Microsoft Word - sadia Bukhari 8 208 Original Article Ocular Trauma in Children Sadia Bukhari, P S Mahar, Umair Qidwai, Israr Ahmed Bhutto, Abdul Sami Memon Pak J Ophthalmol 2011, Vol. 27 No. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . See end of article for authors affiliations …..……………………….. Correspondence to: Sadia Bukhari Ophthalmology Division Isra Postgraduate Institute of Ophthalmology/ Al-Ibrahim Eye Hospital, Malir, Karachi. Submission of paper July’ 2011 Acceptance for publication November’ 2011 …..……………………….. Purpose: To evaluate the causes of ocular trauma, management and visual outcome in children. Materials and Methods: This prospective observational case series was conducted at the Department of Pediatric Ophthalmology, Isra Postgraduate Institute of Ophthalmology / Al-Ibrahim Eye Hospital, Karachi from November 2009 to October 2010. All patients of Ocular trauma aging less than 15 years were included in the study. Results: A total number of 173 children (174 eyes) presented with ocular trauma from November 2009 to October 2010. Minimum age of presentation was 2 months, while the maximum age was 180 months with mean of 97.172 months (SD = 41.82). Out of total number of children, 125 (72.25%) were male and 48 (27.75%) were female. Blunt mode of trauma was the most frequently observed mode of injury among children and was, seen in 88 (50.6%) patients. The causes included Vegetative material in 25 (14.4%) and wooden stick in 23 (13.2%) patients. Fifty four (31%) patients were treated surgically while rest of the patients was treated medically. Most common cause of decreased vision was disorganized globe seen in 21 (12.1%) patients followed by corneal opacity in 18 (10.3%) patients. Conclusion: Pediatric ocular trauma is a common cause of ophthalmic consultation. These injuries are mainly result of the blunt trauma. Majority of patients are young boys. There is a need for increasing awareness among parents. cular trauma in children is a leading cause of visual morbidity. Ocular injuries accounts for approximately 8-14% of total injuries suffered by children1,2. Besides, direct damage to the ocular structures resulting in loss of vision, poor visual outcome may also due to dense amblyopia caused by prolonged period of light and formed vision deprivation2,3. Children are more prone to injuries because of their inability to avoid hazards4. In general, male are more frequently reported to have eye injuries as compared to female due to their adventurous and aggressive nature5-8. Etiologically such injuries are largely accidental. The Infants and children, less than 3 years of age sustain fewer injuries due to close parental supervision9. Older children injure themselves by spikes of toys, pencils, arrows, needles, thorns and stones. Sports related injuries are common in children from 5-15 years of age10. Injuries by animal tail and bird beak are common in rural areas. Fire crackers and toy pistols on religious events such as Eid and Shab-e-barat lead to loss of many eyes every year. We conducted this study to help us in documenting the prevalence of this preventable cause of visual deterioration. MATERIALS AND METHODS This prospective observational case series was conduc- ted at Department of Paediatric Ophthalmology, Isra Postgraduate Institute of Ophthalmology/Al-Ibrahim Eye Hospital, Karachi, from November 2009 to October 2010. All children up to 15 years with ocular trauma were included in the study. The long standing trauma patients with prior management were excluded. All patients were examined in detail including complete history and ocular examination. Visual acuity was measured at the time of presentation. O 209 Children less than 2 years were examined using fixation and follow test patterns, while children between 2-5 years were examined on Cardiff visual acuity charts, Kay pictures and Sheridan-Gardner charts. The children above 5 years were examined with Snellen’s chart and illiterate E chart. The ocular examination was carried out with the help of direct ophthalmoscope, slit lamp and hand held slit lamp. The fundus examination was carried out with the help of indirect ophthalmoscope in cases of clear ocular media with +20 Diopter lens. The B- Scan mode ultrasonography was performed in patients with opaque ocular media for posterior segment exami- nation. The non-cooperative and very young children were examined under general anesthesia. The patients with any insignificant ocular structural damage or simple subconjunctival hemorrhage