About OJO | Search | Ahead of print | Current Issue | Archives | Author Instructions | Reviewer Guidelines | Online submissionLogin 
Oman Journal of Ophthalmology Oman Journal of Ophthalmology
  Editorial Board | Subscribe | Advertise | Contact
https://www.omanophthalmicsociety.org/ Users Online: 56  Wide layoutNarrow layoutFull screen layout Home Print this page  Email this page Small font size Default font size Increase font size


 
 Table of Contents    
ORIGINAL ARTICLE
Year : 2020  |  Volume : 13  |  Issue : 2  |  Page : 84-88  

Surgical management of pediatric eye injuries


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 Submission19-Dec-2019
Date of Decision21-Apr-2020
Date of Acceptance26-Apr-2020
Date of Web Publication28-May-2020

Correspondence Address:
Tahra AlMahmoud
Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University
United Arab Emirates
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ojo.OJO_285_2019

Rights and Permissions
   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 Oct 21];13:84-8. Available from: https://www.ojoonline.org/text.asp?2020/13/2/84/285300




   Introduction Top


Most of the eye injuries occur in the pediatric age group,[1] leaving almost 1 in 1000 children with monocular blindness.[2],[3],[4] Yearly, more than quarter of a million children sustain eye injuries that need hospitalization.[5] There are 3.3–5.7 million annual eye injuries in children under 15 years of age,[5] of which a quarter is penetrating globe injuries.[6]

Activity, aggressive play behavior,[7],[8] poor supervision,[9] lack of risk estimation, immature physical coordination, and susceptible facial nature place children at a high risk for eye injury.[1],[10],[11] 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.[4],[12],[13],[14] 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.[15],[16],[17]

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.[18] 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 Top


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.[19]

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:[20] 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 Top


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

Click here to view
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

Click here to view


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

Click here to view


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

Click here to view
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

Click here to view


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

Click here to view
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

Click here to view



   Discussion Top


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,[3],[21],[22],[23] 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.[3],[4],[24] Boys tend to take more risks compared with girls.[24] Majority of injuries occurred in children <4 years old in our study. Pollard et al.[21] found that this age accounted for 32% of all pediatric injuries, while Adeoye found that it accounted for 12.8% of eye injuries.[25] This may reflect the child development stage, having curiosity, limited perception of danger,[26] and suboptimal hand–eye coordination.

Blindness occurs in one-third of the injured eyes in children, while significant visual impairment occurs in 17.5%.[25] The visual outcome is even worse with perforating eye injuries.[22],[25] A previous study had shown that only 40.8% of the patients who had surgical intervention achieved 20/200 or better final VA.[24] Another study found that 65% had a final VA worse than 20/200.[27] 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.[22] 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.[28] 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.[22] 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.[22]

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.[24] 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.[29] Strategies for the prevention of eye injuries include supervising children during play.[25] 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.[30]


   Conclusions Top


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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Harrison A, Telander DG. Eye injuries in the young athlete: A case-based approach. Pediatr Ann 2002;31:33-40.  Back to cited text no. 1
    
2.
Gilbert C, Foster A. Blindness in children: Control priorities and research opportunities. Br J Ophthalmol 2001;85:1025-7.  Back to cited text no. 2
    
3.
Kadappu S, Silveira S, Martin F. Aetiology and outcome of open and closed globe eye injuries in children. Clin Exp Ophthalmol 2013;41:427-34.  Back to cited text no. 3
    
4.
Eballe AO, Epée E, Koki G, Bella L, Mvogo CE. Unilateral childhood blindness: A hospital-based study in Yaoundé, Cameroon. Clin Ophthalmol 2009;3:461-4.  Back to cited text no. 4
    
5.
Abbott J, Shah P. The epidemiology and etiology of pediatric ocular trauma. Surv Ophthalmol 2013;58:476-85.  Back to cited text no. 5
    
6.
Strahlman E, Elman M, Daub E, Baker S. Causes of pediatric eye injuries. A population-based study. Arch Ophthalmol 1990;108:603-6.  Back to cited text no. 6
    
7.
Grin TR, Nelson LB, Jeffers JB. Eye injuries in childhood. Pediatrics 1987;80:13-7.  Back to cited text no. 7
    
8.
Nelson LB, Wilson TW, Jeffers JB. Eye injuries in childhood: demography, etiology, and prevention. Pediatrics 1989;84:438-41.  Back to cited text no. 8
    
9.
American Academy of Pediatrics, Committee on Sports Medicine and Fitness, American Academy of Ophthalmology, Eye Health and Public Information Task Force. Protective eyewear for young athletes. Ophthalmology 2004;111:600-3.  Back to cited text no. 9
    
10.
Tomazzoli L, Renzi G, Mansoldo C. Eye injuries in childhood: A retrospective investigation of 88 cases from 1988 to 2000. Eur J Ophthalmol 2003;13:710-3.  Back to cited text no. 10
    
