Int Ophthalmol DOI 10.1007/s10792-013-9890-8
ORIGINAL PAPER
Characteristics and outcomes of pediatric open globe injury Janejit Choovuthayakorn • Prapatsorn Patikulsila Direk Patikulsila • Nawat Watanachai • Weeraya Pimolrat
•
Received: 8 July 2013 / Accepted: 8 December 2013 Ó Springer Science+Business Media Dordrecht 2013
Abstract To describe the epidemiology, mechanism of injury, and final visual and anatomical outcomes of pediatric patients with open globe injury. The medical records of patients aged B16 years diagnosed with open globe injury between January 2006 and December 2010 were retrospectively reviewed. Forty-nine pediatric patients were diagnosed with open globe injury during the study period. Forty-one of the 49 patients (83.7 %) were male. The mean age of the patients was 9.3 ± 4.6 years, with 49 % of the injuries occurring in patients between the ages of 11 and 16 years. Ocular penetration was the most common type of injury (63.3 %), occurring most frequently in the cornea (63.3 %). Wooden objects were the most common cause of injury. Following surgical intervention, 40.8 % of the patients obtained a final visual acuity (VA) of C6/60. Pars plana vitrectomy was performed in 51 % of cases, with only 36 % of these patients having a final VA of C6/60. The presence of retinal detachment was the only statistically significant factor (odds ratio 0.05, p \ 0.001) that affected VA improvement of more than one line. Corneal penetration was frequently observed in pediatric patients with ocular trauma. Pediatric patients
J. Choovuthayakorn (&) P. Patikulsila D. Patikulsila N. Watanachai W. Pimolrat Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, 110 Intawaroros Road, Chiang Mai 50200, Thailand e-mail: [email protected]
with a retinal detachment were significantly more likely to have a poor final visual outcome than open globe patients whose retina remained attached. Despite prompt surgical intervention, useful vision was preserved in less than half of the patients requiring pars plana vitrectomy. Keywords Epidemiology Ocular injury Pediatric Retinal detachment
Introduction Open globe injury frequently results in permanent visual morbidity. Final visual outcomes in pediatric and adult patients are similar [1]; however, significant differences in the causative factors between the two groups have been reported [2–4]. Prognostic factors for open globe injury in children have been studied and proposed [5–7]; however, these prognostic factors are confounded by difficulties in obtaining initial visual acuity (VA) in pediatric open globe patients and are further limited by the concomitant amblyopia that frequently occurs in young patients following ocular trauma. Past reports have documented a final VA of C6/12 in only 27–57 % of pediatric patients, with the remaining patients having worse visual outcomes [8– 10]. In addition, a recent study reported that pediatric open globe injury accounted for a higher percentage of
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hospital expenses than any other pediatric ocular injury, highlighting the important economic burden caused by this condition [11]. Understanding the epidemiology and mechanisms of open globe injury in pediatric patients is paramount to the development of ocular safety education and injury prevention programs. The focus on injury prevention is at least as important as the advancement of treatment modalities in this population. The purpose of this study was to evaluate the epidemiology and outcomes of pediatric open globe injury at Chiang Mai University Hospital, Thailand, with the aim of providing data to be used for the development of specific guidelines for prevention of ocular injury in pediatric patients.
Materials and methods The medical records of open globe injury patients aged B16 years who presented to either the outpatient clinic or emergency department at Chiang Mai University Hospital from January 2006 to December 2010 were reviewed in this retrospective cohort study. The study protocol was approved by the Research Ethics Committee of the Faculty of Medicine, Chiang Mai University, and it adhered to the tenets of the Declaration of Helsinki. Open globe injury was defined as a full-thickness laceration of either the cornea or sclera [12]. Demographic patient data were collected. Patients were divided into the following three groups based on age—group A (1–5 years), group B (6–10 years), and group C (11–16 years). Injury types were classified according to the Birmingham eye trauma terminology (BETT) system as rupture, penetration, perforation, and intraocular foreign body (IOFB) [13]. Injury locations were classified into zone I (laceration limited to the cornea), zone II (laceration extending posteriorly into the sclera, within 5 mm of the limbus), and zone III (laceration extending posteriorly into the sclera beyond 5 mm of the limbus) [14]. Ocular findings at presentation and at the time of initial and subsequent surgical intervention were recorded. In cases that presented with active wound leakage, primary surgical closure was performed as the initial management. In cases with self-sealing wounds and cases where primary closure had been performed at outside facilities, additional surgical
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procedures, including lensectomy, pars plana vitrectomy (PPV), evisceration, or enucleation were considered based on each patient’s presentation. PPVs were performed as a second surgery in cases presenting with endophthalmitis, retinal detachment, retained IOFB, non-clearing vitreous hemorrhage, and lens injury involving the posterior segment. Visual and anatomical outcomes were recorded from the last follow-up visit. Snellen VA was converted to a logarithm of the minimal angle of resolution (logMAR) units. Statistical analysis Categorical data were evaluated using the v2 test, while continuous data were analyzed using the Kruskal–Wallis test. Logistic regression was calculated. Statistical analysis was performed with the SPSS program, version 16.0 (SPSS Inc., Chicago, USA). p \ 0.05 was considered significant.
