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Year : 2021  |  Volume : 3  |  Issue : 1  |  Page : 2

Visual outcome of pediatric ocular trauma in a Latin American population

Department Ophthalmology, Fundación Universitaria de Ciencias de la Salud, Hospital de San José, Bogotá, Colombia

Date of Submission23-Aug-2020
Date of Acceptance27-Oct-2020
Date of Web Publication13-Jan-2021

Correspondence Address:
Dr. Adriana Solano
Ophthalmology Department, Hospital de San Jose., Bogota, Colombia. Fundacio.n Universitaria de Ciencias de la Salud, Bogota
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/PAJO.PAJO_43_20

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Objective: The aim is to assess associated factors regarding the type of pediatric ocular trauma and final visual acuity (VA) of the patients received ophthalmology service at tertiary care facility between 2013 and 2018.
Methods: Retrospective cohort study. The clinical history of patients between 0 and 15 years of age diagnosed with ocular trauma was examined. The exposure variable was the type of ocular trauma (open or closed). Other variables related to ocular trauma were studied.
Results: A total of 183 ocular trauma cases were studied. The median age was 9 years (interquartile range: 5–12), most patients were males (65.5%), blunt and sharp objects were the most frequent causes of ocular trauma (41% and 33.3%, respectively). Closed ocular trauma was found in 82.5% of the cases and zone 1 was the most frequently involved (76,5%). Sixty-four percent of cases required surgical management and 26% presented complications at the final follow-up. About 78.7% of the patients had VA equal or higher than 20/40. The risk factors associated with worse visual outcome (worse than 20/40) was found to be open ocular trauma (relative risk [RR] = 5.5; 95%IC: 3.3–9.2), the affected zone (higher risk in zone 3 with RR = 7.62; 95% confidence interval: 7.61–7.63) and time elapsed between the moment of trauma and receiving ophthalmological treatment (RR = 1.01; 95%IC: 1.01–1.01).
Conclusion: Most patients that presented with ocular trauma had satisfactory final VA, considering that closed ocular trauma was more frequent. Open ocular trauma, the affected zone, and the time elapsed before starting treatment were associated with worse VA outcomes in our study.

Keywords: Ocular trauma, pediatrics, visual outcomes

How to cite this article:
Espinosa N, Montoya L, Gaviria A, Solano A. Visual outcome of pediatric ocular trauma in a Latin American population. Pan Am J Ophthalmol 2021;3:2

How to cite this URL:
Espinosa N, Montoya L, Gaviria A, Solano A. Visual outcome of pediatric ocular trauma in a Latin American population. Pan Am J Ophthalmol [serial online] 2021 [cited 2021 Nov 27];3:2. Available from: https://www.thepajo.org/text.asp?2021/3/1/2/306946

  Introduction Top

Ocular trauma is one of the main causes of morbidity and mortality during childhood; every year 250,000 children present with severe eye trauma.[1] The incidence of severe visual impairment or blindness from this cause in children varies between 2% and 14%, according to different studies worldwide.[2] Trauma is the most common cause of enucleation in children over the age of 3, even though 90% of all eye injuries are preventable, according to the United States Eye Injury Registry.[3]

Ocular trauma is defined as an injury caused by a mechanical agent on the eyeball and ocular adnexa; it involves the tissue to varying degrees and alters visual function temporarily or permanently.[4] This is a common reason for consultation in ophthalmology and hospitalization for ophthalmological causes in developed countries.[5]

Children are more prone to ocular trauma due to their immature motor skills, limited common sense, and natural curiosity without regard to risks and possible outcomes. Consequently, it is of utmost importance to implement preventive measures and strict care by family members and caregivers.[2]

Unlike ocular trauma in adults, medical assessment and management of pediatric patients is limited by the poor collaboration of the children, increased inflammatory response, risk of developing amblyopia and multiple sequelae that may compromise the psychosocial development of patients at such an early age. Sequelae can also alter family dynamics and generate high costs to the health system.[6] There are multiple studies that have characterized the sociodemographic and clinical aspects of eye trauma in the pediatric age, as well as predictive factors of blindness due to this cause in different parts of the world; however, it should be taken into account that these characterizations are directly related to specific local social and economic aspects and that results, most of the time, are not extrapolable. For example, in Colombia, according to retrospective studies, one in the northeast of the country by Serrano et al. and another in the city of Bogotá in adult patients by DíazGranados et al., violence is characterized as a cause of ocular trauma, as well as the difficulties in access to the health system that lead to an increase in the time between ocular trauma and its treatment; these factors are of particular importance and could worsen visual prognosis.[7],[8]

The objective of this study was to determine the factors associated with the type of pediatric ocular trauma and the degree of final visual acuity (VA) in patients who consulted the ophthalmology service at our tertiary care facility in Bogotá, Colombia between 2013 and 2018.

