Indian Journal of Clinical and Experimental Ophthalmology

Print ISSN: 2395-1443

Online ISSN: 2395-1451

CODEN : IJCEKF

Indian Journal of Clinical and Experimental Ophthalmology (IJCEO) is open access, a peer-reviewed medical journal, published quarterly, online, and in print, by the Innovative Education and Scientific Research Foundation (IESRF) since 2015. To fulfill our aim of rapid dissemination of knowledge, we publish articles ‘Ahead of Print’ on acceptance. In addition, the journal allows free access (Open Access) of its content, which is likely to attract more readers and citations of articles more...


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Kakkar, Bhatti, and Singh: Profile of ocular injuries amongst various trauma patients presenting to tertiary care centre of Punjab


Introduction

Ocular trauma is a major but under-recognized cause of disability that has affected younger generation commonly. Approximately, 1.6 million people are blind owing to ocular trauma, 2.3 million are bilaterally visually impaired and 19 million have unilateral visual loss.1 In India, the reported incidence of ocular trauma varies from 1-5%.2 Different methods of study of ocular trauma result in geographical and referral bias leading to different conclusions and plenty of misinformation. Data collected from developed countries like U.S.A cannot be applied to developing countries. Analysis of profile of ocular trauma is helpful in identifying the risk factors and planning strategies for the management of ocular injuries.

Material and Methods

This study was conducted for a period of eighteen months in the department of Ophthalmology at SGRD Charitable hospital according to the guidelines of the Declaration of Helsinki and after obtaining approval from ethical committee of Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar. Informed consent was obtained from all individual participants included in the study. All trauma related patients including past history of ocular trauma and those polytrauma patients associated with orbital and ocular injuries were included in the study. Patients in which clinical findings were of non-traumatic origin and with past history of trauma related surgery in the eye were excluded from the study. The patients were informed about the study and a prior written informed consent was taken from all the patients. Detailed history taking was done as per the proforma prepared. Focus was kept on age, sex, occupation, risk factors associated with trauma and location of trauma. Time lag between trauma and presentation to our centre was also documented. Documentation of presenting complaints, type of injury (open globe or closed globe) and extent of ocular involvement (monocular / binocular) was done. Matters of medicolegal concern were also recorded. Detailed ophthalmic work up of all the patients including slit lamp examination, +90D/+78D examination and indirect ophthalmoscopy was carried out. Investigations like B-Scan ultrasonography, CT-scan, MRI with or without contrast, Angiography, VER or any other specific investigation required in any patient was carried out before further management, solely or in collaboration with other speculation. Follow up of these patients was done till their final disposal over 1.5 years.

Results

246 patients fulfilled the inclusion criteria. Large proportion of these patients were males (87%). Pediatric age- group comprised 16.7% of the ocular trauma cases. Majority of the patients were from rural background (86.2%). Most of the patients had unilateral ocular involvement, right eye was involved in 102 (41.5%), left eye in 90 (36.6%) and both eyes were involved in 54 (22%) patients. The elapsed time between injury and presentation varied between 1-7 days in 111 (45.1%) patients followed by 4-24 hours in 66(26.8%) patients. (Table 1) Incidence with respect to place of occurrence of trauma and with respect to occupation of patients has been shown in Figure 1, Figure 2.

Table 1

Profile of injured patients

Variable

Categories

Incidence

Location

Rural

86.2%

Urban

13.8%

Sex

Male

87%

Female

13%

Age

<15 Years

16.7%

15-30 Years

45.9%

31-45 Years

19.1%

46-60 Years

13%

61-75 Years

4.9%

Laterality

Monocular

78.1%

Binocular

22%

Time of presentation

<4 hours

10.6%

4-24 hours

26.8%

1-7 days

45.1%

After 7 days

17.5%

Medicolegal aspect

Yes

28.5%

No

71.5%

Alcohol intake

Yes

17.1%

No

82.9%

Majority (53.3%) of the patients had trauma on roadside and that too in students. 55 (22.35%) patients had injury on hard (cemented) floor followed by injury with metallic object (17.88%) and stone (17.88%) (Figure 3).

Maximum number of ocular injuries in children occurred in the month of January (10 cases) probably due to kite flying around the festival of Lohri while maximum number of ocular injuries in adults occurred in the month of May likely attributed to increased outdoor activities during vacations. Out of the total 235 cases of mechanical injury, closed globe injuries accounted for 209 (88.94%) cases and open globe injuries accounted for 26 cases (11.06%) (Table 2).