Results Four hundred and fifteen cases of open globe injury presented at Chiang Mai University Hospital from January 2006 to December 2010, with 11.8 % (49/ 415) occurring in patients aged B16 years. The mean age of the patients was 9.3 ± 4.6 years (range 2–16, median 10.0). All 49 pediatric patients had unilateral ocular injury, most commonly in the left eye (57.1 %; 28/49). Approximately 84 % of the patients were male (41/49). Forty-nine percent of the injuries occurred in age group C (24/49 patients), followed by age group A with 32.7 % (16/49 patients), and age group B with 18.4 % (9/49 patients). The mean follow-up was 7.7 ± 10.6 months (range 1.0–57.0, median 4.2). Penetration injuries occurred in 63.3 % of the patients (31/49), followed by rupture in 18.4 % (9/49), IOFB in 12.2 % (6/49), and perforation in 6.1 % (3/ 49). Zone I injuries occurred in 63.3 % of the patients (31/49), with zone II and zone III each occurring in 18.4 % (9/49). The majority of injuries occurred accidentally during play. Table 1 shows patient characteristics and demographic data. Table 2 shows data on injury type by age group. Penetration injuries were the most common type of injury in all three age groups. Table 3 shows data on objects causing ocular
Int Ophthalmol Table 1 Pediatric open globe injury patient demographics by age group Characteristics
Age groups (no. %)
Male gender
p value
B5 years (n = 16)
6–10 years (n = 9)
11–16 years (n = 24)
13 (81.2)
7 (77.8)
21 (87.5)
0.678
Zone of injury
0.636
Zone I
12 (75.0)
4 (44.5)
Zone II
2 (12.5)
3 (33.3)
15 (62.5) 4 (16.7)
Zone III
2 (12.5)
2 (22.2)
5 (20.8)
Initial logMAR VA, mean (median; range)
2.2 (2.8; 0.5–3.0)
2.8 (2.9; 2.3–3.0)
2.5 (2.3; 1.8–3.0)
0.443
Associated lens surgery
10 (62.5)
4 (44.5)
15 (62.5)
0.639
RD
3 (18.8)
3 (33.3)
8 (33.3)
0.639
Endophthalmitis
5 (31.2)
4 (44.5)
6 (25.0)
0.549
Final logMAR VA, mean (median; range)
1.8 (1.8; 0.2–3.0)
1.8 (1.8; 0.3–3.0)
1.9 (1.9; 0.2–3.0)
0.369
VA visual acuity, IOFB intraocular foreign body, RD retinal detachment
Table 2 Injury type by age group Type of injury
Age groups (no. %) B5 years (n = 16)
Penetration Rupture
Table 3 Objects causing pediatric open globe injury by age group
6–10 years (n = 9)
11–16 years (n = 24)
12 (75.0)
6 (66.7)
13 (54.2)
1 (6.2)
3 (33.3)
5 (20.8)
Objects
Age groups (no. %) B5 years (n = 16)
6–10 years (n = 9)
11–16 years (n = 24)
Wood
5 (31.3)
4 (44.4)
8 (33.3)
Perforation
2 (12.6)
0 (0.0)
1 (4.2)
Firework
1 (6.3)
2 (22.2)
6 (25.0)
IOFB
1 (6.2)
0 (0.0)
5 (20.8)
Pencil
2 (12.5)
0
0
Bird
2 (12.5)
0
0
Nail/hook
1 (6.3)
0
3 (12.5)
Scissors/needle/wire Stone
2 (12.5) 1 (6.3)
0 1 (11.1)
1 (4.2) 0
IOFB intraocular foreign body
trauma by age group. Wooden objects were the most frequent cause of ocular trauma in all three age groups. Table 4 shows data on initial and final VA for the entire cohort. Eight of the 16 patients in group A tolerated initial VA assessment, with one patient demonstrating no light perception (NLP). Five of the nine patients in group B tolerated initial VA assessment, with two patients demonstrating NLP. All 24 patients in group C tolerated initial VA assessment, with three patients demonstrating NLP. Final visual outcome could not be assessed in three of the 49 patients (all in group A). Approximately 41 % (20/49) of the patients in this cohort achieved an overall final VA of C6/60. Of the 37 patients whose initial and final VA was assessed, 67.6 % (25/37) improved by one line or more, 16.2 % (6/37) had vision within one line of their initial measurement, and another 16.2 % (6/ 37) had a VA decrease of more than one line.
Umbrella
1 (6.3)
0
0
Blunt hit
1 (6.3)
1 (11.1)
0
Elastic band
0
1 (11.1)
0
Glass
0
0
3 (12.5)
Gun bullet
0
0
1 (4.2)
Bottle explosion
0
0
2 (8.3)
Total
16 (100.0)
9 (100.0)
24 (100.0)
Retinal detachment occurred in 14 of the 49 patients (28.6 %). Of these, eight presented with zone I injuries, five with zone II injuries, and one with zone III injury. Final retinal attachment was achieved in four of these patients, with two of them having a final VA of C6/60. In the remaining ten patients, two had a
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Int Ophthalmol Table 4 Initial and final VA of pediatric open globe injury patients Initial Snellen VA (no.)