  Methods Top

This retrospective study adhered to the tenets of the Declaration of Helsinki and received approval from the Committee of ethics in investigation with humans Hospital de San José-Fundación Universitaria de Ciencias de la Salud; this research was considered safe for patients.

Analytical, retrospective cohort study in pediatric patients (aged 0–15 years) with a diagnosis of ocular trauma who attended consultation at our tertiary care facility in Bogotá, Colombia, between January 2013 and January 2018. The statistical program Epidat 4.2 was used to estimate sample size, based on the values reported by Puodžiuviene et al. in 2018 (50% of patients with open eye trauma and 15% with closed eye trauma), a 95% confidence level, and a power of 90%. A minimum sample of 92 patients was obtained.

Patients with incomplete medical history, diagnosis of ocular surface foreign bodies and chemical ocular burn trauma were excluded, as well as patients with a history of ocular trauma who consulted for secondary management and follow-up.

Information on demographic data, place where the trauma occurred, time of evolution, object causing the injury, type of ocular trauma, location of the lesion, and initial and final VA were collected. The type of trauma was categorized according to The Birmingham Eye Trauma Terminology System classification – closed ocular trauma: Blunt, corneal laceration, scleral laceration or mixed laceration, and open ocular trauma: Penetrating, perforating trauma, intraocular foreign-body (intraocular lens) and ocular rupture.[9] The location of the lesion was classified according to the Ocular Trauma Classification Group[9] [Table 1]. VA was evaluated considering the age and collaboration of the patient; in preverbal patients, it was evaluated based on whether they rejected light or not and if they responded to the central, steady, and maintain test (C-S-M). In verbal patients, AV was evaluated with the Snellen chart at 20 feet, and based on their VA, they were classified in 3 groups: 20/20–20/40, 20/50–20/100, and worse or equal to 20/200.
Table 1: Location of closed and open ocular trauma in ocular areas

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A descriptive analysis of demographic and clinical data was performed using central trend and dispersion measures for quantitative variables and percentages for qualitative variables. The binary logistic regression technique was used through bivariate and multivariate analysis to identify the factors related to VA, which was categorized as unfavorable VA with values <20/40, and favorable VA with values > or equal to 20/40. The inclusion of variables with a P < 0.20 in the bivariate analysis was considered for multivariate analysis. In the multivariate analysis, P values of 0.05 or less with a 95% confidence interval (CI) were considered statistically significant. Information was analyzed with the Statistical package Stata 13.

  Results Top

A total of 331 clinical histories of patients assessed during the study period were reviewed; 183 patients met the inclusion criteria, which corresponds to 184 eyes. Closed ocular trauma (82.5%) was more frequent than open ocular trauma. About 49.7% of the sample had right eye involvement and only 1 patient (0.6%) had both eyes involved. The sociodemographic characteristics of the patients, as well as the aspects related to the occurrence of ocular trauma, are described in [Table 2] and [Table 3].
Table 2: Socio-demographic characteristics

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Table 3: Aspects related to ocular trauma

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Ocular trauma occurred more frequently in male patients (65.5%), with a male:female ratio of 1.9:1. The most frequent age of presentation of open trauma was between 6 and 10 years, while closed eye trauma was more frequent between 11 and 15 years of age.

Most ocular trauma cases (36%) occurred at home, and blunt and sharp objects were the most frequent elements (41% and 33%, respectively).

The time elapsed since the ocular injury until receiving ophthalmology treatment had a median of 12 h (interquartile range [IQR]: 1–240 h), while the time elapsed between trauma and first surgical procedure in cases of open ocular trauma had a median of 21 h (IQR: 6–137 h).

