|Year : 2020 | Volume
| Issue : 2 | Page : 84-88
Surgical management of pediatric eye injuries
Tahra AlMahmoud1, Mohamed Elhanan2, Hanan N Alshamsi2, Sameeha M Al Hadhrami2, Rabah Almahmoud3, Fikri M Abu-Zidan4
1 Department of Surgery, College of Medicine and Health Sciences; Department of Ophthalmology, Al-Ain Hospital, United Arab Emirates University, Al-Ain, United Arab Emirates
2 Department of Ophthalmology, Al-Ain Hospital, United Arab Emirates University, Al-Ain, United Arab Emirates
3 Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
4 Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
|Date of Submission||19-Dec-2019|
|Date of Decision||21-Apr-2020|
|Date of Acceptance||26-Apr-2020|
|Date of Web Publication||28-May-2020|
Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University
United Arab Emirates
Source of Support: None, Conflict of Interest: None
| Abstract|| |
BACKGROUND: Eye injury is a leading cause of unilateral childhood blindness. The purpose of this research was to study the management and visual outcome of pediatric eye injuries necessitating hospitalization and surgical repair.
MATERIALS AND METHODS: This is a retrospective study of children having eye injury that needed surgical repair over the period of 2012 and 2017. Demographic data, place of occurrence, activity at the time of injury, place and cause of injury, presenting signs, surgical interventions, visual acuity (VA) before and after surgery, and causes for vision limitations were studied.
RESULTS: Thirty-nine eyes of children were surgically treated. The mean (range) age of the patients was 3 years (1–15 years). Nearly 61.5% were males. Almost 80% of injuries occurred at home and while playing (71.8%). Trauma with sharp objects (35.8%) was the most common cause of injury. Majority presented to the hospital in <6 h (89%), mainly with eye pain (95%). Corneal laceration (53.8%), traumatic cataract (15.3%), and foreign body (15.3%) were the most common clinical findings. Twenty-one (53.8%) eyes sustained open-globe injuries. Fifteen percent had vision of 20/200 or worse at follow-up. The VA improved significantly at follow-up (P < 0.05). The major cause of vision limitation was the cornea (33%).
CONCLUSIONS: Eye injury is a major cause of vision loss in children. Despite early presentation to our hospital and prompt interventions, significant number of our pediatric patients sustained limited VA in ruptured globe injuries.
Keywords: Blindness, pediatric eye injury, prevention, surgical management
|How to cite this article:|
AlMahmoud T, Elhanan M, Alshamsi HN, Al Hadhrami SM, Almahmoud R, Abu-Zidan FM. Surgical management of pediatric eye injuries. Oman J Ophthalmol 2020;13:84-8
|How to cite this URL:|
AlMahmoud T, Elhanan M, Alshamsi HN, Al Hadhrami SM, Almahmoud R, Abu-Zidan FM. Surgical management of pediatric eye injuries. Oman J Ophthalmol [serial online] 2020 [cited 2020 Sep 28];13:84-8. Available from: http://www.ojoonline.org/text.asp?2020/13/2/84/285300
| Introduction|| |
Most of the eye injuries occur in the pediatric age group, leaving almost 1 in 1000 children with monocular blindness.,, Yearly, more than quarter of a million children sustain eye injuries that need hospitalization. There are 3.3–5.7 million annual eye injuries in children under 15 years of age, of which a quarter is penetrating globe injuries.
Activity, aggressive play behavior,, poor supervision, lack of risk estimation, immature physical coordination, and susceptible facial nature place children at a high risk for eye injury.,, The outcome of pediatric eye injury is generally poor especially if the injury occurs at early age and in particular open-globe injuries. This leads to increased years of visual disability, substantial psychosocial effects, and low quality of life.,,, A visual acuity (VA) outcome of 20/40 is preserved in only in 27%–57% of pediatric eye injuries, whereas the remaining has worse outcomes.,,
Al-Ain is the eastern city of Emirate of Abu Dhabi, having a population of 767,000. About 22% are in the 0–14 years' age group. Al-Ain Hospital is the main health-care center for eye treatment of major injuries in Al-Ain City. The pattern and burden of children eye injuries in our setting are not well documented. We aimed to study the management and visual outcome of pediatric eye injuries necessitating hospitalization and surgical repair.
| Patients and Methods|| |
This study was approved by Al-Ain Hospital Research Ethics Committee (AAHEC-09-17-071). All eye injuries to the globe, adnexia, or orbit that required surgical intervention from January 2012 to March 2017 at Al-Ain Hospital were included in the study. A total of 39 consecutive children aged <18 years were admitted for surgical intervention during the study period. Demographic data, activity at the time of injury, place and cause of injury, presenting signs, initial findings, and surgical interventions were retrospectively studied. Initial VA at the time of presentation to the hospital and at last follow-up were recorded. Age-appropriate qualitative or quantitative methods for vision recording are used as circumstances permits for injured eyes. This includes fixation and following target; Lea symbols single and/or crowded cards; Cardiff acuity cards; Lea grating; pictorial projected prototypes; and Snellen E, alphabetic, and/or number chart. We follow amblyopia preferred practice pattern guidelines for patient management.