were reassured and discharged. The superficial foreign bodies were removed using topical anesthesia (Alcain –Alcon, Belgium). The corneal abrasions and superficial corneal lacerations with formed anterior chamber were treated by antibiotic drops (Vigamox – Alcon, Belgium) and ointment (Tobrex - Alcon, Belgium) with patching of the eye. The corneal abscess were treated with topical fortified antibiotic drops (Vancomycin 50mg/ml, Amikacin 33mg/ml), topical antifungal (Amphoteracin 0.05%) and cycloplegics (Mydriacyl - Alcon, Belgium). Any child with uveitis was treated with topical (Predforte - Allergan, Pakistan), subtenon (Triamcinolone Acetonide, Dexamethasone) or systemic corticosteroids (Deltacortil) and cycloplegics (Mydriacyl - Alcon, Belgium). Hyphaema was treated with conservative methods like complete bed rest, topical corticosteroids (Predforte - Allergan, Pakistan), and topical antiglaucoma medication (Betalol - Sante, Pakistan) whenever needed. Any form of surgical intervention like anterior chamber paracentesis or trabeculectomy using Mitomycin C was done in required cases. The surgical intervention was carried out under general anesthesia using operative microscope. All corneal lacerations were repaired with 10-0 nylon and scleral lacerations were sutured with 6- 0 Vicryl. In cases of multiple ocular structure damage, primary globe repair was done as early as possible and further management was carried out according to the severity and residual sequel. Cataract surgery was performed usually after 6-8 weeks of primary repair using irrigation and aspiration of lens matter. For posterior capsular opacity (PCO), posterior capsulotomy and anterior vitrectomy were performed. In cooperative patients with PCO, YAG-laser capsulotomy was substituted. The intraocular lenses (IOL) were implanted in all cases using polymethyl- methacrylate (PMMA) 6.5mm optical diameter or scleral fixation lenses in case of absent posterior capsule. The grossly subluxated lenses were removed through pars plana approach and scleral fixated IOLs were implanted as a secondary procedure. The cases of posterior segment trauma, including posteriorly dislocated lens, vitreous hemorrhage, retinal detachment and intraocular foreign body were referred to vitreo-retinal services in hour hospital. Cases, which required surgical intervention were managed by 3-port pars plana approach. Final visual acuity was measured after 6 months. Data analysis was performed using SPSS version 18.0. Frequency of age, gender and eye involved were calculated with mean ± standard deviation. Paired t- test was used to compare the visual acuity before and after the management of the trauma. RESULTS One hundred and seventy three children attended our hospital with ocular trauma from November 2009 to October 2010. Minimum age of patients was 2 month while the maximum age was 180 months with mean of 97.172 months (standard deviation=41.82). Out of these 173 children, 125 (72.25%) were male and 48 (27.75%) were female Table 1. The right eye was in Eighty one (46.6%) patients and the left eye in 92 (52.9%). Only 1 (0.6%) child had his both eyes involved. One hundred and seventy four eyes were evaluated. Blunt mode of trauma was the most frequently observed mode of injury among children. It was seen in 88 (50.6%) patients. Other modes are seen in (Fig. 2). Vegetative material and wooden stick were the most frequent causative agents. 25 (14.4%) patients had injury by vegetative trauma while 23 (13.2%) had it with wooden stick. Other causative agents are shown in table 2. Most common finding seen in patients after trauma was sub-conjunctival hemorr- hage, which was seen in 20 (11.5%) patients followed by cataract in 14 (8%) patients. Damage to multiple ocular structures was seen in 17 (9.8%) patients. Other findings and their frequencies are shown in table-3. Only 37.9 % patients were 6/18 or better at the time of presentation while after management it improved to 57.9% (p<0.05). Fifty four (31%) patients were treated surgically while 119 (68.78%) were treated medically. (Fig. 3) shows the frequencies of management options used. Change in visual acuity after the management is shown in (Fig.4). Most common cause of decreased vision was disorganized globe which was seen in 21 210 (12.1%) of the patients, followed by corneal opacity in 18 (10.3%) of patients. Other causes of decrease vision are shown in (Fig. 5). Table 1: Gender and age frequencies Gender No. of Patients n (%) Minimum Age Maximum Age Male 125 (72.25) 2 months 