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ORIGINAL ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 1  |  Page : 3-7

Clinical profile of ocular blunt trauma in a rural hospital


Department of Ophthalmology, Adichunchanagiri Institute of Medical Sciences, Mandya, Karnataka, India

Date of Web Publication18-Jan-2018

Correspondence Address:
Anitha S Maiya
Department of Ophthalmology, Adichunchanagiri Institute of Medical Sciences, B.G. Nagara, Mandya - 571 448, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-3897.223566

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  Abstract 

Context: Ocular trauma is the cause of one-third of monocular blindness. The inherent risk factors for ocular injuries among the rural population, and lack of surveys conducted in the rural areas stresses the need for a descriptive study that identifies the cause and pattern of ocular injuries and visual outcome among the rural population. Aims: To analyze blunt ocular trauma with respect to (i) demographic profile, (ii) mode of injury, and (iii) the ocular structures involved. Settings and Design: Prospective study. Subjects and Methods: This study included 95 cases of blunt ocular trauma who attended the casualty and the outpatient Department of Ophthalmology of our institution. All patients underwent a comprehensive ocular examination along with relevant radiological tests. All the cases were appropriately treated and followed at regular intervals to assess the visual outcome and complications. Statistical Analysis Used: Not applicable. Results: The male to female ratio was 4.5:1; majority of the patients (42 patients, 44.2%) belonged to the 21–40 years age group. About fifty patients (52.6%) were from agricultural class. In 46 patients (48.4%) the injuries were agricultural in nature. Subconjunctival hemorrhage was the most common finding (36 patients, 37.89%) followed by traumatic uveitis (27 patients, 28.42%) and lid and adnexal injuries (21 patients, 22.10%). Conclusions: Ocular blunt trauma in the rural population is common in males and mostly agriculture-related with involvement of multiple ocular structures in the same eye. The spectrum of ocular complications can range from trivial to severe sight-threatening injuries. It is recommended that health education highlighting early diagnosis and prompt treatment of ocular injuries can help to reduce the ocular morbidity.

Keywords: Blunt ocular trauma, demographic profile, mode of injury


How to cite this article:
Maiya AS, Dharmesh AM, Jayaram R. Clinical profile of ocular blunt trauma in a rural hospital. J Clin Ophthalmol Res 2018;6:3-7

How to cite this URL:
Maiya AS, Dharmesh AM, Jayaram R. Clinical profile of ocular blunt trauma in a rural hospital. J Clin Ophthalmol Res [serial online] 2018 [cited 2018 Sep 23];6:3-7. Available from: http://www.jcor.in/text.asp?2018/6/1/3/223566



Ocular blunt trauma (OBT) comprises all closed-globe injuries in which mechanical deformation and/or direct energy delivery causes ocular damage.[1] Ocular trauma is a preventable public health problem throughout the world. It is one of the common causes of ophthalmic morbidity and monocular blindness in all parts of the world.[2]

The global annual incidence of ocular trauma is around 55 million, of which 750,000 cases require hospitalization each year.[3] These injuries can occur in almost any setting including recreational and sports related workplace, home, assault, agricultural, and road traffic accidents.[4] In India, the reported incidence of ocular trauma varies from 1% to 5%.[5]

OBT causes ocular damage by the coup and contrecoup mechanism or by ocular compression. The concept of coup and contrecoup injury was first introduced to explain brain damage caused by blunt trauma to the head by Courville.[6],[7] This was later used by Wolter to explain eye injuries.[8] Coup injuries refer to local trauma at the site of impact (e.g., subconjunctival hemorrhage, corneal abrasions, subretinal and choroidal hemorrhages, etc.). Contrecoup refers to injuries at the opposite site of the impact caused by shock waves that traverse the eye (e.g., commotio retinae).

OBT can result in a wide spectrum of ocular complications ranging from trivial injuries like subconjunctival hemorrhage to grievous sight-threatening injuries such as optic neuropathy, retinal detachment, and traumatic cataract.

Apart from obvious ocular damage, blunt trauma may result in long-term effects like traumatic cataract and angle recession glaucoma which can make the prognosis guarded and warrant a vigilant long-term follow-up which has to be emphasized to the patients. Proper assessment of ocular damage and starting treatment immediately after an injury has an important impact on the final outcome. Therefore, early diagnosis and appropriate treatment are imperative to prevent visual morbidity caused by ocular trauma.

We observed that at our hospital, which caters to the rural population, the number of trauma patients were significantly high. The inherent risk factors for ocular injuries among the rural population, and lack of surveys conducted in the rural areas stresses the need for a descriptive study that identifies the cause and pattern of ocular injuries and visual outcome among the rural population. Hence, our study was conducted with an objective to analyze blunt ocular trauma with respect to (i) demographic profile, (ii) mode of injury, and (iii) the ocular structures involved among the rural population.


  Subjects and Methods Top


This prospective study was conducted in our outpatient department after obtaining Ethical clearance from the college Ethics Committee during a 1 year study period.

