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Year : 2019  |  Volume : 32  |  Issue : 4  |  Page : 1430-1435

Incidence and pattern of ocular trauma among ophthalmic patients in Menoufia University Hospitals

1 Department of Ophthalmology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Ophthalmology, Health Insurance Hospital, Cairo, Egypt

Date of Submission07-Aug-2018
Date of Decision01-Sep-2018
Date of Acceptance02-Sep-2018
Date of Web Publication31-Dec-2019

Correspondence Address:
Ahmad Al-Kamel Hamed
Cairo 11659
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mmj.mmj_254_18

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The aim of this study was to determine the incidence and pattern of ocular trauma among ophthalmic patients who presented to Menoufia University Hospitals.
Ocular trauma is a major preventable cause for monocular morbidity and blindness worldwide.
Patients and methods
This was a prospective study estimating patients who sustained ocular trauma within a 1-year period (January 2016–December 2016); the association between variables was checked by the χ2 test.
A total of 1138 eyes of 1129 patients had sustained ocular trauma in a 1-year period (2016). The incidence of ocular trauma was 6.1%, and hospitalized patients accounted for 11.2%. The mean age of the patients was 22.4 ± 19.2 years; 69.1% were male patients and 30.9% were female patients, with a male to female ratio of 2.2: 1. The majority of injuries were adnexal injuries (42.1%) followed by globe injuries (30.6%), ocular surface foreign body (25.2%), ocular wall foreign body (0.4%), chemical injuries (0.4%) and radiation injuries, that is, 'photokeratitis' (1.2%). In globe injuries, 67 (19.3%) were open globe (52 eyes with rupture globe, 13 eyes with penetrating injury, two eyes with intraocular foreign body) and 281 (80.7%) were closed globe [32 (11.4%) were contusion, whereas 249 (88.6%) were lamellar laceration]. The most common eye injury was periocular ecchymosis and edema (40%).
Ocular trauma is a major problem for monocular morbidity and blindness. Students and workers who were involved in street activities and workplaces were the most affected.

Keywords: contusions, corneal injuries, eye injuries, lacerations, orbital fractures, penetrating

How to cite this article:
El-Sobky HM, Ellakwa AF, El-Sawy MF, Hamed AA. Incidence and pattern of ocular trauma among ophthalmic patients in Menoufia University Hospitals. Menoufia Med J 2019;32:1430-5

How to cite this URL:
El-Sobky HM, Ellakwa AF, El-Sawy MF, Hamed AA. Incidence and pattern of ocular trauma among ophthalmic patients in Menoufia University Hospitals. Menoufia Med J [serial online] 2019 [cited 2020 Jun 6];32:1430-5. Available from: http://www.mmj.eg.net/text.asp?2019/32/4/1430/274247

  Introduction Top

Ocular trauma, especially the open globe form, is the most common cause of monocular visual impairment and blindness worldwide, with significant socioeconomic impact [1]. Globally, more than 500 000 blinding injuries occur every year [2]. Although the incidence of ocular trauma has been clearly described in developed countries, limited data are available to determine the characteristics of eye injuries in some developing countries [3]. Most ocular traumas could be prevented by proper use of safety eyewear (e.g. certified eye protectors at workplace and sports activities). Implementing known strategies for eye injury prevention would substantially reduce their incidence, rather than making the use of safety eyewear voluntary [4].

'Birmingham Eye Trauma Terminology' (BETT) adopted by Kuhn et al. [5] has become the internationally accepted standardized eye injury terminology. While the BETT is endorsed by many ophthalmic organizations and journals, it is not free from challenges or controversy [6]. BETT only concerns mechanical eyeball injury. As a result, ocular surface foreign body (OSFB), ocular wall foreign body (OWFB) injuries alone [7], and orbital and ocular adnexa injuries [8] cannot be classified by BETT. Newly proposed modifications have been adopted, to complement the existing BETT for further multicenter study and international acceptance, as reported by Shukla and Shukla [9], in which the term 'ocular trauma' includes structures of ocular adnexa such as the lids, orbit, lacrimal apparatus, and conjunctiva and not just the eyeball; this system also incorporates nonmechanical and destructive globe injuries (e.g. traumatic, evisceration, and enucleation) and associated facial or head injuries; hence, this system is the only one that shows the whole picture and concerns of ocular trauma. Other new classifications care about modification of mechanical eye injuries in BETT, as reported by Xiao et al. [8], in which ocular adnexa injuries were added and retained; foreign body (FB) injury (intraocular FB, OSFB, OWFB, and adnexal FB) is grouped separately; moreover, Shah et al. [7] added certain categories (periocular and extraocular FB injuries) to the BETT. We aimed in this study to describe the incidence and pattern of ocular trauma in our society.