Table 2

Detailed distribution as per ocular trauma classification

Open globe

Closed globe

Type of Injury

Rupture

4

-

Penetrating

17

-

Iofb

1

-

Perforating

-

-

Mixed

4

-

Contusion

-

184

Lamellar laceration

-

8

Superficial F.B

-

17

Grade (V/A)

>6/12

2

155

>6/60 TO <6/12

2

28

>1/60 TO <6/60

2

11

PL TO 1/60

15

11

NLP

5

4

Zone

I

15

195

II

7

11

III

4

3

RAPD

+VE

3

14

-VE

23

195

In closed globe injuries, Contusion (184 patients) was the most common presentation and in open globe injuries, penetrating type of injuries (17 patients) was the most common presentation. Conjunctiva was the ocular structure most commonly involved in injury (196 cases) followed by lids (177 cases), orbit (88 cases), cornea (50 cases), anterior chamber (28 cases) and iris (25 cases). Lacrimal apparatus was least involved in ocular injury (2 cases). In our study, lid edema was the most common finding in 154 cases (62.6%) which was followed by lid ecchymosis in 152 patients (61.8%), subconjunctival hemorrhage in 149 patients (60.6%), orbital fracture in 88 patients (35.8%), lid laceration in 47 patients (19.1%), chemosis and hyphaema in 14 patients (5.7%), corneal laceration, sphincter tear and traumatic optic neuropathy in 12 patients (4.9%), epithelial defect in 10 patients (4.1%), scleral laceration and iris prolapse in 7 patients (2.8%) (Figure 4, Figure 5, Figure 6). Table 3 outlines the grades of visual loss in whole study population.

Table 3

Incidence of visual morbidity in children / adults

Grade of visual loss

Total cases

Adult cases

Children cases

NPL

9

9 (100.0%)

0 (0.00%)

PL To <1/60

27

21 (77.77%)

6 (22.22%)

>1/60 To <6/60

13

11 (84.61%)

2 (15.38%)

>6/60 To<6/18

31

27 (87.1%)

4 (12.90%)

>6/12

166

137 (82.53%)

29 (17.46%)

Total

246

205 (83.33%)

41 (16.66%)

Figure 1

Pie chart showing Incidence with respect to place of occurrence

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/b58b9a4c-bd3a-451c-b77f-ee9cfbe364d5image1.png

Figure 2

Pie chart showing Incidence with respect to occupation

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/b58b9a4c-bd3a-451c-b77f-ee9cfbe364d5image2.png

Figure 3

Bar graph showing distribution as per causative agent

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/b58b9a4c-bd3a-451c-b77f-ee9cfbe364d5image3.png

Figure 4

Upper lid laceration extending to upper eyelid margin

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/b58b9a4c-bd3a-451c-b77f-ee9cfbe364d5image4.png

Figure 5

Black eye both eyes

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/b58b9a4c-bd3a-451c-b77f-ee9cfbe364d5image5.png

Figure 6

Canalicular laceration extending to upper lid with corneoscleral laceration

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/b58b9a4c-bd3a-451c-b77f-ee9cfbe364d5image6.png

Table 4

Comparison of our study with other studies

Study

Year

Place

Duration

Patients

Gender

Laterality

CG/OG

Visual

Morbidity

Present Study

2015-2016

SGRDIMSR, Amritsar

18 months

246

M=214

R=102

CG=88.94%

49

F=32

L=90

OG=11.06%

B=54

Soliman et al3

2008

Kasr El Aini Hospital, CAIRO University

6 months

147

M=80%

CG=19.6%

108

F=20%

0G=80.4%

Omolase et al4

2011

Owo, Nigeria

1 Year

132

M=77.3%

CG-84.1%

F=22.7%

OG=12.1%

Dhasmana et al5

2012

Himalyan Institute, Dehradun

1 Year

88

M=65.9%

CG=53.39%

54

F=34.09%

OG=38.83%

Misra et al6

2013

Pravara Institute, Loni

2 Years

60

M=71.7%

CG=68.33%

39

OG=31.67%

Titiyal et al7

2013

Dr. Sushila Tiwari Govt. Hospital, Haldwani

1 Year

165

M:F= 10:1

CG=31.9%

93

OG=45.5%

Gopinath et al8

2015

K.R Hospital, Mysore

1 Year

60

M:F= 3:1

CG=66.6%

15

OG=26.6%

[i] OG=Open globe, CG=Closed globe

Discussion

Blindness is a serious public health problem as it affects one’s quality of life. It imposes major socioeconomic and psychological burden on patients and their relatives. Incidence of blindness varies in different communities ranging from 0.2-1 percent (WHO).9

The epidemiology of eye injuries varies in different parts of the world and in different age-groups. It depends on many factors including age, sex, profession, life-style, socioeconomic status, traffic behavior, sports and other creative activities. The epidemiology will vary with type of registration and recording of data.10

Though literature available on ocular injuries in developed countries is sufficient while data available on ocular injuries from developing countries is limited. The purpose of this study was to make profile of ocular injuries and critically analyze these injuries for better treatment in developing country like India and especially in this northern region.

