|Year : 2019 | Volume
| Issue : 2 | Page : 78-83
The epidemiology of ocular trauma in Northern India: A teaching hospital study
Rajendra P Maurya1, Tanmay Srivastav1, Virendra Pratap Singh1, CP Mishra2, Abdullah Al-Mujaini3
1 Department of Ophthalmology, IMS BHU, Varanasi, Uttar Pradesh, India
2 Department of Ophthalmology, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Sultante of Oman
3 Department of Community Medicine, IMS BHU, Varanasi, Uttar Pradesh, India
|Date of Web Publication||4-Jun-2019|
Prof. Abdullah Al-Mujaini
Department of Ophthalmology, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat
Source of Support: None, Conflict of Interest: None
| Abstract|| |
AIM: The aim was to determine the epidemiology of ocular trauma in a large teaching hospital in northern India over 4 years from 2010 to 2014.
MATERIALS AND METHODS: This prospective, hospital-based, observational study was conducted at the Ophthalmology and Emergency Outpatient Departments of S. S. Hospital, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India, from March 2012 to February 2016. Detailed history was taken with special consideration to time, place and session of trauma, mode of injury, and type and nature of traumatic agent. All patients were thoroughly examined as per the standard clinical procedures to identify the type, extent, and severity of injury and impact on ocular structure and vision. Follow-up period was 6 months. Statistical analysis was based on age, sex, residence, marital status, occupation, per capita income, type of trauma and nature of damage, etc.
RESULTS: Out of 402 patients, 293 (72.9%) were male and 109 (27.1%) were female. Overall male-to-female sex ratio was 2.7:1. Patients were aged between 2 and 70 years (mean: 26.48 ± 15.88, median: 23 years). The most vulnerable age group was 6–15 years (24.38%) followed by 16–25 years (23.88%). Maximum patients belonged to rural background (61.94%). The extent of ocular trauma was 3.93% (95% confidence interval: 3.23–4.63). Majority of participants were single (78.11%) and rest were married. About 112 (27.9%) participants were illiterate and 24.4% had primary education only. One hundred and eighty-eight (46.8%) participants belonged to lower and lower middle socioeconomic status. The cases were clustered in Rs. 1000–5000 per capita income. Most of the injuries occurred in summer season (46.18%) and in afternoon between 12.00 and 17.59 h (48.8%). Majority of trauma occurred away from home (66.20%) mainly on street (28.6%) and playground (9.2%). The most common injury was nonoccupational (82.3%) including sports related (23.9%) and road traffic accident (23.6%). Mechanical injuries were accounted for 89.3% of all eye injuries, and most common source was wooden object (24.9%) followed by metallic objects (20.9%). Traumatic agents were blunt and sharp in 56% and 17% of cases, respectively. Majority of traumatic agents were solid (82.1%). Seven percent of victims were drowsy during trauma and 98.4% of participants were not using any protective device at the time of injury. In 60.7% of cases, time elapsed between injury and treatment was between 1 and 24 h. Around 44.5% had isolated ocular trauma and rest 55.5% were polytrauma cases. Three hundred and sixty-eight (91.5%) participants had unilateral involvement and 8.5% had bilateral involvement. Almost 52.8% had injuries of adnexa and 32.8% had globe injuries. More than half of the study participants had ≥3 ocular structure involvement. After 6 months, 14.8% of the right eyes and 25.5% of the left eyes showed poor outcome.
CONCLUSION: This study highlights epidemiology of ocular trauma in northern India. Mass health education and awareness about risk of ocular trauma, morbidity caused by delayed presentation, and need to adopt safety or preventive strategies should be focused, especially during travel, playground, and at workplace.