  Patients and Methods Top

This study was approved by the Ethics Committee in faculty of medicine Menoufia University. This was a prospective study carried out within a 1-year period (January 2016–December 2016) that included all patients who sustained ocular trauma and presented to the ophthalmic outpatient clinic and emergency room at Menoufia University Hospitals. Written consent was obtained from each participant after complete clarification of the study. Patients with pathological or neglected ruptured globe, patients with old ocular trauma and polytraumatized patients were excluded from the study. Personal history of the patients and details of the injury were obtained with a full ophthalmological examination. In our study, term 'blindness' was used for cases who had visual acuity (VA) (<3/60), whereas 'low vision' for those had VA (less than 6/18 to 3/60) according to definitions of the WHO. Each patient sheet was reviewed, and epidemiological and examination data were collected and analyzed.

Follow-up was carried out for as long a duration as needed, also according to the type and severity of trauma (Globe injuries were followed-up for 6 months while other injuries were followed-up accordingly). Data were statistically described in terms of mean ± SD, frequency and percentage. Comparison between the study groups was carried out using the χ2 test; a P value less than 0.05 was considered statistically significant. All statistical calculations were carried out using Microsoft Excel 2010 (Microsoft Corporation, New York, New York, USA).

  Results Top

Among 18 553 patients who attended the ophthalmic outpatient clinic and emergency room over a 1-year period (2016), there were 1129 patients who had sustained ocular trauma, with 1138 eye injuries (nine cases had bilateral injury); therefore, the incidence of ocular trauma in Menoufia University Hospitals among ophthalmic patients was 6.1%. The number of hospitalized cases of ocular trauma patients was 126 (11.2%).

The mean age of the patients was 22.4 ± 19.2 years (range, 3 months–80 years), the majority (66.1%) (746) were aged 30 years and younger. The pediatric age group (15 years and younger) constituted 24.3% (274), while adults (above 15 years) constituted 75.7% (855). An overall 69.1% (780) were male individuals and 30.9% (349) were female individuals, with a male to female ratio of 2.2: 1 [Table 1].
Table 1: Characteristics of ocular trauma patients in the study

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Most of the patients were students (31.4%) (354) and workers (30.2%) (341), followed by housewives (15.5%) (175) and farmers (8.2%) (93). The majority of the patients (29.1%) (329) presented to the hospital in the first 2 h from injury, 75.6% (854) presented in the first 24 h and showed no delay of presentation, whereas 24.4% (275) presented after 24 h and showed delayed presentation.

The street-related injuries accounted for 36.1% (408), workplace-related injuries 28.6% (323), home-related injuries 19.4% (219), injuries within the schools 10% (113) and injuries in the farms 5.8% (66). There was a correlation between the place of trauma and gender, and the difference was statistically significant (P < 0.001). In male patients, street-related injuries (40.6%) (317) and workplace-related injuries (39.1%) (305) were more common than in female patients [26.1% (91) and 5.2% (18), respectively], while in female patients, home-related injuries [48.1% (168)] were more common than in male patients [6.5% (51)].

Both mechanical (99%) and nonmechanical (1%) causative agents were encountered. Most of the eye injuries were caused by blunt objects (71.6%), whereas sharp objects accounted for 23.8%, chemical injuries caused by 'cyanoacrylate' adhesive material accounted for 0.4% and radiation injuries in the form of photokeratitis caused by welding arcs accounted for 0.6%. Stones were a more frequent cause of ocular trauma (26.3%), followed by metal particles (25.6%) and fingernails (12.5%) [Figure 1].
Figure 1: Different types of blunt and sharp objects causing ocular trauma in the study.

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In our study, eye injuries were classified into mechanical and nonmechanical injuries. Mechanical injuries involved globe, OSFB, OWFB, and adnexal injuries [Figure 2]. Mechanical globe injuries were classified according to BETT [Figure 3] Adapted from Kuhn et al. [5]. (OSFB, OWFB, and adnexal injuries were categorized as separate items, as their presence alone could not be classified in BETT).
Figure 2: Classification of eye injuries in the study with their frequencies and percentage.

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Figure 3: BETT. The bold boxes indicate those diagnoses that are used as clinical entities. BETT, Birmingham Eye Trauma Terminology.