Inclusion criteria

Patients with a definite history of recent blunt trauma to the eye of all age groups who were willing to participate were included in the study.

Exclusion criteria

  1. Patients with a history of penetrating ocular injury
  2. Patients with orbital injuries involving fractures
  3. Old ocular injuries >1 month before consultation at our hospital
  4. Patients who were not willing to participate in the study.


A detailed history was taken to know the demographic data, mode of injury, and the duration between injury and presentation.

Initial assessment also included injury to other organs, whether there has been loss of consciousness, previous eye surgical history, status of tetanus prophylaxis, possible contamination of the wound.

The examination began with examination of the face, orbital area, eyelids, and eyeball, followed by record of visual acuity with Snellen's chart, anterior segment examination by slit lamp biomicroscopy, pupillary evaluation (reactivity to light, presence of afferent pupillary defect), assessment of extraocular movements and confrontational visual fields. Intraocular pressure measurement and gonioscopy were done after ruling out globe rupture. Posterior segment examination was done by direct and indirect ophthalmoscopy. Investigation like X-ray orbit and/or computed tomography scan and/or ultrasound B-scan was done as and when indicated by examination.

All the cases received treatment according to the injury and were followed at regular intervals to assess the visual outcome and complications.


  Results Top


A total of 95 eyes of 95 patients with OBT who fulfilled the inclusion criteria were studied, and the following observations were made: The study group included 78 men and 17 women (male to female ratio of 4.5:1). The age distribution of the patients is shown in [Table 1]. Majority of the patients (42 patients, 44.2%) who sustained trauma belonged to the 21–40 years age group [Table 2].
Table 1: Age-wise distribution of the patients

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Table 2: Gender distribution, occupation, eye involved, and mode of injury among patients

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In our study, seventy patients (73.7%) presented within 2 days of the trauma, 19 (2%) presented within 2–7 days while six patients (6.3%) after 7 days of injury [Table 3]. Many of the patients had the involvement of more than one ocular structure.
Table 3: Ocular complications of blunt trauma seen in the present study

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  Discussion Top


Worldwide there are approximately 6 million people who are blind from ocular injuries, 2.3 million people who are visually impaired bilaterally; these facts make ocular trauma one of the most common causes of unilateral blindness.[3] Ocular trauma is a major cause of preventable monocular blindness and visual impairment in the world.[9],[10] Despite its public health importance, there is relatively less population-based data on the magnitude and risk factors for ocular trauma, especially from developing countries.[11],[12]

In our study, we found 42 (44.2%) patients were below 30 years with male to female ratio of 4.5:1. It was found in a study at Ethiopia that 63.8% patients were below 30 years of age and male to female ratio of 3.2:1.[13] The higher rate of ocular trauma among males may be attributed to:

  1. The propensity of males to choose hazardous jobs and also of young males to participate in risk-taking and aggressive outdoor activities, all of which puts them at greater risk of injury
  2. In almost all societies, males have better access to health services.


In the JUDO study, 31.6% of patients presented within 48 h whereas 28.6% arrived 1 week or later.[13] In our study, seventy patients (73.7%) presented within 2 days of the trauma, 19 (2%) presented within 2–7 days while six patients (6.3%) after 7 days of injury.

Reason for delay in presentation

  1. Poor access to health care services in rural areas
  2. Social/cultural/superstitious beliefs prevalent among the rural population
  3. Lack of awareness about the importance of early diagnosis and prompt treatment of ocular injuries among the rural population.


Among the 25 patients who presented after 2 days of the injury, four patients were referred by ophthalmologists and had received initial medical therapy, 11 patients had sought the advice of local medical practitioners (nonophthalmologists), four patients were treated by quacks and six patients did not receive any form of treatment.

Our study did not show any significant association between involvements of either eye. Right eye was involved in 48 (50.5%) patients; left eye was involved in 47 (49.5%) patients. The slight predominance of the left eye injuries may be explained by the fact that most people are right handed and the left eye of the victim is the one which is more vulnerable to attack from a right handed person.

Among the causes of injury, agricultural injuries stood out as the most common cause (46 patients; 48.4%). This was followed by road traffic accidents in 14 patients (14.7%), sports, playing and recreational activities in 14 patients (14.7%), and accidental fall in 13 patients (13.7%), and others such as domestic accidents, violence related were other identified causes. Study of JUDO showed the most common causes of injury were violence related in 37.2% of the documented causes.[13]

Blunt trauma can affect any ocular structure. In our study, conjunctiva stood out as the most common ocular structure involved with 36 eyes having a subconjunctival hemorrhage [Figure 1] and nine patients having a conjunctival laceration. These injuries are not sight-threatening and were managed conservatively. Six patients with conjunctival tear >1 cm needed surgical repair.
Figure 1: Subconjunctival hemorrhage

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Figure 2: Traumatic mydriasis

