|Year : 2016 | Volume
| Issue : 1 | Page : 19-23
Ocular trauma in Indian pediatric population
Vishal Katiyar, Sonal Bangwal, Sanjiv Kumar Gupta, Vinita Singh, Kumari Mugdha, Poonam Kishore
Department of Ophthalmology, KGMU, Lucknow, Uttar Pradesh, India
|Date of Submission||13-Mar-2015|
|Date of Acceptance||21-Oct-2015|
|Date of Web Publication||19-Jan-2016|
Department of Ophthalmology, KGMU, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Trauma to the eye and ensuing visual disability is an important cause of preventable mono-ocular blindness in the pediatric age group in India. Policy decisions are helpful in preventing this kind of trauma and improving the required trauma management services warrant an accurate estimate of various aspects of ocular trauma and its outcome in Indian population. Aims: To understand the patterns of ocular trauma in Indian pediatric population and its short-term visual outcome. Settings and Design: A tertiary center based, retrospective, observational study. Materials and Methods: Data collection from January 2010 to June 2013 including demographic profile, place of injury, distance from tertiary center, type of health care facility first sought, time delay in first treatment, medico-legal status, pattern of ocular injury on Birmingham Eye Trauma Terminology System (classification), trauma elsewhere in the body, treatment given by us, and best corrected visual acuity (BCVA) at the time of presentation and 3 months. Statistical Analysis: Multinomial logistic regression analysis to identify factors independently affecting BCVA posttreatment which included age, time of the first contact, and time delay in treatment, pretreatment BCVA. Results and Conclusions: Mean age of injury was 7.6 ± 3.3 years with 151 (79.1%) males and 40 (20.9%) females. Seventy-eight percent of patients were from rural areas and 43% first sought treatment at some other government health facility. Majority of children 83/191 (43.5%) sustained injuries at agricultural fields. Best visual acuity was observed in cases of closed globe injuries which was better than 6/18 in 81.8% (18/22) cases.
Keywords: Best corrected visual outcome, Birmingham Eye Trauma Terminology System (classification), closed globe injuries, globe rupture
|How to cite this article:|
Katiyar V, Bangwal S, Gupta SK, Singh V, Mugdha K, Kishore P. Ocular trauma in Indian pediatric population. J Clin Ophthalmol Res 2016;4:19-23
|How to cite this URL:|
Katiyar V, Bangwal S, Gupta SK, Singh V, Mugdha K, Kishore P. Ocular trauma in Indian pediatric population. J Clin Ophthalmol Res [serial online] 2016 [cited 2020 Jul 10];4:19-23. Available from: http://www.jcor.in/text.asp?2016/4/1/19/174400
Trauma to the eye and ensuing visual disability is an important cause of preventable mono-ocular blindness in the pediatric age group in India. The ensuing visual disability has significant emotional, psychological, and Socio-economical impact on the individual person, family, and to the society as a whole.  Policy decisions helpful in preventing this kind of trauma and improving the required trauma management services warrant an accurate estimate of the pattern of the ocular trauma in Indian population.  Most of our understanding of this issue is based on the studies from developed countries , with very limited studies from India.  We planned this epidemiological study to understand the patterns of ocular trauma in Indian pediatric population and its short-term visual outcome.
| Materials and Methods|| |
The study was conducted after ethical clearance and was performed in accordance to the tenets of the Helsinki Declaration. Retrospective tertiary center-based analysis of medical records of all pediatric patients presenting at the Department of Ophthalmology, from January 2010 to June 2013 was done.
Data collection included demographic profile of the patients, place where injury occurred, its distance from the tertiary center, type of health care facility first sought, time delay in first treatment, medico-legal status of ocular injury on Birmingham Eye Trauma Terminology System (BETTS classification), trauma elsewhere in the body, treatment given by us, and BCVA at the time of presentation and 3 months. Modes of injuries were classified under following heads:
- Domestic environment trauma: This included cases of injury due to stationary items, household items
- Trauma sustained during outdoor activities: This included cases of injuries while playing with ball, stone pellets, bow and arrow, wooden top, sticks, "Gulli Danda" (a local sport involving sharp wooden sticks)
- Fire cracker injuries during Diwali and other festive occasions
- Road traffic accidents
- Animal attacks
- Agriculture field and work place related injuries: Injuries sustained in agricultural fields and other places not meant for recreation
The visual acuity was charted in Snellen's score and converted to LogMAR equivalent for further analysis.
| Results|| |
We retrospectively reviewed the records of 191 pediatric patients from January 2010 to June 3013. Multinomial logistic regression analysis was done to identify the factors independently affecting BCVA posttreatment namely age, time of first contact, time delay in treatment, and pretreatment BCVA. Mean age of injury was 7.6 ± 3.3 years (range 1-14 years) with 151 (79.1%) males. Seventy-eight percent of patients were from rural areas. Male children between the age of 6 and 10 years constituted the largest group accounting for 41.1% (80/191) of total patients. Fifty percent (20/40) female patients were below 5 years of age.