Final Snellen VA (no.) C6/60
\6/60 LP
NLP
Unknown
C6/60
6
0
0
0
\6/60 LP
10
9
6
0
NLP
0
1
5
0
Unknown
5
4
0
3
VA visual acuity, LP light perception, NLP = no light perception
detached retina at the last examination, and eight of these ten patients ultimately required enucleation. Endophthalmitis occurred in 15 of the 49 patients (30.6 %)—following penetration injury in nine patients, rupture in three patients, perforating injury in two patients, and IOFB in one patient. The type of injury did not predict endophthalmitis (Fisher’s exact test, p = 0.497). Endophthalmitis occurred most commonly in patients injured by a wooden object (40 %; 6/15), followed by scissors or needle (20 %; 3/15 patients). Gram stain identified Gram-positive cocci in five cases, while vitreous culture demonstrated Staphylococcus epidermidis in one patient and Bacillus cereus in another patient. Among the patients with endophthalmitis, five had a final VA of C6/60, four were \6/60, and the remaining six were NLP. Sixteen of 49 patients (32.7 %) required one operation, 20 (40.8 %) required two operations, and 13 (26.5 %) required three or more operations. PPV was performed in 51 % of patients (25/49), with nine of the 25 (36 %) achieving a final VA of C6/60, seven (28 %) achieving\6/60, seven (28 %) demonstrating NLP, and two (8 %) who could not tolerate final VA measurement. Lens surgery was performed in 59.2 % of patients (29/49), with 12 of these 29 patients (41.4 %) achieving a final VA of C6/60, 10 (34.5 %) achieving \6/60, five (17.2 %) demonstrating NLP, and two (6.9 %) who could not tolerate final VA assessment. Enucleation was performed in ten of the 49 patients (20.4 %). Sympathetic ophthalmia was not observed in this cohort. Logistic regression analysis was performed on the 37 patients who tolerated initial and final VA to assess for prognostic factors relating to improvement of final VA by more than one line (Table 5). Retinal
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detachment was found to have a statistically significant predictive value.
Discussion This study found an increase in open globe injury in patients aged C11 years, with the majority of the patients in all age groups suffering from penetration injuries. The presence of a retinal detachment predicted a worse visual outcome with statistical significance, while other factors did not achieve statistical significance in this cohort. Male gender and penetrating corneal injuries were frequently observed in this cohort, which is similar to the results of other published reports [9, 10, 15–17]. The increased incidence of ocular trauma in male patients may reflect the predilection of male patients to engage in higher risk activities, as this finding has been observed across different cultures. On the contrary, the age ranges of children with ocular trauma, the activities resulting in trauma, and the specific objects causing injury have been reported variably in the literature. This study reported the highest incidence of injury in children aged 11–16 years (group C), while other studies have reported a greater incidence of injury in preschool children [4, 18] or an even distribution of risk between age groups [9]. The lower rate of injury in pre-school children in this cohort may be due to the fact that grandparents commonly provide very close supervision for their pre-school aged grandchildren in the Thai culture. Wooden objects were the most common causative object of ocular trauma in this study, which was in line with a report by El-Sebaity et al. [4]. Previous reports have found glass, knives, scissors, or metallic objects to be more frequent causative objects [6, 9, 10, 18, 19]. This information is helpful for educating both parents and caregivers regarding the importance of paying more attention to older children who typically require less direct supervision. In addition, children should be discouraged from playing in environments with branches or sticks to decrease the rates of penetrating open globe injury. Firework-related ocular injury frequently occurs in children and young people, with the majority of cases resulting in open globe injury [20]. This study demonstrated an increasing incidence of fireworkrelated injury correlating with increasing age, highlighting the importance of appropriate safety
Int Ophthalmol Table 5 Logistic regression analysis of factors influencing improvement of final VA by more than one line Variables
Improvement of final VA (no. %)
Non-improvement of final VA (no. %)
Odds ratio
95 % CI
p value
Gender (male:female)
23:2
9:3
3.83
0.55–26.89
0.304
1–5 years
6 (24.0)
2 (16.7)
1
6–10 years
3 (12.0)
2 (16.7)
0.50
0.05–5.51
0.875
11–16 years
16 (64.0)
8 (66.7)
0.68
Rupture
6 (24.0)
1 (8.3)
1
Penetration
15 (60.0)
7 (58.3)
0.36
0.04–3.56
0.635
Perforation
2 (8.0)
1 (8.3)
0.33
0.01–8.18
0.894
IOFB
2 (8.0)
3 (25.0)
0.11
Age group
0.01–4.08
0.923
Type of injury
0.01–1.78
0.222
Zone of injury I
16 (64.0)
6 (50.0)
1
II
7 (30.4)
1 (14.3)
2.63
0.26–26.07
III
2 (11.1)
5 (45.5)
0.15
0.02–0.99
0.071
3 (12.0) 6 (24.0)
9 (75.0) 4 (33.3)
0.05 1.17
0.01–0.27 0.67–2.06
\0.001 0.696
Retinal detachment Endophthalmitis
0.638
CI confidence interval, VA visual acuity, IOFB intraocular foreign body
education for both parents and their children especially during holidays and festivals. This study did not find a significant correlation between the type of injury and the final VA. This finding may be explained by the small number of ruptures, perforations, and IOFBs that were observed in this cohort. It is possible that a larger study may demonstrate a statistically significant correlation. Initial VA measurement was not obtained in 24.5 % of the patients in this study due to poor compliance or the inability of children to cooperate during initial examination. The majority of the patients who could not tolerate initial VA measurement were in group A. Retinal detachment was significantly correlated with poor final visual outcomes, which has been demonstrated in a previous study [10]. This finding reinforces the need to counsel patients and their parents about the poor visual prognosis in this group of patients. However, posttraumatic retinal detachment was repaired in a two-stage procedure in this report. Prompt diagnosis and referral of traumatic retinal detachments to centers with expertise in pediatric retina may lead to improved visual outcomes in these patients. Further study of primary traumatic retinal detachment repair in children is warranted. This report did not find a significant association between lens surgery and final visual outcome.