In our study, majority (86.2%) of the patients were from rural background. Incidence of ocular injuries is less in urban population because of increased awareness amongst them. This rural/urban disparity may be due to urban patients preferring private practitioners which seldom contribute to statistics.

The incidence of ocular trauma was found to be maximum in 15-30 year age group (45.9%), it being the most active period of human life. A gradual decline in incidence was noted after 60 years of age (4.9%). This may be due to sedentary life style adopted by many people in this age-group. The incidence in children (less than 15 years of age) is reported to be 16.7% which may be because children of this age group in this region are more involved in outdoor activities and actively participate in games like bow and arrow and gilli-danda without understanding dangers associated with them. These children are often left to play without protective measures and being supervised by elders.

The latent period between occurrence of injury and reporting to the hospital has an important bearing on the outcome of vision in ocular trauma patients. In developing countries, people generally report late to the hospitals due to many reasons like ignorance, inaccessibility etc. In the present study, 92 (37.4%) cases of ocular trauma reported to the hospital within 24 hours of the occurrence of the injury. Most of these patients were injured in road traffic accidents and many of them were students. Other than this big chunk (45.1%) of the cases reported after 24 hours i.e. between 1-7 days of injury to the hospital. Only amongst them were few patients who reported late and also left the hospital against medical advice. Due to late reporting, chances of complications increase which in turn contribute to increased morbidity and poor visual outcome. Hence, time factor carries an important role in reducing the amplitude of visual morbidity in these ocular trauma patients. The findings in the other studies are different because of many factors like variability in awareness amongst people and accessibility to health care facilities. Table 4 gives the comparison of our study with other studies.

Visual prognosis in cases of ocular trauma is determined by multitude of factors like latent period between injury and reporting, mode, severity of injury and associated complications.In the present study, complete vision loss was observed in 9 adult cases. 40 cases had vision PL to 6/60 of which 32 were adults and 8 were children. 166 cases had vision more than 6/12 of which 137 were adults and 29 were children. Closed globe injuries were less severe and had better visual outcome than open globe injuries. Visual morbidity in our study was less as compared to other studies. This may be due to more number of benign injuries, prompt referral and close follow up and less industrial injuries (which are usually of severe nature) in our study.

Conclusion

Our study, inspite of having the limitation of short duration of study, gives a good idea of statistics of eye trauma. It will help to design appropriate preventive and therapeutic interventions. The same surveillance system is used to monitor the effectiveness of preventive, acute care and rehabilitative interventions. In a developing country like India, people should be made aware regarding early referral to tertiary care centres to reduce visual morbidity.

Source of Funding

None.

Conflict of Interest

The authors declare no conflict of interest.

References

1 

AD Negrel B Thylefors The global impact of eye injuriesOphthalmic Epidemiol19985314369

2 

B Shukla B Shukla S Natrajan Epidemiology of ocular traumaManagement of ocular trauma1st editionMeenakshi PrintersDelhi200534

3 

CO Osmolase EO Omolade OT Ogunleye BO Omolase CO Ihemedu OA Adeosun Pattern of ocular injuries in Owo, Nigeria.J Ophthalmic Vis Res2011621148

4 

GS Gopinath S Hegde P Vijaylaxmi AA Acharya BK Sudharani A Study of Clinical Profile and Visual Outcome in Ocular TraumaInt J Sci Stud2015325760

5 

GS Titiyal C Prakash S Gupta V Joshi Pattern of Ocular Trauma in Tertiary Care Hospital of Kumaon RegionJ Indian Acad Forensic Med20133521169

6 

S Misra R Nandwani P Gogri N Misra Clinical profile and visual outcome of ocular injuries in a rural area of western IndiaAustralas Med J20136115604

7 

R Dhasmana H Bahadur K Jain Profile of ocular trauma in Uttarakhand. A Hospital Based StudyIndian J Community Health2012244297303

8 

MM Soliman TA Macky Pattern of ocular trauma in EgyptGraefes Arch Clin Exp Ophthalmol2008246220512

9 

S Resnikoff D Pascolini D Etya’ale I Kocur R Pararajasegaram G P Pokharel Global data on visual impairment in the year 2002Bull World Health Organ2004821184451

10 

HS Al-Mahdi A Bener SP Hashim Clinical pattern of pediatric ocular trauma in fast developing countryInt Emerg Nurs201119418691



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© This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Article type

Original Article


Article page

642-647


Authors Details

Arushi Kakkar, Anubha Bhatti*, Shakeen Singh


Article History

Received : 27-04-2021

Accepted : 13-08-2021

Available online : 03-01-2022


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