There was a mean inflow of 4.54 ± 1.97 cases per month, ranging from a single case in month of September to 17 cases in the month of October. Almost one-fourth (26.7%) of pediatric patients were from the same district, 46.2% cases from adjoining six districts and 27.1% patients from far off 12 districts [Figure 1].
|Figure 1: Pattern of inflow of cases to trauma centre from adjoining districts|
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Less than half of the cases (43%), first sought treatment at some other government health facility (Peripheral Health Centre or Community Health Centre) before being referred to the tertiary center. Almost similar number (42%) sought medical or surgical help at the tertiary center on the first place. Only 14.7% patients sought treatment from a private practitioner on the first place.
Mean time interval from the onset of event/symptoms to the first contact with any health facility was 8.25 ± 14.6 h (range 1 h-5 days). Similarly, mean time interval from the onset of event/symptoms to definitive treatment at the tertiary center was 27.6 ± 37.9 h (range 1 h-8 days). The mean first contact time interval and mean definitive treatment time interval (11.8 ± 20.3 h, 39.4 ± 45.4 h) was significantly higher when patients sought other government health facility, rather than coming directly to the tertiary center (5.2 ± 5.7 h, 11.2 ± 25.1 h) (P < 0.001), respectively.
[Table 1] shows the distribution of various modes of injuries in patients presenting as ocular emergencies. Majority of children 83/191 (43.5%) sustained injuries at agriculture fields and work places adjoining their residence, out of which 83.5% were males and 49% were in age group of 6-10 years. This was followed by injuries sustained in domestic environments and accounted for 21.5% (41/191) cases. Ocular injuries associated with road traffic accidents accounted for 8.4% (16/191) of patients presenting in emergency with majority (75%) related to two wheelers. Fire cracker injuries accounted for about 7.3% (14/191) of injuries, mostly during Diwali season (October or November). Eye injuries due to fire arm accounted for just one case. Five out of 191 (2.4%) had come with emergencies not associated with trauma such as retinoblastoma or orbital cellulitis.
Laceration in the corneo-scleral region of eye 92/191 (48.2%), closed globe injuries 59/191 (30.9%), and globe rupture 24/191 (12.6%) were the common injuries seen in the patients presenting as emergencies [Table 2].
|Table 2: Pattern of injuries as per Birmingham Eye Trauma Terminology System (BETTS classification)|
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Eighteen percentage of patients had facial trauma along with ocular injury and 8.8% cases had associated head trauma. 2.8% patients had injuries elsewhere at the time of presentation. Of all the ocular emergencies, only one case (0.5%) was registered as medico-legal elsewhere.
Of all the cases, 62.3% (119/191) patients required surgical intervention at the time of presentation, and the rest were conservatively managed.
BCVA at presentation and 3 months after management is shown in [Table 3]. At 3 months posttreatment, only 34/122 (26.7%) could achieve a visual acuity better than 6/18. Percent (22/34) of these patients had closed globe injuries. One-third of these patients had lacerations (12/34) and were able to achieve a BCVA better that 6/18. Forty-four percentage (54/122) had a BCVA <3/60 at 3 months posttreatment. Globe rupture (23/54) and laceration (27/54) together accounted for 92.5% (50/54) of all cases with final BCVA <3/60 at 3 months post treatment. BCVA at 3 months was below 3/60 in cent percent (23/23) cases of globe rupture and in 42.1% (27/64) cases of laceration. The best visual outcome was observed in cases of closed globe injuries which was better than 6/18 in 81.8% (18/22) cases.
Linear regression analysis of the factors affecting the BCVA at 3 months revealed that the BCVA at the time of presentation was the only factor independently affecting the final visual outcome [Table 4]. The age of the child and delay in presentation did not affect the final outcome. In the multinomial logistic regression of factors affecting the final BCVA, we observed that only patients with closed globe injury or contusion had final BCVA better than 3/60 after 3 months.
| Discussion|| |
In the present study, we observed a distinct dip in the average inflow of pediatric ocular trauma patients, in months of July and September and a surge in the month of October. This pattern of rise and fall in patient's inflow is parallel to a similar fall and rise in overall Out-patient Department patients, observed in clinical practice, in this region. The sowing season of Kharif crops (paddy and sugarcane) lasts from the mid of June to end of July which demands significant investment in low levels of public financing, lack of a comprehensive risk pooling mechanism, and high out-of-pocket expenditures in the context of rising health costs are key factors impacting the utilization of health services by poor people especially from rural areas.  Only around 10% of the Indian population is covered under some form of social or voluntary health insurance,  rest are forced to make an out-of-pocket expenditures to seek medical treatment. The poor, more so in rural areas,  are affected more by immediate availability of money to avail health care;  hence are less likely to seek health services. The inefficient allocation of resources to different levels of services and different geographical regions could be responsible for patients seeking treatment outside their districts.  It could also be due to high absenteeism among health workers (reported to be higher than 40% in some studies), limited opening hours, limited availability of drugs and other supplies, poor physical environments, and poor provider training and knowledge in such areas. , Health expenditures per capita in state is estimated to be mere 974 rupees in 2004-2005. 
