|Year : 2016 | Volume
| Issue : 2 | Page : 65-69
Ocular trauma has fallen on our blind spot
Kirti Nath Jha
Department of Ophthalmology, Mahatma Gandhi Medical College and Research Institute (Sri Balaji Vidyapeeth University), Pillaiyarkuppam, Puducherry, India
|Date of Submission||10-May-2015|
|Date of Acceptance||06-Nov-2015|
|Date of Web Publication||9-Jun-2016|
Kirti Nath Jha
Department of Ophthalmology, Mahatma Gandhi Medical College and Research Institute, Pillaiyarkuppam, Puducherry - 607 402
Source of Support: None, Conflict of Interest: None
Trauma-related visual impairment is an unrecognized public health problem. Insufficient epidemiological data on eye injuries underlies the prevailing apathy. We conducted PubMed search for articles on prevalence/incidence, and epidemiology of eye injuries/ocular trauma in India published from year 2000 to 2014 and included for analysis the studies with sufficient statistical power. We also retrieved data from National Sample Survey Organization (NSSO) and Census of India. Book chapters were also searched for relevant references. Available data throw light on the magnitude and dimensions of trauma-related visual impairment. Andhra Pradesh eye diseases study recorded history of eye injuries in 7.5% of a South Indian population, resulting in unilateral blindness in 0.6% of eye-injured. NSSO 1991 too has recorded high prevalence (35/1000 in rural areas, and 32/1000 in urban areas) of injury-related visual impairment. Results reveal the majority of injuries occur at work in an unorganized sector where Occupational Safety and Health (OSH) cover are almost nonexistent. Data on eye injuries at home, at sports, and combat-related injuries are incomplete. Due to their cataract-centric design, rapid assessment of avoidable blindness surveys fails to reveal injury-related visual impairment. To estimate injury-related visual impairment, we recommend the establishment of a National Ocular Trauma Registry. Comprehensive population-based surveys shall provide additional sources of data. Compliance with OSH measures, education of workforce, provision of eye protective device for hazardous occupations, mandatory reporting, and monitoring and audit of eye injuries should go hand-in-hand.
Keywords: Eye injury, injury prevention, injury-related visual impairment and blindness, occupation safety and health
|How to cite this article:|
Jha KN. Ocular trauma has fallen on our blind spot. J Clin Ophthalmol Res 2016;4:65-9
The ocular morbidity and burden of ocular trauma are enormous.  In 1998, globally there was an estimated 1.6 million blind from injuries. The number of people with unilateral blindness and low vision and bilateral low vision due to ocular trauma was even higher.  The 47 round of National Sample Survey Organization (NSSO) recorded a high prevalence of injury-related visual impairment in India.  Yet, eye injuries are considered accidents, and a clinical rather than a public health issue.  Furthermore, ocular injuries do not figure among blindness control programs. Has ocular trauma fallen on our blind spot? To find the answer to this question, and to reveal the magnitude of injury-related visual impairment in India, we conducted PubMed search for articles on prevalence/incidence and epidemiology of eye injury/ocular trauma in India published from year 2000 to the end of the year 2014, and retrieved and included for analysis data from the studies with sufficient statistical power. We also retrieved data from NSSO, Census of India, and book chapters references. Analysis of available data forms the basis of our findings and recommendations.
| Epidemiology of Ocular Trauma and its Limitations|| |
Epidemiological data on eye injuries are still rare or totally lacking in large parts of the world.  Blindness prevalence surveys from the developing countries indicate that in absolute rates blindness from trauma is small.  In fact, lack of reliable and good quality national or regional data has thwarted recognition of injuries as a public health problem in India.  PubMed search on the epidemiology of ocular trauma yields very few population-based prevalence studies from India. Few available population-based studies provide an estimate and help us highlight, ocular trauma-related visual impairment. The Andhra Pradesh Eye Disease Study (APEDS) recorded age- and gender-adjusted prevalence of a history of eye injury in 7.5% of population, resulting in unilateral blindness in 0.6% of the population. If these data were projected on the whole of the rural population of southern India, the number of people with a history of ocular trauma, and blindness from trauma would be large.  Aravind Comprehensive Eye Survey on ocular trauma noted the lifetime prevalence of ocular trauma (4.5%) higher than that reported for glaucoma, age-related macular degeneration, or diabetic retinopathy. They suggested that eye care programs might need to consider ocular trauma as a priority in this regional population.  The prevalence of injury-related visual impairment in the urban areas is higher. A study from urban slums in Delhi noted 2.4% prevalence rate for ocular trauma resulting in blindness in 11% of injured eyes.  Data from these population-based surveys find support from 2 NSSO. Forty-seventh round of NSSO, 1991 noted high prevalence of injury-related visual disability (35/1000 in rural and 32/1000 in urban areas).  According to the 58 th round of NSSO report, 2002, injury-related visual disability increased to 51/1000 population.  [Figure 1] shows the state-wise data on visual impairment and blindness.  [Figure 2] shows the etiological breakdown of visual disability at national level. 