11.
MacEwen CJ, Baines PS, Desai P. Eye injuries in children: The current picture. Br J Ophthalmol 1999;83:933-6.  Back to cited text no. 11
    
12.
Kim T, Nunes AP, Mello MJ, Greenberg PB. Incidence of sports-related eye injuries in the United States: 2001–2009. Graefes Arch Clin Exp Ophthalmol 2011;249:1743-4.  Back to cited text no. 12
    
13.
Ong HS, Barsam A, Morris OC, Siriwardena D, Verma S. A survey of ocular sports trauma and the role of eye protection. Cont Lens Anterior Eye 2012;35:285-7.  Back to cited text no. 13
    
14.
MacEwen CJ. Sport associated eye injury: A casualty department survey. Br J Ophthalmol 1987;71:701-5.  Back to cited text no. 14
    
15.
Bunting H, Stephens D, Mireskandari K. Prediction of visual outcomes after open globe injury in children: A 17-year Canadian experience. J AAPOS 2013;17:43-8.  Back to cited text no. 15
    
16.
Tok O, Tok L, Ozkaya D, Eraslan E, Ornek F, Bardak Y. Epidemiological characteristics and visual outcome after open globe injuries in children. J AAPOS 2011;15:556-61.  Back to cited text no. 16
    
17.
Lee CH, Lee L, Kao LY, Lin KK, Yang ML. Prognostic indicators of open globe injuries in children. Am J Emerg Med 2009;27:530-5.  Back to cited text no. 17
    
18.
Statistics Center-Abu Dhabi (SCAD). Statistical Year Book-Population 2016. SCAD. Available from: https://www.scad.ae. [Last accessed on 2018 Dec 24].  Back to cited text no. 18
    
19.
Wallace DK, Repka MX, Lee KA, Melia M, Christiansen SP, Morse CL, et al. Amblyopia preferred practice pattern®. Ophthalmology 2018;125:P105-42.  Back to cited text no. 19
    
20.
Pieramici DJ, SternbergPJr., Aaberg TM, Bridges WZ Jr., Capone A Jr., Cardillo JA, et al. A system for classifying mechanical injuries of the eye (globe). The Ocular Trauma Classification Group. Am J Ophthalmol 1997;123:820-31.  Back to cited text no. 20
    
21.
Pollard KA, Xiang H, Smith GA. Pediatric eye injuries treated in US emergency departments, 1990-2009. Clin Pediatr (Phila) 2012;51:374-81.  Back to cited text no. 21
    
22.
Ashaye AO. Eye injuries in children and adolescents: A report of 205 cases. J Natl Med Assoc 2009;101:51-6.  Back to cited text no. 22
    
23.
Sii F, Barry RJ, Abbott J, Blanch RJ, MacEwen CJ, Shah P. The UK Paediatric Ocular Trauma Study 2 (POTS2): Demographics and mechanisms of injuries. Clin Ophthalmol 2018;12:105-11.  Back to cited text no. 23
    
24.
Choovuthayakorn J, Patikulsila P, Patikulsila D, Watanachai N, Pimolrat W. Characteristics and outcomes of pediatric open globe injury. Int Ophthalmol 2014;34:839-44.  Back to cited text no. 24
    
25.
Adeoye AO. Eye injuries in the young in Ile-Ife, Nigeria. Niger J Med 2002;11:26-9.  Back to cited text no. 25
    
26.
Kliegman RM, Behrman RE, Jenson HB, Stanton BM. Nelson Textbook of Pediatrics. Saunders: Elsevier Health Sciences; 2007.  Back to cited text no. 26
    
27.
Kutlutürk Karagöz I, Söǧütlü Sarı E, Kubaloǧlu A, Elbay A, Çallı Ü, Pinero DP, et al. Characteristics of pediatric and adult cases with open globe injury and factors affecting visual outcomes: A retrospective analysis of 294 cases from Turkey. Ulus Travma Acil Cerrahi Derg 2018;24:31-8.  Back to cited text no. 27
    
28.
Murithi I, Gichuhi S, Njuguna MW. Ocular injuries in children. East Afr Med J 2008;85:39-45.  Back to cited text no. 28
    
29.
May DR, Kuhn FP, Morris RE, Witherspoon CD, Danis RP, Matthews GP, et al. The epidemiology of serious eye injuries from the United States Eye Injury Registry. Graefes Arch Clin Exp Ophthalmol 2000;238:153-7.  Back to cited text no. 29
    
30.
Healthy People 2020. Available from: https://www.healthypeople.gov/. [Last accessed on 2019 Feb 08].  Back to cited text no. 30
    


    Figures

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

  [Table 1], [Table 2], [Table 3], [Table 4]



 

Top
   
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
   Patients and Methods
   Results
   Discussion
   Conclusions
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed439    
    Printed25    
    Emailed0    
    PDF Downloaded2    
    Comments [Add]    

Recommend this journal