Furthermore, previous reports have found endophthalmitis to be a predictive factor for poor visual outcome [10]; however, endophthalmitis did not attain statistical significance as a predictive factor of final VA in this report. This finding may be due to our small sample size, although it is also possible that recent advancements in microsurgical technique and improvements in medical endophthalmitis management of open globe injury in pediatric patients may have contributed to this result. Only one-third of the patients who underwent vitrectomy in this study attained a final VA of C6/60, while Sheard et al. [21] reported a VA of C6/60 in approximately two-thirds of their patients following vitrectomy. However, a direct comparison between these two studies is complicated by the small sample size in both studies and differences in injury severity between the two reports. A more definitive analysis of the benefits of vitrectomy in this patient population awaits a larger study. This study is not without limitations, including those inherent to retrospective chart reviews. It is possible that a larger sample size would have enabled a more complete analysis of factors influencing final VA; however, our sample size was sufficient to identify the role that retinal detachment plays in VA
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outcomes. Finally, it is possible that the cases presenting to Chiang Mai University Hospital, a major referral center, represented more severe ocular pathology, as less severe injuries may have been managed at regional ophthalmic centers. This referral bias may have resulted in our reporting worse visual outcomes than would be expected in a population-based cohort. Pediatric open globe injury occurred most commonly in male patients, with penetration injury representing the most frequent type of injury. Wooden objects were the most common cause of open globe injury in this cohort. The presence of a retinal detachment was a significant predictor of poor final VA, with the majority of these patients ultimately requiring enucleation. These findings emphasize the important role of preventive education to reduce the occurrence of severe ocular trauma in children, especially as they age. Pediatric patients and their parents should be counseled regarding specific activities and objects that may predispose them to open globe trauma. Specifically, parents and older pediatric patients should be warned about the dangers of playing in wooded environments, playing with sticks, and using fireworks, as these frequently result in pediatric open globe injuries. Additionally, patients with retinal detachment have a poor final visual prognosis, and parents and patients should be counseled appropriately. Further investigation of the ideal surgical management of open globe injury in pediatric patients is warranted. Acknowledgments All authors would like to thank Nimitr Ittipunkul, Head of the Retinal Unit, for his general support and Rochana Phuackchantuck, statistician of the Research Administration Unit, Faculty of Medicine, Chiang Mai University Hospital, for her statistical assistance. Conflict of Interest
None.
References 1. Gupta A, Srinivasan R, Babu KR, Setia S (2010) Comparison of the clinical presentation and visual outcome in open globe injuries in adults and children over 30 months. Eur J Ophthalmol 20:590–595 2. Kanoff JM, Turalba AV, Andreoli MT, Andreoli CM (2010) Characteristics and outcomes of work-related open globe injuries. Am J Ophthalmol 150:265–269 3. Tok L, Yalcın Tok O, Ozkaya D et al (2011) Characteristics of open globe injuries in geriatric patients. Ulus Travma Acil Cerrahi Derg 17:413–418
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4. El-Sebaity DM, Soliman W, Soliman AM, Fathalla AM (2011) Pediatric eye injuries in upper Egypt. Clin Ophthalmol. 5:1417–1423 5. Uysal Y, Mutlu FM, Sobaci G (2008) Ocular trauma score in childhood open-globe injuries. J Trauma 65:1284–1286 6. Acar U, Tok OY, Acar DE, Burcu A, Ornek F (2011) A new ocular trauma score in pediatric penetrating eye injuries. Eye 25:370–374 7. Kadappu S, Silveira S, Martin F (2013) Aetiology and outcome of open and closed globe eye injuries in children. Clin Exp Ophthalmol. 41:427–434 8. Bunting H, Stephens D, Mireskandari K (2013) Prediction of visual outcomes after open globe injury in children: a 17-year Canadian experience. J AAPOS 17:43–48 9. Tok O, Tok L, Ozkaya D, Eraslan E, Ornek F, Bardak Y (2011) Epidemiological characteristics and visual outcome after open globe injuries in children. J AAPOS 15:556–561 10. Lee CH, Lee L, Kao LY, Lin KK, Yang ML (2009) Prognostic indicators of open globe injuries in children. Am J Emerg Med 27:530–535 11. Cao H, Li L, Zhang M, Li H (2013) Epidemiology of pediatric ocular trauma in the Chaoshan region, China, 2001–2010. PLoS One 8:e60844 12. Kuhn F, Morris R, Witherspoon CD, Heimann K, Jeffers JB, Treister G (1996) A standardized classification of ocular trauma. Ophthalmology 103:240–243 13. Kuhn F, Morris R, Witherspoon CD, Mester V (2004) The Birmingham eye trauma terminology system (BETT). J Fr Ophthalmol 27:206–210 14. Pieramici DJ, Sternberg P, Aaberg TM et al (1997) A system for classifying mechanical injuries of the eye (globe): the ocular trauma classification group. Am J Ophthalmol 123:820–831 15. Lesniak SP, Bauza A, Son JH et al (2012) Twelve-year review of pediatric traumatic open globe injuries in an urban U.S. population. J Pediatr Ophthalmol Strabismus 49:73–79 16. Hosseini H, Masoumpour M, Keshavarz-Fazl F, Razeghinejad MR, Salouti R, Nowroozzadeh MH (2011) Clinical and epidemiologic characteristics of severe childhood ocular injuries in southern Iran. Middle East Afr J Ophthalmol. 