The Global Data on Visual Impairment 2010 offer a contrast; they do not throw light on ocular trauma as they have drawn data from the three rapid assessment of avoidable blindness surveys in the last 10 years for ages 50 years and older.  Authors of the Global Data on Visual Impairment 2010 recognize the paucity of national studies with or without World Health Organization (WHO) eye survey protocol. The authors concede the attribution of the causes of visual impairment is prone to uncertainties. Although trauma does not figure as a cause of visual impairment and blindness among the Global Data on Visual Impairment 2010, a large proportion (21% blindness and 18% of visual impairment) is attributed to undetermined cause.  The experts have questioned the effectiveness of current eye care policy focussed almost exclusively on cataract in dealing with blindness in India. They have suggested changes in the study design of the population-based epidemiological studies and have also suggested a revised approach to epidemiological monitoring of visual impairment. ,
A systematic analysis of causes of vision loss worldwide: 1999-2010 too fails to recognize the impact of ocular trauma although other causes/unidentified account for 31.4%.  As a result, ocular trauma continues to remain on out blind spot. WHO recognizes this, and feels injuries are low in priority for policymakers.  This view is shared also by some experts from developed countries who consider ocular trauma a neglected disorder. 
| Ocular Trauma and Occupation|| |
Ocular trauma occurs in a variety of settings. Workplace and household activities, road traffic accidents, violence, sports and leisure, and warfare form the common settings.
Workplace-related ocular trauma
Workplace-related injuries constitute the majority of the eye injuries.  These injuries affect young adults in their productive years with obvious economic consequences. Since the majority of our workforce are employed in the unorganized sectors without a system of reporting injuries, we do not have national data on cause of work-related injuries in India.  Population-based studies give some insight into the problem. In the APEDS, workplace-related injuries constituted 55.9% eye injuries.  We have a few studies that give estimates of eye injuries during agricultural activities. Eye injuries during agricultural labor accounted for 46.9% injuries in the Aravind Comprehensive Eye Survey on ocular trauma.  These Findings support the findings of International Labour Organisation that considers agriculture a hazardous activity. 
Construction-workers constitute another vulnerable group. Nature of work exposes them to a wide variety of serious occupational hazards. A number of labor laws are applicable to construction workers. Yet, in the absence of voluntary compliance of safety norms, safety audit by the industry, and effective monitoring by regulatory authorities, construction workers lack adequate provisions for safety and health. 
Manufacturing sector poses a different set of challenges. We have limited data from manufacturing sectors. Data from Singapore highlights both the dangers and low compliance with safety measures in manufacturing. In a hospital-based prospective study from Singapore, work-related injuries accounted for 71.4% cases of eye injuries. Works involved grinding, cutting metal, and drilling in more than 90% of these cases. More than three-fourths (78.6%) of the injuries in Singapore resulted from a lack of provision, or failure to use the eye protective device (EPD) at the time of injury. 
Domestic ocular trauma
Eye injuries at home rank second only to work-related eye injuries.  Most injuries at home occur under avoidable circumstances. Environmental modification and awareness may help prevent ocular injuries, particularly among children.
Road traffic injuries-related ocular trauma
Road traffic injuries (RTI)-related ocular trauma constitute between 5% and 13% of all ocular trauma.  RTI in India has been increasing over past 20 years.  Therefore, road traffic injuries related eye injuries are expected to rise. We have extremely limited information on injury patterns, nature, and outcome of RTI-related eye injuries are in India. Cross-sectional surveys underestimate the magnitude of RTI-associated eye injuries since blinding ocular injuries are often associated with multiple organ injuries with high case fatality. 
Sports- and leisure-related ocular trauma
Sports- and leisure-related injuries form significant eye health hazard worldwide particularly among the youth. In the USA baseball, ice hockey, and racquet sports account for the most of the sports-related eye injuries.  Epidemiological statistics on sports-related eye injuries in India are not available. In India, sportspersons other than cricket and hockey players seldom use any EPD.