Keywords: Blunt trauma, epidemiology, eye trauma, India
|How to cite this article:|
Maurya RP, Srivastav T, Singh VP, Mishra C P, Al-Mujaini A. The epidemiology of ocular trauma in Northern India: A teaching hospital study. Oman J Ophthalmol 2019;12:78-83
|How to cite this URL:|
Maurya RP, Srivastav T, Singh VP, Mishra C P, Al-Mujaini A. The epidemiology of ocular trauma in Northern India: A teaching hospital study. Oman J Ophthalmol [serial online] 2019 [cited 2020 Oct 29];12:78-83. Available from: https://www.ojoonline.org/text.asp?2019/12/2/78/259686
| Introduction|| |
Ocular trauma, once described as a neglected disorder, has recently been highlighted as one of the major etiologies of monocular and noncongenital visual impairment and blindness in all part of the world. Eye trauma constitutes 7% of all bodily injuries and 10%–15% of all eye diseases. Globally, there are approximately 1.6 million people who are blind from eye injuries, 2.3 million are bilaterally visually impaired, and 1.9 million have unilateral visual loss., It has been estimated that 90% of all ocular injuries are preventable. Thus, prevention should form the basis of management of ocular trauma, and in order to formulate the preventive strategies, we need detailed epidemiological data. The climatic and geographical condition, population, and lifestyle of the societies with their cultural and socioeconomic condition influence the nature and cause of trauma., Most of the clinico-epidemiological studies on ocular trauma has been carried out in developed countries. As the prevailing conditions in our country are different from that in developed countries, western model, therefore, cannot be applied in our country. With this background, this study was conducted at a largest teaching hospital in northern India; S. S. Hospital, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India.
| Materials and Methods|| |
This prospective, hospital-based, observational study was conducted at the Ophthalmology and Emergency Outpatient Departments of S. S. Hospital, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India, from March 2012 to February 2016. The sample size was estimated using standard formula after considering presumed prevalence of ocular trauma and permissible level of error. Patients of all age groups with ocular trauma visiting for the first time and giving consent were selected. Patients with old ocular trauma (>1 month), surgically treated elsewhere or those having preexisting vision-threatening ocular diseases like glaucoma, age-related macular degeneration, etc., injury in blind or atrophic eye and comatose or unconscious patients were excluded from the study.
The study was approved by the Research Ethical Committee of Institute of Medical Sciences, Banaras Hindu University. Prior informed consent was obtained from the study participants. Detailed history was taken from all patients including demographic information such as age, gender, religion, caste, residential area, marital status, occupation, per capita family income, and education level of patients. Specific history of trauma including date, time, place and seasonal predilection, nature of injury (mechanical or nonmechanical), circumstances of injury (occupational or nonoccupational), type of trauma (blunt or sharp), characteristic of traumatic agent (solid, fluid, or gas) and mode of injury (projectile object, fall, impact), persons condition at time of injury, and information about use of protective measures at the time of injury were noted.
All patients were examined by standard ophthalmological procedures to note the type, extent, and severity of injury. Structural and functional loss was noted. All the information was collected in a predesigned and pretested pro forma. The collected data were entered and analyzed using SPSS (version 17.0 Chicago, USA: SPSS Inc). Categorical and numerical variables were analyzed as frequency and percentage. Chi-square test of significance was applied, and P < 0.05 was taken as statistically significant.
| Results|| |
Total 436 eyes of 402 patients were studied. Two hundred and ninety-three (72.9%) were male and 109 (27.1%) were female. Overall sex ratio was 2.7:1. Patients were aged between 2 and 70 years (mean: 26.48 ± 15.88, median: 23 years). Most vulnerable age group was 6–15 years (24.38%) followed by 16–25 years (23.88%). About 5.97% of patients were below 5 years of age and 1.49% of patients were above 65 years of age [Table 1].
Maximum number of patients belonged to rural background (61.94%) followed by semi-urban (23.38%) and urban (14.68%) background. Majority (27.9%) of participants were illiterate and 24.4% had primary education only. Almost 17.4% had middle-class education and 17.7% occupied secondary class education. Around 11.9% of study participants were graduate and only 0.70% of patients were postgraduate [Table 2]. One hundred and eighty-eight (46.8%) belonged to lower and lower middle socioeconomic status. One hundred and thirteen (28.1%) belonged to middle class and 63 (15.7%) belonged to upper-middle-class socioeconomic status. Among all participants, 46.3% were students, whereas 11.7%, 11.2%, 10.9%, and 9.5% of participants were farmers, in service, housewife, and laborers, respectively. Most cases were clustered in Rs. 1000–5000 per capita income (84.58%), followed by 37 (9.20%) in Rs. 5001–10000 per capita income, 23 (5.72%) in below Rs. 1000, and only 2 (0.50%) in greater than Rs. 10000 per capita income group.