18:136–140 17. Ahmadabadi MN, Alipour F, Tabataei SA, Karkhane R, Rezaei H, Ahmadabadi EN (2011) Sharp-object-induced open-globe injuries in Iranian children admitted to a major tertiary center: a prospective review of 125 cases. Ophthalmic Res 45:149–154 18. Rostomian K, Thach AB, Isfahani A, Pakkar A, Pakkar R, Borchert M (1998) Open globe injuries in children. J AAPOS 2:234–238 19. Hill JR, Crawford BD, Lee H, Tawansy KA (2006) Evaluation of open globe injuries of children in the last 12 years. Retina 26:S65–S68 20. Jing Y, Yi-qiao X, Yan-ning Y, Ming A, An-huai Y, Lianhong Z (2010) Clinical analysis of firework-related ocular injuries during spring festival 2009. Graefes Arch Clin Exp Ophthalmol 248:333–338 21. Sheard RM, Mireskandari K, Ezra E, Sullivan PM (2007) Vitreoretinal surgery after childhood ocular trauma. Eye 21:793–798
ORIGINAL PAPER
Characteristics and outcomes of pediatric open globe injury Janejit Choovuthayakorn • Prapatsorn Patikulsila Direk Patikulsila • Nawat Watanachai • Weeraya Pimolrat
•
Received: 8 July 2013 / Accepted: 8 December 2013 Ó Springer Science+Business Media Dordrecht 2013
Abstract To describe the epidemiology, mechanism of injury, and final visual and anatomical outcomes of pediatric patients with open globe injury. The medical records of patients aged B16 years diagnosed with open globe injury between January 2006 and December 2010 were retrospectively reviewed. Forty-nine pediatric patients were diagnosed with open globe injury during the study period. Forty-one of the 49 patients (83.7 %) were male. The mean age of the patients was 9.3 ± 4.6 years, with 49 % of the injuries occurring in patients between the ages of 11 and 16 years. Ocular penetration was the most common type of injury (63.3 %), occurring most frequently in the cornea (63.3 %). Wooden objects were the most common cause of injury. Following surgical intervention, 40.8 % of the patients obtained a final visual acuity (VA) of C6/60. Pars plana vitrectomy was performed in 51 % of cases, with only 36 % of these patients having a final VA of C6/60. The presence of retinal detachment was the only statistically significant factor (odds ratio 0.05, p \ 0.001) that affected VA improvement of more than one line. Corneal penetration was frequently observed in pediatric patients with ocular trauma. Pediatric patients
J. Choovuthayakorn (&) P. Patikulsila D. Patikulsila N. Watanachai W. Pimolrat Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, 110 Intawaroros Road, Chiang Mai 50200, Thailand e-mail: [email protected]
with a retinal detachment were significantly more likely to have a poor final visual outcome than open globe patients whose retina remained attached. Despite prompt surgical intervention, useful vision was preserved in less than half of the patients requiring pars plana vitrectomy. Keywords Epidemiology Ocular injury Pediatric Retinal detachment
Introduction Open globe injury frequently results in permanent visual morbidity. Final visual outcomes in pediatric and adult patients are similar [1]; however, significant differences in the causative factors between the two groups have been reported [2–4]. Prognostic factors for open globe injury in children have been studied and proposed [5–7]; however, these prognostic factors are confounded by difficulties in obtaining initial visual acuity (VA) in pediatric open globe patients and are further limited by the concomitant amblyopia that frequently occurs in young patients following ocular trauma. Past reports have documented a final VA of C6/12 in only 27–57 % of pediatric patients, with the remaining patients having worse visual outcomes [8– 10]. In addition, a recent study reported that pediatric open globe injury accounted for a higher percentage of
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hospital expenses than any other pediatric ocular injury, highlighting the important economic burden caused by this condition [11]. Understanding the epidemiology and mechanisms of open globe injury in pediatric patients is paramount to the development of ocular safety education and injury prevention programs. The focus on injury prevention is at least as important as the advancement of treatment modalities in this population. The purpose of this study was to evaluate the epidemiology and outcomes of pediatric open globe injury at Chiang Mai University Hospital, Thailand, with the aim of providing data to be used for the development of specific guidelines for prevention of ocular injury in pediatric patients.
