|Year : 2019 | Volume
| Issue : 4 | Page : 166-171
Causes and clinical manifestations of ocular trauma
Elsayed M Elsayed, Sameh M Saleh, Dalia Sabry, Adel M Hassan
Ophthalmology Center, Mansoura University, Mansoura, Egypt
|Date of Submission||03-Dec-2018|
|Date of Acceptance||09-Aug-2019|
|Date of Web Publication||17-Dec-2019|
MD Sameh M Saleh
Ophthalmology Center, Faculty of Medicine, Mansoura University, Mansoura 35516
Source of Support: None, Conflict of Interest: None
Purpose The aim of this work was to provide data about the causes and nature of ocular trauma and to find the relationship of these causes with age and sex.
Patients and methods Patients with all types of eye injuries such as mechanical (by blunt object, sharp object, or foreign body), chemical or physical injuries were enrolled in the current study from April 2015 to August 2015 in both Mansoura Ophthalmic Center and Alsinbelaween Ophthalmic Section. Thereafter, patients were classified according to the demographic information, causes, and nature of trauma.
Results This study included 200 patients with ocular injuries. Patients living in urban areas constituted the majority of the cases (123=61.5%), while patients living in rural areas accounted for 77/200 (38.5%) patients. Closed-globe injuries constituted most of the cases (33.75%), while 49.25% were for contusions and lamellar lacerations. Open-globe injuries constituted most of the cases of admitted patients (17% of all patients), and rupture globe accounted for 12% of cases of all patients.
Conclusion Blunt trauma is a major type of ocular trauma that can produce marked sudden distortion of the globe, resulting in more severe damage than may be clinically apparent. Severe trauma leads to lesions in the globe ranging from relatively superficial to vision-threatening lesions.
Keywords: ocular injuries, ocular trauma, trauma
|How to cite this article:|
Elsayed EM, Saleh SM, Sabry D, Hassan AM. Causes and clinical manifestations of ocular trauma. Delta J Ophthalmol 2019;20:166-71
| Introduction|| |
The occurrence of ocular injuries in patients who have major trauma is low, but there is a combination of ocular injuries and fracture of facial bones. Adults have the highest occurrence of ocular injuries. Road traffic accidents are the main reason for ocular injuries. All patients who have major trauma should be checked especially for an ocular injury .
In rural areas, eye care services are of a lower standard than urban areas. In urban areas, eye care is usually at a relatively high standard, and, in these areas, the cost for medical care is covered by the government .
The Birmingham Eye Trauma Terminology refers to the whole globe, not to a defined tissue. If a tissue is determined, it may show the site. In [Figure 1], injury ‘b’ shows a penetrating trauma; if it is characterized as a ‘penetrating corneal injury,’ it means that the wound is corneal .
|Figure 1 (a) Is a closed globe injury but a penetrating injury of the cornea (i.e. not of the globe): the object violated the cornea but did not cause a through and through wound. Injury b is an open-globe trauma; it is a perforating (through-and-through) injury of the cornea but a penetrating (into, not through) injury of the globe .|
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The aim of this work was to provide data about the causes and nature of ocular trauma and to find the relationship of these causes with age and sex.
| Patients and methods|| |
Patients with all types of eye injuries such as mechanical (by blunt object, sharp object, or foreign body), chemical or physical injuries were enrolled in the study from April 2015 to August 2015 in both Mansoura Ophthalmic Center and Alsinbelaween Ophthalmic Section.
All patients were examined in accordance with the Declaration of the World Medical Association. The study was approved by Mansoura University Hospital Trust Ethics Committee. Each patient signed a written informed consent statement before being enrolled in the study.
Patients with completely normal slit-lamp examination and comatosed patients were excluded from the study.
Complete personal history of age, sex, residence, occupation, cause of the injury and period lapsing between the time of injury and time of presentation to hospital were taken from the patients.