|Table 2: Distribution of the study participants according to their educational status|
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A bimodal distribution of injury was observed with first spike between April and June and second between August and October. Extent of ocular injuries in summer season (43.5%) was higher than rainy (31.6%) and winter (24.9%) seasons [Figure 1]. Majority of cases suffered trauma in afternoon between 12.00 and 17.59 h (48.8%) followed by evening between 18.00 and 23.59 h (30.8%), morning between 6.00 and 11.59 h (14.9%), and in night between 00.00 and 5.59 h (5.5%). The most common place of injury was away from home (66.20%) mainly on street (28.6%) and playground (9.2%). About 9.0% suffered trauma in school and 17.4% in workplace. Around 33.8% sustained injury at home [Figure 2].
The most common injury was nonoccupational (82.3%) including sports related (23.9%) and road traffic accident (RTA) (23.6%). About 17.2% suffered assault and 15.2% suffered domestic accident [Table 3]. Mechanical injuries were accounted for 89.3% of all eye injuries, and the most common source was wooden object (24.9%) followed by metallic objects (20.9%). Rest sources were stone (16.7%), ball (6.0%), and glass (3.7%). Majority of traumatic agent were solid (82.1%). Traumatic agents were blunt and sharp in 56% and 17% of cases, respectively. About 7% of victims were drowsy during trauma and 98.4% of participants were not using any protective device at the time of injury. Out of 43 (10.7%) participants with nonmechanical injury, thermal, cracker, and alkali burn were present in 25.58%, 39.53%, and 18.6% of participants, respectively [Figure 3].
|Figure 3: Clinical photograph of a child having cracker blast showing facial/periocular burn|
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In 60.7% of cases, time elapsed between injury and treatment was >1–24 h. In 24.4% of cases, time elapsed was <1 h, and 14.4% received treatment next day after 24 h.
Only 44.5% of patients had single-organ (eye) involvement. The rest 55.5% were poly-trauma patients. Among them, about 36% had two-organ involvement and 18.4% had three-organ involvement. Majority of single-organ involvement were observed in sports-related activity (19.4%) and domestic accidents (9.2%) while maximum two- or three-organ involvement occurred in RTA (16%) and assault-related trauma (7.7%). Only 45% of injury victims had isolated ocular trauma and rest 55% of patients had associated injury. These included maxillofacial and eye injury (18.2%), head and eye injury (15.2%), and eye, head, and maxillofacial (11.9%).
Three hundred sixty-eight (91.5%) had unilateral eye involvement and only 8.5% had bilateral injuries. There was a slight predominance of left eye involvement (46.5%). The most common ocular part involved was adnexa [Figure 4] about in 83% of cases followed by globe injury. Open-globe injury was more common in the left eye (n = 85, 38.46%) [Figure 5] and close-globe injury was more common in the right eye (42.79%). However, nonmechanical globe injury was observed in 12% cases of right eye injury and in 7% cases of left eye injury.
|Figure 4: Clinical photograph of a child having canalicular laceration caused by sharp object|
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|Figure 5: (a-c) Clinical photograph of an elderly patient having cow horn injury. The left eyeball showing scleral rupture wound repaired|
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In all, 79.4% of participants improved after treatment, this was 82.7% when time elapsed between injury and treatment was <1 h, whereas 50% of participants improved when time gap between injury and treatment was >1 week.
| Discussion|| |
Ocular trauma is one of the major causes of avoidable blindness. This is the most recent and large-scale epidemiological study of ocular trauma in northern India. In this hospital-based study, extent of ocular trauma was 3.93% (95% confidence interval: 3.23–4.63). As observed in this study (male:female – 2.7:1), several workers have reported male predominance in case of ocular trauma.,,, Male preponderance is true for all age groups except for infants and elderly people. Higher preponderance of ocular trauma in males can be explained by their increased outdoor activities, taking more part in adventurous games. They also indulge more in violence and rash driving and are more employed in factories and manual jobs. In pediatric age, boys generally are granted more liberty than girls.