Regarding closed ocular trauma, blunt trauma was the most common (47.1%); in the case of open eye trauma, penetrating trauma was the most frequent type (90.6%) [Table 4].
Table 4: Clinical characteristics of pediatric ocular trauma cases

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Zone I was most frequently involved in both open and closed ocular trauma (76.5%). With respect to ocular structures, the retina was most involved in cases of closed ocular trauma (10.6%), while the lens was the most affected structure in cases of open ocular trauma (40.6%) [Table 5].
Table 5: Involved ocular zones and structures, surgical management and complications according to the type of trauma

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Surgical management was required in 64% of the cases; suturing of the conjunctiva was the most frequently performed procedure in patients with closed ocular trauma (25%), while corneal suturing was the most frequent surgery for open ocular trauma (81.2%). No case required evisceration as primary surgical approach and only 1 patient was taken to evisceration as a secondary surgical procedure. Vitreoretinal surgery was the most commonly performed surgical procedure (2.2%); all cases requiring this procedure presented with open ocular trauma [Table 5].

In 26% of the cases, some complication and/or sequelae were observed at the end of the follow-up. In closed ocular trauma, ocular hypertension or glaucoma and angle recession were most frequently found (2.6% each), while leukoma was more common in open ocular trauma (56.2%), followed by phthisis bulbi and retinal detachment (12.5% each) [Table 5].

Of the 28 preverbal patients, 89.3% presented complete C-S-M VA and there was no significant variation with respect to the final VA [Figure 1]. In verbal patients (n = 155), 66% presented initial VA between 20/20 and 20/40, and 78.7% of patients reached this VA range at the end of follow-up [Figure 2].
Figure 1: Visual acuity on admission and at end of follow-up in preverbal patients

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Figure 2: Visual acuity on admission and at end of follow-up in verbal patients

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The correlation between the different VA values at the end of the follow-up was evaluated according to the type of trauma and area involved; a significant difference was found regarding the type of trauma (open vs. closed) and VA. As for the different types of open ocular trauma, it was found that the mechanism of trauma does not impact the final visual outcome; regarding the different types of closed ocular trauma, there was a greater number of cases with VA between 20/20 and 20/40 than in the remaining two groups. Moreover, no influence of the closed ocular trauma mechanism (blunt, corneal, scleral, and mixed lamellar wound) on the final visual result was found. Concerning the involved areas, it was evident that more than 70% of the cases in zone 1 had VA between 20/20 and 20/40. A significant difference (P = 0.001) was found between the involved zone and its correlation with the alteration of the final VA [Table 6].
Table 6: Final visual acuity with respect to type of trauma and eye zone involved

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At the end of the follow-up, 78.7% of the eyes had VA better than or equal to 20/40. Risk factors associated with an unfavorable visual outcome (worse than 20/40) were open ocular trauma (relative risk [RR] = 5.5; 95%CI: 3.3–9.2), affected zone (zone 3 with the highest risk; RR = 7.62; 95%CI: 7.61–7.63), and time elapsed between the moment when the trauma occurred and treatment (RR = 1.01; 95%CI: 1.01–1.01). No statistically significant differences were found for the variables age, sex, and place of residence [Table 7] and [Table 8].
Table 7: Predictive risk factors for visual acuity outcome worse than 20/40 by bivariate logistic analysis

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Table 8: Predictive risk factors for visual acuity outcome worse than 20/40 by multivariate logistic analysis

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  Discussion Top

Ocular trauma is one of the main causes of visual morbidity in the pediatric age. Estimates are that 6 million cases of ocular trauma occur worldwide every year and that it is responsible for 280,000 hospital admissions in children under 15.

This study found that >50% of the cases of ocular trauma occurred in patients between 5 and 12 years of age, with a median age of 9, which coincides with the 72.8% of ocular injuries reported by Puodžiuviene in children under 7 years of age in Lithuania. These findings may be related to exposure to sports and recreational activities, as well as to the school environment that may favor physical contact and increase susceptibility to eye trauma.

The predominance of ocular trauma was almost twice as high in males as in females (male:female ratio 1.9:1), which is consistent with other epidemiological studies where ratios male:female 1.8–3.6:1 are reported. This variation has been associated with the activities performed by the children, which involve greater physical contact, aggressiveness, and sometimes violence.[2],[7],[10],[11],[12]

Home was the most common place where eye trauma occurred (36%), which correlates with what MacEwen reported in Scotland (51%) and the UK (41%).[2],[10],[12] This could be explained by the longer time that children stay at home, especially the youngest; however, it should be noted that places such as schools, outdoor spaces, and recreational and/or sports venues (30.5%) are also associated with eye trauma, perhaps due to faults in the supervision of children by adults.