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In a study on blunt trauma, it was found that hyphema [Figure 3] is a common complication of eye blunt trauma that occurs in approximately 50% of the patients with eye blunt trauma.[14] In our study, hyphema was seen in 11 patients (11.6%) of which three patients had total hyphema. Conservative management with bed rest, pressure bandage and topical steroids, cycloplegics and antiglaucoma therapy helped in the resolution of hyphema without any sequelae.
Figure 3: Hyphema

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In our study, 14 patients (14.7%) showed early evidence of traumatic cataract during their follow-up visits. They were managed conservatively and advised regular follow-up visits to plan cataract surgery if the vision gets impaired. Three patients has displacement of the lens; of whom one patient underwent lens extraction with anterior vitrectomy for dislocation of the lens into the anterior chamber, one patient underwent prophylactic neodymium-doped yttrium aluminum garnet laser peripheral iridotomy to prevent secondary angle closure glaucoma.

Vitreous hemorrhage was noted in two patients in our study, which was diagnosed on B-scan and managed conservatively. Although most causes of vitreous hemorrhage are nontraumatic (diabetic retinopathy, sickle cell disease, posterior vitreous detachment, retinal vein occlusion, leukemia), trauma accounts for 12%–31% (in various studies) and is the most common cause of vitreous hemorrhage in younger patients.[15],[16]

Commotio retina, also known as “Berlin's edema,” [Figure 4] is characterized by a transient, well defined greyish-white opacification of the retina occurring after blunt ocular trauma. Studies have demonstrated this injury to be present in 9%–14% of blowout fractures.[17] We found ten cases of commotio retinae which were managed conservatively.
Figure 4: Fundus picture showing Berlin's edema

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Figure 5: Ultrasonography B-scan showing retinal detachment

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  Conclusions Top


OBT in the rural population involved mainly young males were work-related and associated with involvement of multiple ocular structures in the same eye. While most of the injuries may be minor and treated conservatively with complete recovery, a few complications like retinal detachment and traumatic optic neuropathy require referral to tertiary care centers for surgical management.

This study also has shown that agricultural accidents are the most common causes of ocular injuries among the rural population followed by road traffic accidents and sports and recreational activities. Thus, it is recommended that preventive measures advocated by health workers to emphasize the importance of early health seeking behavior and follow-up of patients with ocular trauma can help in the early diagnosis and prompt treatment of ocular injuries which can reduce the ocular morbidity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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Parmar IP, Nagpal RC, Sunandan S. Pattern of ocular injuries in Haryana. Indian J Ophthalmol 1985;33:141-4.  Back to cited text no. 4
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Courville CB. Coup-contre coup mechanism of craniocerebral injuries. Arch Surg 1942;45:9.  Back to cited text no. 6
    
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Courville CB. Forensic neuropathology. J Forensic Sci 1962;7:1.  Back to cited text no. 7
    
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Wolter JR. Coup-contrecoup mechanism of ocular injuries. Am J Ophthalmol 1963;56:785-96.  Back to cited text no. 8
    
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Katz J, Tielsch JM. Lifetime prevalence of ocular injuries from the Baltimore Eye Survey. Arch Ophthalmol 1993;111:1564-8.  Back to cited text no. 9
    
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Schein OD, Hibberd PL, Shingleton BJ, Kunzweiler T, Frambach DA, Seddon JM, et al. The spectrum and burden of ocular injury. Ophthalmology 1988;95:300-5.  Back to cited text no. 10
    
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Dandona L, Dandona R, Srinivas M, John RK, McCarty CA, Rao GN. Ocular trauma in an urban population in Southern India: The Andhra Pradesh Eye Disease Study. Clin Exp Ophthalmol 2000;28:350-6.  Back to cited text no. 11
    
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Nirmalan PK, Katz J, Tielsch JM, Robin AL, Thulasiraj RD, Krishnadas R, et al. Ocular trauma in a rural South Indian population: The Aravind Comprehensive Eye Survey. Ophthalmology 2004;111:1778-81.  Back to cited text no. 12
    
13.
Asaminew T, Gelaw Y, Alemseged F. A 2-year review of ocular trauma in JIMMA University Specialized Hospital. Ethiop J Health Sci 2009;19:67-76.  Back to cited text no. 13
    
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Liggett PE, Pince KJ, Barlow W, Ragen M, Ryan SJ. Ocular trauma in an urban population. Review of 1132 cases. Ophthalmology 1990;97:581-4.  Back to cited text no. 14
    
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Dana MR, Werner MS, Viana MA, Shapiro MJ. Spontaneous and traumatic vitreous hemorrhage. Ophthalmology 1993;100:1377-83.  Back to cited text no. 15
    
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Pieramici DJ. Vitreoretinal trauma. Ophthalmol Clin North Am 2002;15:225-34, vii.  Back to cited text no. 16
    
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Zagelbaum BM, Tostanoski JR, Kerner DJ, Hersh PS. Urban eye trauma. A one-year prospective study. Ophthalmology 1993;100:851-6.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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