Materials and methods The medical records of open globe injury patients aged B16 years who presented to either the outpatient clinic or emergency department at Chiang Mai University Hospital from January 2006 to December 2010 were reviewed in this retrospective cohort study. The study protocol was approved by the Research Ethics Committee of the Faculty of Medicine, Chiang Mai University, and it adhered to the tenets of the Declaration of Helsinki. Open globe injury was defined as a full-thickness laceration of either the cornea or sclera [12]. Demographic patient data were collected. Patients were divided into the following three groups based on age—group A (1–5 years), group B (6–10 years), and group C (11–16 years). Injury types were classified according to the Birmingham eye trauma terminology (BETT) system as rupture, penetration, perforation, and intraocular foreign body (IOFB) [13]. Injury locations were classified into zone I (laceration limited to the cornea), zone II (laceration extending posteriorly into the sclera, within 5 mm of the limbus), and zone III (laceration extending posteriorly into the sclera beyond 5 mm of the limbus) [14]. Ocular findings at presentation and at the time of initial and subsequent surgical intervention were recorded. In cases that presented with active wound leakage, primary surgical closure was performed as the initial management. In cases with self-sealing wounds and cases where primary closure had been performed at outside facilities, additional surgical
123
procedures, including lensectomy, pars plana vitrectomy (PPV), evisceration, or enucleation were considered based on each patient’s presentation. PPVs were performed as a second surgery in cases presenting with endophthalmitis, retinal detachment, retained IOFB, non-clearing vitreous hemorrhage, and lens injury involving the posterior segment. Visual and anatomical outcomes were recorded from the last follow-up visit. Snellen VA was converted to a logarithm of the minimal angle of resolution (logMAR) units. Statistical analysis Categorical data were evaluated using the v2 test, while continuous data were analyzed using the Kruskal–Wallis test. Logistic regression was calculated. Statistical analysis was performed with the SPSS program, version 16.0 (SPSS Inc., Chicago, USA). p \ 0.05 was considered significant.
Results Four hundred and fifteen cases of open globe injury presented at Chiang Mai University Hospital from January 2006 to December 2010, with 11.8 % (49/ 415) occurring in patients aged B16 years. The mean age of the patients was 9.3 ± 4.6 years (range 2–16, median 10.0). All 49 pediatric patients had unilateral ocular injury, most commonly in the left eye (57.1 %; 28/49). Approximately 84 % of the patients were male (41/49). Forty-nine percent of the injuries occurred in age group C (24/49 patients), followed by age group A with 32.7 % (16/49 patients), and age group B with 18.4 % (9/49 patients). The mean follow-up was 7.7 ± 10.6 months (range 1.0–57.0, median 4.2). Penetration injuries occurred in 63.3 % of the patients (31/49), followed by rupture in 18.4 % (9/49), IOFB in 12.2 % (6/49), and perforation in 6.1 % (3/ 49). Zone I injuries occurred in 63.3 % of the patients (31/49), with zone II and zone III each occurring in 18.4 % (9/49). The majority of injuries occurred accidentally during play. Table 1 shows patient characteristics and demographic data. Table 2 shows data on injury type by age group. Penetration injuries were the most common type of injury in all three age groups. Table 3 shows data on objects causing ocular
Int Ophthalmol Table 1 Pediatric open globe injury patient demographics by age group Characteristics
Age groups (no. %)
Male gender
p value
B5 years (n = 16)
6–10 years (n = 9)
11–16 years (n = 24)
13 (81.2)
7 (77.8)
21 (87.5)
0.678
Zone of injury
0.636
Zone I
12 (75.0)
4 (44.5)
Zone II
2 (12.5)
3 (33.3)
15 (62.5) 4 (16.7)
Zone III
2 (12.5)
2 (22.2)
5 (20.8)
Initial logMAR VA, mean (median; range)
2.2 (2.8; 0.5–3.0)
2.8 (2.9; 2.3–3.0)
2.5 (2.3; 1.8–3.0)
0.443
Associated lens surgery
10 (62.5)
4 (44.5)
15 (62.5)
0.639
RD
3 (18.8)
3 (33.3)
8 (33.3)
0.639
Endophthalmitis
5 (31.2)
4 (44.5)
6 (25.0)
0.549
Final logMAR VA, mean (median; range)
1.8 (1.8; 0.2–3.0)
1.8 (1.8; 0.3–3.0)
1.9 (1.9; 0.2–3.0)
0.369
VA visual acuity, IOFB intraocular foreign body, RD retinal detachment
Table 2 Injury type by age group Type of injury
Age groups (no. %) B5 years (n = 16)
Penetration Rupture
Table 3 Objects causing pediatric open globe injury by age group
6–10 years (n = 9)
11–16 years (n = 24)
12 (75.0)
6 (66.7)
13 (54.2)
1 (6.2)
3 (33.3)
5 (20.8)
Objects
Age groups (no. %) B5 years (n = 16)
6–10 years (n = 9)
11–16 years (n = 24)
Wood
5 (31.3)
4 (44.4)
8 (33.3)
Perforation
2 (12.6)
0 (0.0)
1 (4.2)
Firework
1 (6.3)
2 (22.2)
6 (25.0)
IOFB
1 (6.2)
0 (0.0)
5 (20.8)
Pencil
2 (12.5)
0
0
Bird
2 (12.5)
0
0
Nail/hook
1 (6.3)
0
3 (12.5)
Scissors/needle/wire Stone
2 (12.5) 1 (6.3)
0 1 (11.1)
1 (4.2) 0
IOFB intraocular foreign body
trauma by age group. Wooden objects were the most frequent cause of ocular trauma in all three age groups. Table 4 shows data on initial and final VA for the entire cohort. Eight of the 16 patients in group A tolerated initial VA assessment, with one patient demonstrating no light perception (NLP). Five of the nine patients in group B tolerated initial VA assessment, with two patients demonstrating NLP. All 24 patients in group C tolerated initial VA assessment, with three patients demonstrating NLP. Final visual outcome could not be assessed in three of the 49 patients (all in group A). Approximately 41 % (20/49) of the patients in this cohort achieved an overall final VA of C6/60. Of the 37 patients whose initial and final VA was assessed, 67.6 % (25/37) improved by one line or more, 16.2 % (6/37) had vision within one line of their initial measurement, and another 16.2 % (6/ 37) had a VA decrease of more than one line.