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Globe injuries were found in 30.6% (348); among them 19.3% (67) were open globe injuries (OGIs) and 80.7% (281) were closed globe injuries (CGIs). Some globe injuries [2.6% (9)] were associated with adnexal injuries. OGIs were reported in 67 eyes representing 19.3% of globe injuries and 5.9% of eye injuries; there were a total of 52 eyes with a ruptured globe, 13 eyes with penetrating injury, two eyes with intraocular foreign body [one in the anterior chamber (iron) and one intravitreal, due to shooting (lead)], and perforating injury was not encountered. CGIs were reported in 281 eyes representing 80.7% of globe injuries and 24.7% of eye injuries. An overall 11.4% (32) were contusion cases, whereas 88.6 (249) were cases of lamellar laceration.

OSFB represented 25.2% (287) of eye injuries and 1.5% of total ophthalmic patients; all were superficial corneal FBs (scleral FB was not encountered). Male individuals were affected more than female individuals (P = 0.01507). OWFB represented 0.4% (five) of eye injuries; all were midstromal corneal FBs. Adnexal injuries accounted for 42.1% (479).

There were nine cases with bilateral injury; the other eye of a patient with a ruptured globe showed blowout fracture of the orbit, one case of chemical injury was bilateral and the seven cases of radiation injury were bilateral. No bilateral globe injury was encountered. The right eye was affected in 51.5% (582) and the left eye in 47.7% (538), while both eyes were affected in 0.8% (nine).

We could not obtain presenting and/or final VA in about 14.3% (163) of eye injuries, because either they were preverbal children or there was difficulty in recording follow-up progress data, especially in elderly patients, as a result of poor compliance. The majority of patients (39.3%) (447) had good vision at presentation. The final VA was 6/12 or better in 77.2% (879) of eyes, (6/18–6/60) in 4.1% (47) of eyes, and less than (3/60) in 1.5% (17) of eyes.

The majority of hospitalized patients (50.8%) (64) fell in the age group of 6–30 years. OGIs (53.2%) were commoner than CGIs (8.7%). OGIs were found to affect all age groups with the majority in the age group of 6–30 years and least in the age group of 0–5 years. CGIs were found to affect middle-age groups (16–45 years) with the least in extreme ages (0–5 and <45 years). Lid lacerations were found to affect younger and middle-age groups (0–30 years).

The most common eye injury in our study was periocular ecchymosis and edema (40%), followed by subconjunctival hemorrhage (30.8%).

  Discussion Top

Our study is the first one in Egypt with respect to BETT and its newly proposed modifications. As regards criticisms and difficulties in classifying some injuries in BETT, we felt these realistic and practical when performing our study, necessitating international acceptance and adoption of these modifications.

The incidence of ocular injuries is more in developing countries than in developed countries. In developed countries, the incidence seems to be higher in industrialized areas than in nonindustrialized areas [10]. Studies that have focused exclusively on hospitalized injuries have generally reported low rates of eye injury relative to those studies that have included both emergency department-treated and hospitalized injuries [11]. Similarly to our results, the incidence of ocular trauma between all attending ophthalmic patients was 5% in Central Ethiopia [12] and 4.5% in India [13].

Most of the studies in developed countries were designed as population-based studies and estimated the incidence of ocular trauma as the annual incidence rate (per 100 000 populations per year), as reported in the USA (423 per 100 000 population) [4].

All ages were found susceptible to ocular trauma irrespective of the sex. The incidence of ocular injury was higher in male individuals (69.1%) than in female individuals (30.9%) of all ages. Most ocular injuries (66.1%) (746) were encountered in patients aged 30 years and younger. In our country, the mean age for ocular trauma ranges from 22 to 25 years [14],[15]. On the contrary, in developed countries like Italy and USA, the mean age was 30 years and above [16],[17]. In our study, trauma was found to affect male individuals doubly more than female individuals, as male individuals are prone to do rough work and take part in dangerous playing and daily activities than female individuals. These coincide with the universal pattern of ocular trauma, as occurring in young adult male individuals, irrespective of its severity and country of origin [18].

The main burden of ocular injury in our country and other developing countries has been found in students and workers due to the high incidence of violence and occupational hazards. In Ghana, 49.5% of the patients were students, 19.6% were farmers and 8.2% were artisans [19]. In the UK, the majority of injuries (69.7%) still occur in industrial workers [20]. However, in China, the most commonly affected were farmers (49.4%) followed by workers (23.7%) [21].