The number of government hospital beds in urban areas is more than twice that in rural areas. As physical distance to facilities is a key determinant for access, overcoming this through outreach or better transport, roads and communication networks is important. This may partly explain that 43% of patients seeking treatment were from adjoining districts, which are well connected to Lucknow by highways. Predominance of males (79%) seeking treatment could be due to preference to invest in male child rather than a female, a phenomenon common in India and in other Asian countries or because of higher involvement of the same in agriculture activities, as compared to females who are engaged in domestic chores.
Only 15.7% patients in our study sought treatment from a private practitioner before coming to a trauma center. This may be because private practitioners tend to be centered in wealthier urban areas and have bias against poor patients with medical condition having a poor prognosis and medico-legal implications such as pediatric ophthalmic emergencies. The private sector dominates service provision of high-end curative services. 
Male child in the age group of 6-10 years was found to be most commonly affected group in the study. Besides the obvious preference of the parents to seek treatment for the injured male child, higher incidence of injuries in males.
This can be explained by the fact that in most of the Indian households, children are routinely engaged in farming or domestic chores (such as cooking and fetching fire wood)  as many households lack sufficient infrastructure.  Agriculture continues to employ nearly 50% of Indian work force in 2009, which is again labor-intensive and dominated by small holders.  Children are employed in farming as it requires more labor input. In 2009-2010, state recorded a gross dropout rate of 26.3% in elementary grades (class 1-8) out of which one-fourth children were employed in agriculture. 
Diwali season witnesses a surge in fire cracker injuries. We observed that fire cracker injuries alone account for about 7.3% (14/191) of injuries. This is like most of the earlier studies in which the most common group affected was formed by children below 16 years of age. The Firework Act 2003 and The Firework Regulation Act, 2004, banned the purchase and possession of firecrackers around bonfire night by children below 18 years of age. Edwin et al. noticed that there was a positive impact of this ban and, in 2004, the injuries reduced to 83% of previous years.  Prophylactic actions in the form of change of legislation, implementation of legislation and dissemination of information were effective in reducing the incidence significantly in Denmark.  Public education in schools, strict standardization of firecrackers, supervision by adults, restriction in personal use of firecrackers, and promotion of public display of firecrackers are the other means suggested.
Laceration in the corneo-scleral region was the most common injury 92/191 (48.2%) and globe rupture 24/191 (12.6%) together constituted half of all injuries higher incidence of open globe injuries in common in the studies from poor developing countries mostly sustained while working in agriculture fields,  but the studies from developed world shows a predominance of closed globe injuries mostly sustained while playing in school.  Laceration and more so the globe rupture was associated with extremely poor visual prognosis. All the patients who had globe rupture and 22.6% of patients with laceration in the corneo-scleral region had the final visual acuity <3/60. More than half of the patients with closed globe injuries (18/34) had final visual outcome better that 6/18 on Snellen's. As seen in regression analysis shown in [Table 4], we also observed that final BCVA of the patient after the treatment was independently affected only by the BCVA charted at the time of presentation. The age of the patient, delay in presentation and treatment, were the factors not found to be independently affecting the final BCVA of the patients as shown. Among accurate predictors of final visual acuity, studies on pediatric trauma have reported poor visual acuity at presentation and open globe injuries to be associated with poorer visual outcome,  We did not find the age of child a predictor of the final visual outcome like other studies.  There was a significantly larger delay, not only in receiving the definitive treatment (27.6 ± 37.9 h [range 1 h-8 days]) but also in presentation of child to any health facility after the trauma (8.25 ± 14.6 h [range 1 h-5 days]). The high incidence of open globe injuries and their association with poorer visual outcome even with adequate early treatment were possible reasons for this observation. Although our study duration was fairly long (January 2010-June 2013), follow-up could not be extended beyond 3 months because of dropouts.
| Conclusion|| |
Most of the injuries were sustained in work places which can be avoided by discouraging child labor. Activities such as fireworks should be done under proper supervision. The inefficient allocation of resources to different levels of services and different geographical regions and absenteeism among health workers should be corrected. Better health care facilities should be provided in rural areas so that the delay in seek of treatment is avoided.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]