Combat-related ocular trauma
With each succeeding war, injuries to the eyes have been increasing. Combat-related eye injuries are frequently bilateral and associated with globe perforation, retained intraocular foreign bodies, and visual impairment.  Combat-related eye injuries are a common cause of disablement among the soldiers, and they often render the combatants unfit for military service.  During Indo-Pakistan Wars, eye injuries resulted in bilateral blindness in 3.1-5.5% and unilateral blindness in of 20.6-39% of cases.  In a recent study, Israel Defense Forces noted high incidence of disablement, and discharge from service on account of disablement, from combat-related eye injuries. 
Status of ocular trauma prevention in India
Recognition of injury and violence as a public health problem has been a recent phenomenon in India.  The Government of India recognizes that Occupational Safety and Health (OSH) cover for the unorganized sector is almost nonexistent.  In recent years, the Government of India has come up with several policy formulations for implementation and monitoring by individual states. Lack of good information system on injury burden, its pattern and impact prove a barrier to injury prevention. Occupational Health Policy was one of the components of National Health Policy 1983, and also 2002. Yet, very little attention has been paid to mitigate the effect of occupational diseases through proper program.  Awareness and attitude of the workers and employers toward the safety norms are partly responsible for low compliance. Therefore, the workers in manufacturing, agriculture, and construction sectors remain largely without provision of eye protection.
Situation is no different in the Indian Armed Forces where soldiers often undertake extremely hazardous duties. The Indian Armed Forces do not provide soldiers EPD although data show certain benefit from such a device.  In the fields of sports and leisure situation are similar. Sportspersons other than cricket and hockey players seldom use any EPD. Furthermore, there is no visible public campaign to educate public on prevention of eye injuries. Therefore, today in India protection of eyes and prevention of ocular trauma remain a neglected area.
A road map for ocular trauma prevention
Ninety percent of all eye injuries are preventable.  Comprehensive suggestions on injury prevention and control exist in literature.  Prevention of injury-related visual impairment requires a holistic approach. Compilation and analysis of ocular trauma-related data forms the first step. Campaigns to generate public awareness should go side-by-side. Compliance and monitoring of safety norms come next. Furthermore, we require changes in epidemiological approach to reveal the magnitude, setting, and causation of whole spectrum of eye injury-related visual impairment. In the USA, United States Eye Injury Registry and US National Eye Trauma System have proved useful epidemiological tools. , National Ocular Trauma Registry on similar lines shall provide us national and regional data across sectors. We also need a population-based survey on ocular trauma. Population-based surveys shall prove supplementary sources. Data generated from National Ocular Trauma Registry and population-based surveys shall help devise long-term preventive strategies and corrective interventions. We need public education to bring about behavioral changes and to enhance worker compliance. Labor force in the unorganized sector and in hazardous industries deserves priority both for awareness campaigns and provision of EPDs. Under the law, employers need to provide workers both the safe working environment and EPD where hazards exist.  Industry needs to undertake periodic in-house safety audit of the workplace. Mandatory reporting of ocular trauma on a standard form common to all the sectors should be a norm. A central coordinating agency with a mechanism for coordination across all the sectors of the industries shall facilitate implementation and monitoring of safety norms. Ergonomic and acceptable EPD that do not limit the function of the soldiers are now available.  Armed forces should consider introducing these EPD for the combatant undertaking dangerous operations.
| Conclusion|| |
Ocular trauma-related visual impairment is an unrecognized public health problem. Paucity of epidemiological data on injury-related visual impairment underlies the problem. Collection and analysis of data on injury-related visual impairment should be a priority area for policy makers. There is a need also for changes in epidemiological approach. Establishment of National Ocular Trauma Registry shall help estimate the magnitude of ocular trauma and injury-related visual impairment. As mandated by OSH norms, the employers need to ensure safe working environment and provide EPDs for the workers in hazardous occupations. Industries need also to conduct periodic, in-house safety audit of the workplace. Regulatory bodies need to monitor and ensure compliance of OSH norms. Provisions of EPDs for the combatant in Armed Forces are overdue. Public education and worker compliance should be responsibility of all the government, the nongovernmental organizations, and the industries. Multipronged action and cooperation of all stakeholders shall minimize injury-related visual disablement.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]