Umbrella
1 (6.3)
0
0
Blunt hit
1 (6.3)
1 (11.1)
0
Elastic band
0
1 (11.1)
0
Glass
0
0
3 (12.5)
Gun bullet
0
0
1 (4.2)
Bottle explosion
0
0
2 (8.3)
Total
16 (100.0)
9 (100.0)
24 (100.0)
Retinal detachment occurred in 14 of the 49 patients (28.6 %). Of these, eight presented with zone I injuries, five with zone II injuries, and one with zone III injury. Final retinal attachment was achieved in four of these patients, with two of them having a final VA of C6/60. In the remaining ten patients, two had a
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Int Ophthalmol Table 4 Initial and final VA of pediatric open globe injury patients Initial Snellen VA (no.)
Final Snellen VA (no.) C6/60
\6/60 LP
NLP
Unknown
C6/60
6
0
0
0
\6/60 LP
10
9
6
0
NLP
0
1
5
0
Unknown
5
4
0
3
VA visual acuity, LP light perception, NLP = no light perception
detached retina at the last examination, and eight of these ten patients ultimately required enucleation. Endophthalmitis occurred in 15 of the 49 patients (30.6 %)—following penetration injury in nine patients, rupture in three patients, perforating injury in two patients, and IOFB in one patient. The type of injury did not predict endophthalmitis (Fisher’s exact test, p = 0.497). Endophthalmitis occurred most commonly in patients injured by a wooden object (40 %; 6/15), followed by scissors or needle (20 %; 3/15 patients). Gram stain identified Gram-positive cocci in five cases, while vitreous culture demonstrated Staphylococcus epidermidis in one patient and Bacillus cereus in another patient. Among the patients with endophthalmitis, five had a final VA of C6/60, four were \6/60, and the remaining six were NLP. Sixteen of 49 patients (32.7 %) required one operation, 20 (40.8 %) required two operations, and 13 (26.5 %) required three or more operations. PPV was performed in 51 % of patients (25/49), with nine of the 25 (36 %) achieving a final VA of C6/60, seven (28 %) achieving\6/60, seven (28 %) demonstrating NLP, and two (8 %) who could not tolerate final VA measurement. Lens surgery was performed in 59.2 % of patients (29/49), with 12 of these 29 patients (41.4 %) achieving a final VA of C6/60, 10 (34.5 %) achieving \6/60, five (17.2 %) demonstrating NLP, and two (6.9 %) who could not tolerate final VA assessment. Enucleation was performed in ten of the 49 patients (20.4 %). Sympathetic ophthalmia was not observed in this cohort. Logistic regression analysis was performed on the 37 patients who tolerated initial and final VA to assess for prognostic factors relating to improvement of final VA by more than one line (Table 5). Retinal
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detachment was found to have a statistically significant predictive value.