The street represents the main site of occurrence of ocular trauma in several studies. Soliman and Macky [14] reported that streets comprised 54% of the sites of occurrence of ocular trauma. The workplace and homes came next, (23 and 19%, respectively) and lastly sport-related places (4%). Similarly to our study, Cillino et al. [16] reported a correlation between the place of trauma and gender: in men, the outdoor activity-related injuries were 30.9%, followed by work-related injuries (25.4%) and sport-related injuries (17.5%), while the most frequent cause of ocular trauma in women was home-related work (52.2%), followed by the outdoor activity-related injuries (30.4%). In the past few decades, in most developed countries, home-related injuries came first followed by work-related or street-related injuries [11],[22]. Another distribution was found in Singapore and Korea, as the workplace was the most common site where the injury occurred, followed by the home and, lastly, the street [23],[24].

Similarly to our results, the stone was the commonest (22%) material causing trauma in a retrospective study in India [25]. As mentioned before, epidemiology of ocular trauma varies from country to country depending on the level of education, socioeconomic development, etc. In our study, there is a reflection of this fact, as 0.8% of ocular trauma cases was due to animal kicking in some rural areas, especially among children, in contrast to eyelid injuries among children due to animal biting in developed countries [26].

Concerning the type of injury, we found that CGIs (24.7%) were more common than OGIs (5.9%), and adnexal injuries (42.1%) were more common than both. Similarly, in our country, Elhesy [15] reported that CGIs (68.9%) were more common than OGIs (24.9%). Lid wounds and hematomas accounted for 5.7% of cases and orbital fractures represented 0.5%. Moreover, in Korea, CGIs represent 85.8% of cases, and OGIs represent 14.2% [24]. On the contrary, a retrospective study in India showed that OGIs were more common (45.3%) than CGIs (31.3%) and adnexal injuries represented 23.3% [25].

In our study, initial VA was found to be correlated with final VA (Spearman's correlation coefficient = 0.928; P = 0.0067) and was a predictor of visual outcome, which was directly related to the severity of eye injury. The incidence of blindness at final discharge was 1.5% (17). Visual outcome was worse in OGIs (especially rupture) than in CGIs. Furthermore, Soliman and Macky [14] reported that worst VA occurred with OGIs. Desai et al. [18] reported similar results to ours, as 86.8% of patients had a final VA of 6/12 or better, 2.5% had 6/18–6/60 and 10.7% had a final VA less than 6/60.

The incidence of hospitalized patients among patients who sustained ocular trauma may be low (3.2%), as reported in Singapore [23], intermediate (9.5%), as reported in Ghana [19] or may be high (53.2%), as reported in Malaysia [10].

In our study, OGIs (53.2%) were commoner than CGIs (8.7%) and adnexal injuries (31.7%) in hospitalized patients. Similarly, Soliman and Macky [14] found that patients with OGIs were the majority of admitted patients (80.4%), whereas patients with CGIs accounted for 13.7%. Lid wounds, orbital FBs, and chemical injury accounted for 5.9%. In China, OGIs showed a higher frequency (70.7%) than CGIs (28.6%), adnexal injuries were next (10.6%) followed by thermal/chemical injuries (0.7%) [21]. Other studies showed that CGIs were more common than OGIs, as reported in Croatia, wherein the incidence of CGIs was 67.3% and that of OGIs was 32.7% [22]. However, in Italy, Cillino et al. [16] reported a similar incidence of OGIs (49%) and CGIs (51%).

The most common eye injury in our study was periocular ecchymosis and edema (40%). In our country, superficial corneal FB was the most common reason for presenting to the ophthalmic casualty room [27]. Superficial FB (58.2%) and corneal abrasion (24.9%) were the most common diagnoses in Singapore [23]. In the USA, the most common eye injury was a contusion or abrasion (44.4%) followed by FB (30.8%) [11].

  Conclusion Top

Ocular trauma in Egypt, like in other developing countries, is a major problem for monocular morbidity and blindness. Persons involved in street activities and some workplaces were at a higher risk of ocular trauma. Violent behavior in our streets, throwing stones, fist fights, and use of sticks, knives and guns were the main risk factors, in addition to high-risk occupations, for example, welding, hammering, drilling and grinding. Preventive measures should be implemented upon the targeted population, together with social awareness about hazards of violence, throwing stones and irresponsible use of guns, which should be prohibited. Moreover, parents' awareness about the importance of supervising their children while playing should be stressed. Implementing health care programs for eye injury prevention in primary health care units, schools and media, with the application of strict occupational safety standards in factories and small workshops, and making use of protective eyewear mandatory rather than voluntary or leaving it to the individual are important measures.

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Conflicts of interest

There are no conflicts of interest.

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