In this study, blunt and sharp objects were the most common causes of ocular trauma, followed by sand and small particles, injuries caused by animals, metallic elements, falls, and traffic accidents, which is similar to that reported by Puodžiuviene et al. and Serrano et al.[2],[7] The objects associated with the occurrence of ocular trauma were pencils, scissors, razors, glasses, stones, among others, which suggests that although they are known to be dangerous elements, they are part of the daily activities of children at the family, educational, and recreational levels. Consequently, supervision and instruction for the use of certain elements should be reinforced.

Closed ocular trauma was more frequent (82.5%) and only 17.5% of patients presented open ocular trauma. This coincides with what was reported in Mexico by Razo-Blanco-Hernández et al., who found that 87% of the cases were associated with closed ocular trauma and 13% with open ocular trauma, and with Serrano et al., who reported 82.9% of cases of closed trauma and 17.1% of open ocular trauma.[7],[13]

Closed ocular trauma was more common in patients between 11 and 15 years of age, while open ocular trauma was more common in patients between 6 and 10 years of age. This differs from the reports by Puodžiuviene et al., where open ocular trauma is more frequent in children under 7, but both agree that closed ocular trauma occurs in patients with older ages (13–18 years old).[2]

Of the cases of closed ocular trauma, the most frequent type of trauma was blunt trauma (47.1%), followed by conjunctival wound (28.5%), data consistent with Kadappu et al. and Singh et al., but different from Serrano et al., who reported lamellar wound as the most frequent type of closed trauma. On the other hand, with respect to cases of open ocular trauma, penetrating trauma and ocular rupture were the most frequent trauma mechanisms (90.6% and 9.3%, respectively), which differs from Singh et al. and Serrano et al., who reported perforating trauma and intraocular foreign body as the second-most common cause.[2],[6],[14]

The majority of eye injuries (76.5%) occurred in zone 1, similar to what has been reported by other studies.[15] In terms of surgical procedures performed, primary wound closure was the most frequent surgery (45.2%), which is consistent Kadappu et al.[6]

Complications and sequelae occurred in a low percentage (26%); the most frequent sequela in cases of open eye trauma was leukoma, while angle recession and ocular hypertension/glaucoma were the most frequent for cases of closed eye trauma.[16],[17] These findings coincide with those reported by Puodžiuviene et al. for cases of open ocular trauma but differ from cases of closed ocular trauma in which retinal injury was the most common complication.[2]

With respect to VA, in our study, 78.7% of cases with ocular trauma achieved VA better than or equal to 20/40, and although it is difficult to compare this result with other studies due to its design and variability, different studies show similar data. Such is the case of the Australian study conducted by Kadappu et al., who reported VA better than 6/12 in 68% of cases, and the study conducted by Puodžiuviene et al. with VA better than 0.5 in 65.4% of cases.[2],[6],[18] These results can be explained by the nature and severity of the injuries since in our study, the majority of cases were secondary to closed ocular trauma and the most involved area was zone 1.

Concerning the risk factors related to worse visual outcomes, our study coincides with what has been reported in the literature regarding the type of trauma and the involved area: Open ocular trauma and involved zone 3 determine a worse visual prognosis.[6],[19] In addition to these factors, this study found that the time elapsed between the moment when the trauma occurred and the initiation of ophthalmologic management is another possible predictor of visual outcome, coinciding with the study performed by Singh in India, in which cases of open and closed ocular trauma were taken into account. In the study conducted by Flores-Boza in Peru in patients with only open ocular trauma, attention time was not a predictor of visual outcome; however, it was a case series, and therefore, it did not have any methodological strength that supported this relation.[15],[20]

Finally, our study coincides with the literature in need to propose and emphasize on preventive measures for eye trauma, especially in younger children since, as shown above, most cases occur at home, with objects of daily use. Supervising children's activities is a key factor to prevent complications and eye sequelae that could affect the quality of life of children in the long-term.

The limitations of our study must be taken into account, given its retrospective nature and difficulty for clinical follow-up.

  Conclusion Top

In open ocular trauma, zones 2 and 3 and consultation time are associated with worse outcomes in VA of pediatric patients. This is explained by the severity of the lesions and the risk of complications and sequelae due to delayed treatment. On the other hand, male and school-age patients are the most frequent victims of eye trauma, and blunt and sharp objects are the most frequent cause of trauma. Most patients who presented with ocular trauma had a satisfactory final VA, considering that closed ocular trauma was the most frequently observed in our study.

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Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]


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