The patients’ occupations were categorized into groups as workers, pupils, drivers, and housewives. Other occupations were put under the term ‘others’ 42/200 (21%).
The initial visual acuity was recorded in all patients using Landolt’s broken rings’ chart. Examination of the globe and its adnexa and slit-lamp examination were carried out.
Patients’ visual acuity was classified into groups as 6/12 or better, 6/18–6/60, 5/60–1/60, hand movement-perception of light, no perception of light and cannot assess group, which included patients whose visual acuity could not be measured.
Ocular movement was examined in all directions.
The pupil was then inspected for size, shape, and reaction to light, with special attention to comparing results between the two eyes.
The conjunctiva was inspected for any lesions. A foreign body sensation in the eyelid or any suspicion of an intraocular foreign body or a puncture was recorded.
The cornea was examined for any wound or foreign body. Corneal foreign bodies were removed using a 26 G needle.
A dilated fundus examination was carried out (whenever possible) using noncontact Volk 90 D lens and indirect ophthalmoscopy, and any findings were recorded. Further investigations such as B-scan ultrasound, optical coherence tomography and computed tomographic scan were performed as required.
The exact date and time of trauma and the time lapsing between the trauma and time of presentation were recorded and put into different groups as less than 24, 24–48 h, 48 h–1 week and more than 1 week (according to the main researcher decision).
The cause of trauma and the object causing the injury were mentioned and were put into different groups as sharp instruments, blunt objects, projectile traumas, chemical injuries, and laser burn. Foreign bodies were put into a different category and classified into corneal foreign bodies, intraocular foreign bodies, and orbital foreign bodies.
Comparison of the type of injury with different age groups, sex, and occupations was carried out. Comparison of the type of injury between rural and urban areas was also noted. Full description of ocular manifestations and classification of ocular trauma were based on the Birmingham Eye Trauma Terminology .
Statistical analysis was performed by using excel program and SPSS version 10 (SPSS program, Chicago, Illinois, USA). Data description was carried out in the mean±SD for quantitative data, and frequency and proportion for qualitative data. Data analysis was carried out to assess statistically significant differences between groups. For quantitative data, Student t test was used to compare between two groups. χ2 test was used to compare qualitative data. P value was considered significant if less than or equal to 0.05 at confidence interval of 95%.
| Results|| |
This study included 200 patients with ocular injuries. Patients living in urban areas constituted the majority of the cases (123=61.5%), while patients living in rural areas accounted for 77/200 (38.5%) patients. The mean age of the patients was 25 years. The patients’ age was classified into different groups. The majority of the patients were 25–34 years’ old (53/200=26.5%). Most of the patients were younger than 45 years’ old (160/200=80%), with 40/200 (20%) of the patients being above 45 years of age. Comparison of the occurrence of ocular trauma in different age groups with respect to urban and rural distribution showed that the incidence was nearly the same in age groups 25–34 and 35–44 years (14 and 7.5%, respectively) for urban areas and 12.5 and 7.5%, respectively for rural areas ([Figure 2]).
|Figure 2 Distribution of ocular trauma in rural and urban areas with respect to age.|
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Male individuals were more injured than female individuals. The number of male patients was 175 (87.5%), whereas the number of female patients was 25 (12.5%) ([Figure 3]).
|Figure 3 Distribution of ocular trauma in urban and rural areas with respect to sex and age.|
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Among the causes of injury, blunt objects were present in most of the cases (60/200=30%) followed by sharp instruments (22/200=11%), and projectile trauma, which accounted for injuries in 13/200 (6.5%) patients, was the next most common injury, followed by chemical injuries, which accounted for 6/200 (3%) patients, and, lastly, laser burns, which accounted for one (0.5%) patient.
On comparing the distribution of ocular trauma with respect to the causative factor, blunt objects still accounted for the largest number in both urban and rural areas being 38/123 (30.9%) and 22/77 (28.6%), respectively.