Our study showed that about 30.35% of ocular traumas occurred in pediatric age group. The most vulnerable age group was 6–15 years (24.38%) while age ranging from 0 to 5 years (preschool) constituted 5.9% of the total patients. It has been reported that incidence of eye injury decreases with increasing age. MacEwen et al. reported that one out of five patients of ocular trauma admitted to hospital were children <15 years of age. Majority of the authors have found the highest incidence of ocular trauma in the young and very young age group., Young children are more susceptible to ocular trauma because of their physical vulnerability, lack of coordination, and curiosity/desire to explore, which may lead to serious hazards. People belonging to rural background with lower education level and low-socioeconomic status are more affected by ocular trauma due to delay in seeking medical care.
In this study, cases are particularly concentrated in summer (43.5%) than rainy (31.6%) and winter (24.9%) season, depicting its seasonal trend in occurrence. Mackiewicz et al., Keklikci et al., and Gyasi et al. reported peak ocular injuries in summer months.,, In summer, due to school holiday, students involved in outdoor game and season of marriage and in winter days are shorter, students are busy in examination and cold, foggy climate limit outdoor activities. In the current study, approximately 5 out of 10 cases are found to be affected between 12.00 and 17.00 h, which are the peak hours for outdoor activity and productive hours for every individual. In this study, the most common place of injury was home (33.8%) followed by street or road (28.6%), workplace (17.4%), playground (9.2%), and school (9.0%). The Egyptian study showed that the most frequent place of injury was roads (54.7%) and only 6.7% of injuries occurred in school. In our study, the most common type of injury was nonoccupational in 333 (82.3%) cases; however, 69 (17.2%) had occupational injury. Most common nonoccupational injury was recreational or sports-related injury (23.9%) followed by RTA (23.6%), assault related (17.2%), and domestic accidents (15.2%). Blomdahl and Norell reported a similar incidence of sports-related injuries. Mackay reported 70% of eye injuries due to RTA.
In this study, blunt injuries predominate (56%) and only 17% of injuries were caused by sharp objects. This was consistent with those of MacEwen et al. In majority (82.1%) of our cases, traumatic agent was solid in nature and the most common mode of injury was projectile object (35.8%). About 45% of injury victims had isolated ocular trauma and rest 55% had polytrauma. Majority (98.4%) of participants were not using any protective device at the time of injury. Almost 91.5% of victims had unilateral eye involvement and only 8.5% had bilateral injuries. There was a slight predominance of left eye involvement (46.5%). MacEwen et al. had 98% with unilateral involvement in their 93 patients, and only 2% had bilateral involvement. Similar low bilaterality was reported by Babar et al. (2.9%), Jahangir et al. (3%), and Bućan et al. (1%).,, In this study, the most common ocular part involved was adnexa in 83% of cases followed by globe injury. Kaur and Agrawal study revealed that 78.94% of injuries were open globe injury, whereas Al-Mahrouqi et al. reported that 94% of all ocular injuries were closed glob., Nearly 50% of patients were treated medically, 40% underwent ocular surgery while rest 10% required multidisciplinary surgery.
One limitation of our study is that it is a hospital-based study; therefore, trends cannot be stipulated directly to general population. Another limitation of this study is its relatively small size for internal subgroup comparison, and the study had attrition of participants during follow-up.
| Conclusion|| |
This study highlights epidemiology of ocular trauma in northern India. Based on this study, services recommended are, public should be educated about importance of eyes. They should be motivated for utilization of services in the event of trauma irrespective of gender. Mass health education and awareness about risk of ocular trauma, morbidity caused by delayed presentation, and need to adopt safety equipment such as goggles, visors, or preventive strategies should be focused, especially during travel, playground, and at workplace.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]