The VA was converted to LogMAR unit for the purpose of analysis. Causes for vision limitation, time to hospital presentation, and time to procedure performance were obtained.
Zone of injury was defined for open globes and classified according to the Ocular Trauma Classification Group: Zone I were injuries of the cornea and/or corneoscleral limbus, Zone II were wounds of the anterior 5 mm of the sclera, and Zone III were ruptures posterior to Zone II.
Data were entered into an Excel Spreadsheet and coded. Data were presented as number (%) or mean (range) as appropriate. Wilcoxon signed-rank test was used to compare VA at presentation and at follow-up in the same patient. Data were analyzed with the PASW Statistics version 25, SPSS Inc., Chicago, Illinois, USA. P < 0.05 was accepted as statistically significant.
| Results|| |
There were 39 children having a mean (range) age of 3 years (1–15), 61.5% were males. Eighteen patients were 4 years old or less (46.1%) [Figure 1]. Nearly 48.7% were Emirati, while the rest were from other nationalities. Almost 80% of eye injuries occurred at home and while playing (71.8%), 7.7% occurred at school and similar numbers at the place of recreation and sport, and 5% at other places. [Table 1] shows the causes of eye injury. The most common causes were sharp objects (35.8%), of which four were by pencils, blunt objects (23%), and falls (17.9%). Majority were to the left eye (22 [56.4%]), whereas 17 (43.6%) were in the right eye.
|Figure 1: Age histogram of 39 hospitalized children who had an eye injury and required surgical intervention during the period of January 2012–March 2017|
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|Table 1: Cause of eye injury of 39 hospitalized children who required surgery after admission to Al-Ain Hospital during the period of January 2012-March 2017|
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Majority of the patients presented to the hospital in <6 h (89%). Eye pain (95%), bleeding (27.5%), and decreased vision (20%) were the most common presenting symptoms, while corneal laceration (53.8%), traumatic cataract (15.3%), foreign body (FB) (15.3%), and hyphema (12.8%) were the most common physical findings [Table 2]. Eighteen patients had Zone I injury (46.2%), three had Zone II injury, and none in Zone III. The follow-up of three patients with posttrauma amblyopia or secondary surgery was available. The first patient was a 9-year-old girl who sustained a perforating eye injury with a metal barbeque skewer. She underwent corneal transplant and phaco-aspiration and intraocular lens (IOL) implant in another hospital. Her vision at presentation was light perception and after 5 years with astigmatic corrected spectacles was 20/30. The second patient was a 3-year-old girl who presented with corneal laceration and traumatic cataract sustained after trauma with a knife. She received secondary IOL implant. Three years post trauma, her vision was 20/400. The third patient was a 5-year-old boy who sustained corneal perforation with a pencil. His vision at 1-year follow-up was 20/200.
|Table 2: Presenting symptoms and signs of 39 hospitalized children who sustained eye injury and required surgery at Al-Ain Hospital during the period of January 2012-March 2017|
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Imaging was not used in our study unless clinically indicated. One patient had an orbit X-ray with evidence of tripod fracture of the maxilla and floor of the orbit, which was followed by computed tomography (CT) investigation of the orbit, which confirmed the findings. CT was done in nine patients; one showed absence of crystalline lens, one had intraocular FB, and one had intra-orbital FB. One patient had depressed fracture of the frontal process of maxillary bone, fractures of the left side of nasal bone, and ethmoid hemo-sinus. One patient had a magnetic resonance imaging following postoperative removal of an intraocular FB, which showed intra-orbital hematoma.