Superficial corneal foreign bodies were the commonest causes of attending the Ophthalmic Emergency Room and were managed in the outpatient clinic. It accounted for 89/200 patients (44.5%). Intraocular foreign bodies accounted for 8/200 (4%) patients. Posterior segment foreign bodies represented most of the intraocular foreign bodies, while orbital foreign body accounted for one (0.5%) patient. On comparing the distribution of ocular trauma in urban and rural areas, with respect to foreign bodies as a causative factor, the incidence of corneal foreign bodies in urban areas was twice the incidence in rural areas (29.5 and 15%, respectively, [Figure 4]).
|Figure 4 Distribution of ocular trauma in urban and rural areas with respect to the cause.|
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Workers and pupils comprised the majority of patients who had ocular trauma. They constituted 97/200 (48.5%) and 29/200 (14.5%), respectively, of all patients. However, the injuries of the pupils did not happen at school but mainly in neighboring areas. Drivers were seriously affected by ocular trauma at their work (2/200=1%). Housewives were the next most affected, constituting 20/200 (10%) of the ocular injury cases.
Most of the patients presented to the emergency room in less than 24 h of trauma (152/200=76%); patients who presented to the emergency room within 24 to 48 h accounted for 28/200 patients (14%), while patients who presented within 48 h to 1 week constituted 15/200 (7.5%), and patients who presented after 1 week of trauma accounted for 5/200 (2.5%) and were associated with poorer visual outcome.
On comparing the distribution of ocular trauma in urban and rural areas with respect to the duration of presentation, the delay of presentation of more than 24 h was found to be more in urban than in rural areas, but it was statistically insignificant.
Visual acuity assessment was carried out at the time of presentation. Patients having visual acuity of 6/18–6/60 were 73/200 (36.5%). Visual acuity hand movement-perception of light was present in 26/200 (13%) patients.
There were only three (1.5%) eyes with orbital bone fractures, all occurring only in unilateral cases. Eleven (5.5%) eyes had lid wounds, eight of them were involving the margin (4%) and the canaliculi in two (1%) cases. Anterior segment findings included traumatic cataract and traumatic hyphema in 37.5 and 33% of patients, respectively. Posterior segment findings included vitreous hemorrhage, retinal detachment and commotio retinae in 4, 3, and 1.5% of the patients, respectively.
Injury classification according to Birmingham classification
Closed-globe injuries constituted most of the cases (33.75 and 49.25%) for contusions and lamellar lacerations, respectively. Open-globe injuries constituted most of the cases of admitted patients (17% of all patients), while rupture globe accounted for 12% of injuries in all patients ([Table 1]).
|Table 1 Injury classification according to the Birmingham classification|
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| Discussion|| |
Trauma affects the eye in various ways, according to its type and degree, and may lead to complete loss of vision . Because of the special properties of ocular tissues, an injury that would not be significant in any part of the body may be a severe one in the eye .
The data of epidemiology changes from one area to another . The occurrence of eye injuries is more in developing countries. Hospital-based studies revealed that 5–16% of all ophthalmic admissions to eye hospitals/units are related to ocular injuries .
Cruciani et al.  reported that the eyes are in the third place, after hands and feet, among the most frequently involved anatomical region exposed to blunt trauma. The affection of these regions may lead to loss of career opportunities, major lifestyle changes, and even permanent physical disfigurement.
In the present study, it was noticeable that all ages were exposed to ocular trauma, and the average age was 25 years, which is less than what was reported by other studies . This is because Egyptians usually start work at an earlier age. Therefore, workers were the majority of patients . In agreement with the current study, Akbar et al.  found that the commonest age group was between 20 and 40 years.
Comparison of the occurrence of ocular trauma in different age groups with respect to urban and rural distribution showed that the incidence was nearly the same in age groups 25–34 and 35–44 years (14 and 7.5%, respectively) for urban areas and 12.5 and 7.5%, respectively for rural areas.