180 months Female 48 (27.75) 24 months 176 months Table 2: Causative agents Causative Agent Frequency n (%) Vegetative material 25 (14.4) Stores 13 (7.5) Ball 8 (4.6) Plastic pallet 7 (4.0) Toys 4 (2.3) Wooden stick 23 (13.2) Fire cracker 5 (2.9) Needle 9 (5.2) Finger 1 (0.6) Fist or hand 5 (2.9) Kinfe 4 (2.3) Iron rod 6 (3.4) Animal horn / bird beak 7 (4.0) Others 27 (15.5) Missing 30 (17.2) Total 174 (100) DISCUSSION Ocular trauma is the leading cause of acquired monocular blindness in young patients. This pros- pective study focuses on the causes of eye injuries in children who presented to the Department of Pediatric Ophthalmology in a tertiary eye center. We also evaluated the severity, primary management, initial and final visual acuity in these patients. Children are more susceptible to the ocular trauma because of their immature motor skills and curious nature. A marked preponderance of injuries is seen in 6-10 years of age group11. Adult supervision has been found to be an important factor in the prevention of injuries to children. Infants and children of less than 3 years of age sustain fewer injuries because of close supervision by parents. In our study the mean age of child was high i.e. 97.172 months (8.09 years). The male children are affected more than female, because boys generally are granted more liberty than girls in our society and they tend to spend more time outside. In our study we also found higher number of male children affected i.e. 71.8% as compared to female i.e. 27.6%. The type of injury, its severity and initial visual Table 3: Frequency of ophthalmic findings Ophthalmic Findings Frequency n (%) Lid tear 5 (2.9) Ecchymosis 6 (3.4) Sub conj hg 20 (11.5) Conj tear 3 (1.7) Sclera tear 1 (0.6) Corneal abscess 13 (7.5) Corneal opacity / adherent leucoma 4 (2.3) Corneal abrasion / laceration 7 (4.0) Corneal tear 6 (3.4) Corneal foreign body 12 (6.9) Uveal prolapsed 9 (5.2) Uveitis 5 (2.9) Hyphema 12 (6.9) Cataract 14 (8.0) Subluxated lens 7 (4.0) Dislocated lens 3 (1.7) Endophthalmitis 7 (4.0) Vitreous hemorrhage 1 (0.6) Retinal detachment 7 (4.0) Optic atrophy 2 (1.1) Multiple ocular structure damage 17 (9.8) Phthisis 3 (1.7) Other 4 (2.3) Painful blind eye 4 (2.3) Macular / retinal edema 2 (1.1) Total 174 (100 211 Table 4: Comparison of mechanism of ocular injuries Mechanism of Injury Present Study % of Cases Krishnan M and Sreeni- vasan R % of Cases Mac. Ewal et al % of Cases Blunt 51 30.80 65 Penetrating 29 69.20 24 Chemical 1 — 1 0 10 20 30 1st Day Within 3 Days Within 1 Week 1 Week - 1 Month 1 Month - 3 Months Missing % of Patients Fig. 1: Duration of patient presentation after trauma Missing 7% Others 6% Foreign Body 6% Chemical Trauma 1% Penetrating 29% Blunt Trauma 51% Fig. 2: Modes of trauma acuity are known prognostic factors for the final outcome. In our cohort of patients, most cases were not severe and did not cause any initial visual impairment. Our study also showed that closed globe injuries were more common (50.6%) than open globe injuries (28%). Chemical burns accounted for only 0.6% cases. Our results are comparable to the results published by Mc Ewen and coworkers10. The percentage of patients sustaining close globe injuries in their series was 65% comparing to 24% receiving open globe injuries. In contrast Krishnan12 found open globe injuries in more number in India at 69.20%. Serrano and colleagues13 published epidemiology of ocular injuries involving children less than 15 years of age. In their series of 393 children, 64.9% patients were boys. The highest proportion of injuries (44.4%) occurred at home. Closed-globe injuries were far more frequent than open-globe injuries for boys (82.4% vs 17.6%) and girls (83.8% vs 16.2%). Most closed-globe injuries (223 [92.1%]) did not cause any final visual impairment in the affected eye whereas 26 open-globe injuries (55.3%) caused severe visual impairment. Ocular trauma among 126 children in Nepal and their visual outcome was reported by Adhikari et al. 14 Fifty seven percent of their reported children were male with open-globe injury registered in 5% of cases. The common agents of trauma were wood sticks and grass leaves. Nine percent of the children had final vision of less than 6/60 and 5% with no perception of light after treatment. On the home front Malik and coworkers 15 reported 200 cases of ocular trauma in children less than 15 years of age attending a local hospital in Peshawar. In this study male children constituted 47% of the total cases. The injury caused by blunt