Discussion This study found an increase in open globe injury in patients aged C11 years, with the majority of the patients in all age groups suffering from penetration injuries. The presence of a retinal detachment predicted a worse visual outcome with statistical significance, while other factors did not achieve statistical significance in this cohort. Male gender and penetrating corneal injuries were frequently observed in this cohort, which is similar to the results of other published reports [9, 10, 15–17]. The increased incidence of ocular trauma in male patients may reflect the predilection of male patients to engage in higher risk activities, as this finding has been observed across different cultures. On the contrary, the age ranges of children with ocular trauma, the activities resulting in trauma, and the specific objects causing injury have been reported variably in the literature. This study reported the highest incidence of injury in children aged 11–16 years (group C), while other studies have reported a greater incidence of injury in preschool children [4, 18] or an even distribution of risk between age groups [9]. The lower rate of injury in pre-school children in this cohort may be due to the fact that grandparents commonly provide very close supervision for their pre-school aged grandchildren in the Thai culture. Wooden objects were the most common causative object of ocular trauma in this study, which was in line with a report by El-Sebaity et al. [4]. Previous reports have found glass, knives, scissors, or metallic objects to be more frequent causative objects [6, 9, 10, 18, 19]. This information is helpful for educating both parents and caregivers regarding the importance of paying more attention to older children who typically require less direct supervision. In addition, children should be discouraged from playing in environments with branches or sticks to decrease the rates of penetrating open globe injury. Firework-related ocular injury frequently occurs in children and young people, with the majority of cases resulting in open globe injury [20]. This study demonstrated an increasing incidence of fireworkrelated injury correlating with increasing age, highlighting the importance of appropriate safety
Int Ophthalmol Table 5 Logistic regression analysis of factors influencing improvement of final VA by more than one line Variables
Improvement of final VA (no. %)
Non-improvement of final VA (no. %)
Odds ratio
95 % CI
p value
Gender (male:female)
23:2
9:3
3.83
0.55–26.89
0.304
1–5 years
6 (24.0)
2 (16.7)
1
6–10 years
3 (12.0)
2 (16.7)
0.50
0.05–5.51
0.875
11–16 years
16 (64.0)
8 (66.7)
0.68
Rupture
6 (24.0)
1 (8.3)
1
Penetration
15 (60.0)
7 (58.3)
0.36
0.04–3.56
0.635
Perforation
2 (8.0)
1 (8.3)
0.33
0.01–8.18
0.894
IOFB
2 (8.0)
3 (25.0)
0.11
Age group
0.01–4.08
0.923
Type of injury
0.01–1.78
0.222
Zone of injury I
16 (64.0)
6 (50.0)
1
II
7 (30.4)
1 (14.3)
2.63
0.26–26.07
III
2 (11.1)
5 (45.5)
0.15
0.02–0.99
0.071
3 (12.0) 6 (24.0)
9 (75.0) 4 (33.3)
0.05 1.17
0.01–0.27 0.67–2.06
\0.001 0.696
Retinal detachment Endophthalmitis
0.638
CI confidence interval, VA visual acuity, IOFB intraocular foreign body
education for both parents and their children especially during holidays and festivals. This study did not find a significant correlation between the type of injury and the final VA. This finding may be explained by the small number of ruptures, perforations, and IOFBs that were observed in this cohort. It is possible that a larger study may demonstrate a statistically significant correlation. Initial VA measurement was not obtained in 24.5 % of the patients in this study due to poor compliance or the inability of children to cooperate during initial examination. The majority of the patients who could not tolerate initial VA measurement were in group A. Retinal detachment was significantly correlated with poor final visual outcomes, which has been demonstrated in a previous study [10]. This finding reinforces the need to counsel patients and their parents about the poor visual prognosis in this group of patients. However, posttraumatic retinal detachment was repaired in a two-stage procedure in this report. Prompt diagnosis and referral of traumatic retinal detachments to centers with expertise in pediatric retina may lead to improved visual outcomes in these patients. Further study of primary traumatic retinal detachment repair in children is warranted. This report did not find a significant association between lens surgery and final visual outcome.
Furthermore, previous reports have found endophthalmitis to be a predictive factor for poor visual outcome [10]; however, endophthalmitis did not attain statistical significance as a predictive factor of final VA in this report. This finding may be due to our small sample size, although it is also possible that recent advancements in microsurgical technique and improvements in medical endophthalmitis management of open globe injury in pediatric patients may have contributed to this result. Only one-third of the patients who underwent vitrectomy in this study attained a final VA of C6/60, while Sheard et al. [21] reported a VA of C6/60 in approximately two-thirds of their patients following vitrectomy. However, a direct comparison between these two studies is complicated by the small sample size in both studies and differences in injury severity between the two reports. A more definitive analysis of the benefits of vitrectomy in this patient population awaits a larger study. This study is not without limitations, including those inherent to retrospective chart reviews. It is possible that a larger sample size would have enabled a more complete analysis of factors influencing final VA; however, our sample size was sufficient to identify the role that retinal detachment plays in VA
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outcomes. Finally, it is possible that the cases presenting to Chiang Mai University Hospital, a major referral center, represented more severe ocular pathology, as less severe injuries may have been managed at regional ophthalmic centers. This referral bias may have resulted in our reporting worse visual outcomes than would be expected in a population-based cohort. Pediatric open globe injury occurred most commonly in male patients, with penetration injury representing the most frequent type of injury. Wooden objects were the most common cause of open globe injury in this cohort. The presence of a retinal detachment was a significant predictor of poor final VA, with the majority of these patients ultimately requiring enucleation. These findings emphasize the important role of preventive education to reduce the occurrence of severe ocular trauma in children, especially as they age. Pediatric patients and their parents should be counseled regarding specific activities and objects that may predispose them to open globe trauma. Specifically, parents and older pediatric patients should be warned about the dangers of playing in wooded environments, playing with sticks, and using fireworks, as these frequently result in pediatric open globe injuries. Additionally, patients with retinal detachment have a poor final visual prognosis, and parents and patients should be counseled appropriately. Further investigation of the ideal surgical management of open globe injury in pediatric patients is warranted. Acknowledgments All authors would like to thank Nimitr Ittipunkul, Head of the Retinal Unit, for his general support and Rochana Phuackchantuck, statistician of the Research Administration Unit, Faculty of Medicine, Chiang Mai University Hospital, for her statistical assistance. Conflict of Interest
None.
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