injuries (40.59%) were found to be lower than closed globe injuries (59.41%) [19]. In our opinion, this difference is due to the fact that the patients are frequently in the older age groups that can protect themselves better than the younger age group.

In this study, we noticed that the emergency department physicians did not inform the patients and families about ocular trauma and prevention methods, and even if they did, they did not write this in the patient’s medical records. Emergency department doctors can play an important role in preventing ocular trauma. They can inform patients and their families about what to do when an ocular injury occurs and what precautions can be taken before it happens.

Conclusion

In conclusion, pediatric acute eye trauma remains an important source of preventable monocular blindness. Children are vulnerable to ocular trauma and need more supervision. Toys, playgrounds, and entertainment places must be under parental supervision. The great majority of ocular traumas could be prevented, especially by wearing protective goggles during at-risk activities. Sharp objects such as pens, scissors, needles, knives, and household chemicals such as acidic or alkaline cleaning materials should be out of the reach of children. Awareness and education are needed to implement preventive measures and prevent sequelae. Parents must repeat educational warnings to their children handling sharp objects. Therefore, more studies are needed in the pediatric age group.

Limitations

The study has some limitations as it is retrospective. Our study is limited by the data available in the patient medical records. Some demographic data may have been affected due to the fact that the population of our city tripled in the summer season. Due to the presence of more developed hospitals in the surrounding provinces, especially the patients in the peripheral residence area may have preferred hospitals in other provinces.