object was seen in 64.05% (129) of children and mostly it was due to stone in 21.5% (71) cases. The visual acuity on arrival was perception of light only In 35.5% patients with open-globe injury. At the end of 2 months 13.5% eyes were physical. Babar et al16 in a retrospective study looked at the medical records of 481 children of 0 10 20 30 40 50 60 S ur gi ca lly T re at ed M ed ic al ly T re at ed C yc ly oc rio /D io de La se r O th er F B R em ov al N on e Frequency N um be r of P at ie nt s Fig. 3: Management options used 212 up to 16 years who had sustained ocular trauma. About 51% injuries were of open-globe type and 37.6% were closed-globe injuries. At the time of admission, 14.6% eyes were infected with 2.3% requiring evisceration or enucleation. 0 10 20 30 40 50 60 6/6-6/18 6/24-6/36 6/60-3/60 <3/60-PL NPL VA at Presentation VA after Management Fig. 4: Change in Visual acuity. 5%6%3% 13% 11% 62% Noamal Vision Corneal Opacity Disorganized Globe Optic Atrophy Pthysis Old Retinal Detachment Fig. 5: Normal vision / cause of decreased vision Our study showed that vegetative material (branches of trees, thorns) and wooden sticks were the common causative agents. Stones, sharp needles and cricket balls also cause grave ocular injuries. The Injuries from plastic pallets (toy pistols) and fire crackers on religious events of Eid and Shab-e-barat accounted for significant number of ocular injuries and can lead to ocular damage either because of trauma but also due to late presentation because of government holidays on these events (Table 2). The visual prognosis of eye injuries improves when prompt examination, diagnosis and treatment is provided. However socioeconomic, cultural and awareness factors may also play a role in receiving timely attention. Twenty percent (20%) of children in this study received medical attention during 24 hours after injury, while 24.1% children presented after 72 hours. The open-globe injuries generally results in poorer visual outcome compared to close-globe trauma17. Blunt trauma involving anterior segment has better visual outcome than when posterior segment is involved. The non-perforating vegetative trauma can cause corneal erosions and ulcers which can be complicated by polymicrobial infections leading to severe visual deterioration. Therefore proper antimicrobial treatment is required at an early stage. The traumatic hyphaema is usually managed conservatively. The glaucoma resulting from trauma may have early, intermediate and delayed presentation. The lens injuries can lead to cataract formation or subluxation of crystalline lens. The perforating anterior segment trauma may cause corneal or scleral injury with varying degree of uveal tissue, lens and vitreous involvement. Unrepaired cases may carry a potential risk of endophthalmitis and panophthalmitis. The reported incidence of post- traumatic endophthalmitis is high compared to intraocular surgery18. The Posterior segment involvement adversely affects visual outcome. 17 It manifests as commotio retinae, choroidal rupture, macular hole, retinal breaks, retinal dialysis and retinal detachment. Patients with traumatic retinal detachments need to be operated as early as possible. CONCLUSION Ocular trauma leads to diminution of vision, cosmetic blemishes and resultant personality defects. The most important aspect of pediatric trauma is prevention. The parents, caretakers and teachers have an important role to play in prevention of these injuries. Playing with hazardous objects, toy pistols and fire crackers should be discouraged. The appropriate management by primary health care physician and general ophthalmologist, before ophthalmic consultation at tertiary eye care center, is a key factor in improving visual prognosis. Author’s affiliation Dr. Sadia Bukhari Assistant Professor Isra Postgraduate Institute of Ophthalmology Al-Ibrahim Eye Hospital, Malir, Karachi % o f P at ie nt s 213 Dr. P S Mahar Professor of Ophthalmology Isra Postgraduate Institute of Ophthalmology Al-Ibrahim Eye Hospital, Malir, Karachi Dr. Umair Qidwai Postgraduate Student Isra Postgraduate Institute of Ophthalmology Al-Ibrahim Eye Hospital, Malir, Karachi Dr. Israr Ahmed Bhutto Senior Registrar Isra Postgraduate Institute of Ophthalmology Al-Ibrahim Eye Hospital, Malir, Karachi Dr. Abdul Sami Memon Senior Registrar Isra Postgraduate Institute of Ophthalmology Al-Ibrahim Eye Hospital, Malir, Karachi REFERENCE 1. Scribano PV, Nance M, Reilly P et al. 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