In the present study, men were significantly more injured than women. The number of male patients was 175 (87.5%), whereas the number of female patients was 25 (12.5%). Abdellateef  explained that male individuals are more commonly exposed to different types of accidents that may lead to ocular trauma.
Workers were the main group affected by ocular injuries followed by pupils because of wide exposure to sharp instruments.
Our hospital received patients from different areas of the country. Patients living in urban areas constituted the majority of cases (123=61.5%), while patients living in rural areas comprised 77 (38.5%) patients.
Blunt-object trauma was the main cause of eye injuries in most of the previous studies . This kind of trauma is due to sticks and thrown stones. Less frequent were fist fights and injuries during sports. However, in the current study, there was an increase of injuries by sharp instruments, as compared with other studies. Sharp trauma was mainly due to injuries by knives and less frequently by scissors, glass and pens. Beshay et al.  found that the causes of open-globe injuries varied in association with age, with older people being injured mostly due to falls, while young adults were injured through assault and working with metal.
In the present study, superficial corneal foreign bodies were the commonest causes of attending the Ophthalmic Emergency Room and were treated at once. They accounted for injuries in 89/200 (44.5%) patients. The incidence of corneal foreign bodies in urban areas was twice its incidence in rural areas (29.5 and 15%, respectively). Foreign bodies were put into a different category due to their high prevalence and were classified into corneal foreign bodies, intraocular foreign bodies, and orbital foreign bodies. Intraocular foreign bodies accounted for 8/200 (4%) patients, while posterior segment foreign bodies represented most of the intraocular foreign bodies, followed by orbital foreign body, which was present in one patient (0.5%).
Sayal et al. , found that closed-globe injuries were more common, accounting for 60.5% of the cases.
In this study, most traumas occurred in the street. Streets involve car accidents, sidewalk injuries and also recreational places. However, in other studies , most traumas occurred at the work place.
In the present study, it was found that 24% of the patients attended late (>24 h), and this is a low rate of delay when compared with the Bronx–Lebanon Hospital Center study, which showed that 37% of the patients were delayed for more than 24 h . It was a surprise to find that more than 70% of the patients attending late (>24 h) came from urban regions. Moreover, all patients who presented more than 1 week later also were from urban regions. This indicates that the cause of delay is not the distance but the negligence. Those patients claimed that they did not expect the severity of injury. Some of them asked medical advice in a small medical center, but they did not get the appropriate care. Mayeka et al.  found that only 2.5% of the patients presented within the first 24 h of injury, 55.2% presented within 1 week, and 16.8% presented after more than 1 week. It has been reported that patients in the lower socioeconomic levels had a delayed presentation for longer than in those in higher socioeconomic levels, regardless of whether the injury was mild or severe.
There were many problems in estimating the vision of the patients on arrival. We could not asses the visual acuity in 15/200 (7.5%) patients. In most cases, the magnitude of the trauma placed the patients in a state of apprehension and fear of losing their sight, and therefore getting the patient’s attention and cooperation was a challenge.
Anterior segment injuries alone happened in 72% of the cases, while injuries of the posterior segment were often associated with anterior segment injuries. However, the worst and commonest posterior segment injury was vitreous hemorrhage. On classifying the trauma according to the Birmingham classification, we found that closed-globe injuries represented the majority of cases, with 33.75 and 49.25%, for contusions and lamellar lacerations, respectively. Open-globe injuries constituted most of the injuries in admitted patients (17% of all patients), while rupture globe accounted for 12% of all patients.
As per the universal literature, primary management of open-globe injuries involves suture of the wound with excision, reposition of prolapsed contents or lensectomy .
Adel M. Hassan designed and conceived the study. Elsayed M. Elsayed, Sameh M. Saleh, and Dalia Sabry examined the patients included in the study and collected the data from the records. Sameh M. Saleh and Dalia Sabry wrote the manuscript, analyzed the data, and shared in the statistical analysis and in the final revision of the manuscript. Sameh M. Saleh reviewed the manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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