Surgery was performed at two peaks, the first within 4–6 h and the second at 12–18 h after presentation [Figure 2]. [Table 3] shows the primary and secondary ophthalmic operations for eye injuries. Corneal laceration repair (53.8%) and eyelid laceration repair (46%) were the most common performed procedures. FBs were removed in seven patients (17.9%), of which five were in the anterior chamber. Intravenous Augmentin (amoxicillin–clavulanate) was used routinely followed by oral intake in open-globe injuries with or without intra-ocular FB for a total of 7–10 days.
|Figure 2: Histogram of the time (hours) between hospital presentation and eye surgery from 39 hospitalized patients treated during the period of January 2012–March 2017|
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|Table 3: Type of primary and secondary surgical procedures for 39 hospitalized children who had eye injury that required surgery at Al-Ain Hospital during the period of January 2012-March 2017|
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The average days of hospital admission was 3 days (1–16 days). The patients were followed up for a median (range) of 1 (0–60) months and were seen for a median (range) 2 (0–26) visits. During this period, there were no cases of endophthalmitis or evisceration. The VA significantly improved at follow-up [P < 0.05, Wilcoxon signed-rank test, [Figure 3]. Four out of 27 patients (14.8%) that had vision evaluation at the last follow-up had a vision of 20/200 or worse. At the last follow-up, 14 eyes with ruptured globe had documented vision and three eyes (21.4%) had a vision worse than 20/200; two eyes in Zone I and one eye in Zone II. Nineteen children (70.3%) had vision ≥20/40. The major cause of vision limitation was the cornea (33%) [Table 4].
|Figure 3: Initial and final visual acuity for 39 hospitalized patients who had eye injuries and required surgical intervention during the period of January 2012–March 2017. *P < 0.05, Wilcoxon signed-rank test|
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|Table 4: Causes for vision limitation for 39 children who sustained eye injury and required surgery at Al-Ain Hospital during the period of January 2012-March 2017|
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| Discussion|| |
Our study shows the outcome of eye injuries in children who were surgically treated in a tertiary hospital in our setting. Half of the patients were 4 years old and less. Most of the injuries occurred at home by sharp objects. Half of the cases sustained open-globe injuries. Nearly 15% sustained limited VA. Cornea was a major cause of vision limitation.
Consistent with others,,,, eye injuries necessitating hospitalizations occur most commonly at homes during playing with sharp pointed objects. Homes are filled with objects that may cause child eye injuries. We speculate that the change in the lifestyle including spending more time at homes without supervision increases the risk for eye injury.
Eye injuries are common in young boys.,, Boys tend to take more risks compared with girls. Majority of injuries occurred in children <4 years old in our study. Pollard et al. found that this age accounted for 32% of all pediatric injuries, while Adeoye found that it accounted for 12.8% of eye injuries. This may reflect the child development stage, having curiosity, limited perception of danger, and suboptimal hand–eye coordination.
Blindness occurs in one-third of the injured eyes in children, while significant visual impairment occurs in 17.5%. The visual outcome is even worse with perforating eye injuries., A previous study had shown that only 40.8% of the patients who had surgical intervention achieved 20/200 or better final VA. Another study found that 65% had a final VA worse than 20/200. In our study, 15% had a vision of 20/200 or worse. This might be an underestimation as many charts lacked these data at the last follow-up.
Timely appropriate intervention is important for a better clinical outcome. Delayed presentation of open-globe injury may cause postoperative wound leak and endophthalmitis. Prompt and meticulous wound management of open-globe injury may reduce these complications. The improved accessibility to health care in the UAE including the transport system may explain our good results. The time lapse between injury and hospital presentation and the time to surgery in our study were adequate. In contrast, Ashaye from Nigeria reported that fewer than 24% of their eye-injured patients presented within 24 h of injury. Nearly 48.4% of their patients had a vision of 20/200 or worse. This may be explained by the severity of injury or delay in the presentation to the health-care facility.
There are certain limitations to this study. The data come from a single center, and one have to be caution about generalizability as eye injuries might have different patterns in other regions of the UAE. We acknowledge that the reported VA might be confined by obstacles that are faced during the initial assessment and are further constrained by subsequent surgeries and amblyopia development. Furthermore, there are missing data because of the retrospective nature of the study. In addition, there were limited follow-up records. Patients may have traveled to their home countries or referred to other facilities for further management such as corneal transplant as this service is not provided at our hospital. Hence, the results of vision outcome should be interpreted with caution. Furthermore, there might be selection bias as we studied only patients who are operated and not with other eye injuries that presented to the hospital. Our study population is the tip of an iceberg of eye injuries as 95% of ocular injuries do not require admission. Strategies for the prevention of eye injuries include supervising children during play. Parents and caregivers should be aware of pediatric eye injury risks. The use of protective eyewear in recreational activities and hazardous situations around the home among children should be promoted.
| Conclusions|| |
Eye injury is a major cause of vision loss in children. Despite early presentation to our hospital and prompt interventions, significant number of our pediatric patients sustained limited VA in ruptured globe injuries.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]