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Mohd Alhashki*, MD
Department of Ophthalmology, Royal
Medical Services
Jamal ALmaaita, MD,
Department of Pediatric, Royal Medical
Services.
Mohd ALhashki,
Department of Ophthalmology,
Royal Medical Services
Amman, Jordan
P.O.Box: 710618 post code 11171
e-mail: mhashki@yahoo.com
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ABSTRACT
Aims and Objectives:
To analyze the causes and the
outcome of pediatric ocular trauma
at Prince Ali Hospital in Al-karak
city, in the south of Jordan, between
January 2001 and January 2004.
Materials and Methods: Reviewing
the medical files of all children
below the age of 14 years, who were
presented to the eye clinic or referred
from pediatric emergency clinic with
ocular injuries. Overall p value for
predictors of visual and ocular outcome,
was determined.
Results: One hundred and twelve
children represents 11% of all pediatric
attendances presenting with ocular
trauma. The male to female ratio was
2:1. Eight (7.2%) patients had open
globe injury, one hundred and four
(92.8%) had closed globe injury. Eighty-two
(73.2%) patients were treated as out-patients
and followed up in the clinic by regular
visits; thirty (26.8%) patients needed
hospital admission. Eighty-eight (78.6%)
occurred while at play and 24 (21.4%)
occurred at home. Ninety-eight (87.5%)
of the patients had normal or near
normal visual acuity at time of discharge
from the clinic, thirteen (11.6%)
suffered moderate to severe decrease
in their visual acuity, one case only
(0.9%) lost his vision in the affected
eye .No child had a bilateral injury.
Conclusions: Ocular trauma
in children is a common cause of hospital
attendance. This study has shown the
majority or presentations often result
in good visual outcome. Poor final
visual acuity was related to poor
presenting visual acuity, injury to
multiple ocular structures and penetrating
injuries. It is necessary to ensure
safe places for children to play under
adult supervision to avoid ocular
trauma and to encourage early attendance
to the hospital in case of ocular
trauma. Early management at the hospital
should be prompt, and special care
in management of post-operative problems
is needed to improve the visual outcome.
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Key
Words: Ocular trauma, Children, Visual
outcome
Ocular trauma in children
is a common cause of ocular morbidity despite
introduction of new methods
of treatment and improvement of management,
and is a leading cause of non-congenital
unilateral blindness in this age group [1,2]
. Children are at risk of ocular trauma
because of their inability to avoid hazards
[3]. Most of these hazards are found while
children play, or are at home. Identifying
the causes of ocular injuries may help in
determining the effective methods in reducing
the incidence of serious ocular traumas.
This
retrospective study reviews the medical
records of children who presented with ocular
trauma at Prince Ali Military Hospital in
the south of Jordan over a period of three
years; analyzing the causes of ocular injuries,
discussing different treatment modalities,
determining the visual outcome, and the
possible methods to reduce their incidence.
A review of medical files
of two hundred and fifteen patients of whom
one hundred and twelve (52%) were below
the age of 14 years, with a history of ocular
trauma presenting to the eye clinic or referred
from the paediatric clinic at Prince Ali
Hospital, over a period of three years from
January 2001 to January 2004. Seventy-five
were male and thirty-seven female.
Ocular trauma was classified
as either closed globe like contusion, superficial
foreign body, small corneal laceration,
or open globe injuries like penetrating,
perforating, rupture or intra ocular foreign
body.
Initial management included
the following:
a. Determining if there
were life threatening problems.
b. Taking a full history about the cause
and mechanism of injury, and
c. Examination of both eyes
Visual acuity was tested
using Snellen's chart or illiterate E chart,
and for young children by naming pictures
or matching letters.
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Superficial foreign body
was removed by using topical anesthesia;
corneal abrasion was treated by ointment
and patching of the eye; small corneal laceration
with formed anterior chamber was treated
by eye patching or using a soft bandage
contact lens. Injury needing surgical repair
was done under general anesthesia using
the operating microscope, corneal wounds
were sutured by 10/0 nylon while scleral
wounds sutured by 6/0 ethibond or 6/0 vicryl.
Visco-elastic material was used depending
on the need. In cases with multiple ocular
structure traumas, primary suturing was
done while further management was done by
a vitreo-retinal surgeon at King Hussein
Medical Center (KHMC). Hyphaema was treated
by conservative measures like complete bed
rest, sedatives, eye patching, anti-glaucoma
if needed, but if conservative treatment
was unsatisfactory, anterior chamber paracentesis
was done under general anesthesia.
Post-operative treatment
included topical antibiotics, steroid, and
mydriatics. Follow up was carried out for
a period of 2 months in 70% of cases and
only for 4 weeks in the remainder. Those
patients referred to KHMC, came back for
follow up and to continue their treatment.
Near normal visual acuity
was taken as 6/12 or better. Blindness was
regarded as that defined by World Health
Organization, with visual acuity less than
3/60.
A total of 215 patients
who presented with ocular injury during
the study period, of whom 112 (52%) were
children with ocular trauma, 75(67%) of
the children were male and 37(33%) were
female with a ratio 2:1. 6 patients (5.5%)
were aged 4 years or less and 106 (94.5%)
were between 5-14 years of age. Age and
sex distribution is shown in Table
1.
All patients were injured
in one eye. 67(59.8%) had right and 45(40.2%)
left eye injury. The commonest type of injury
was contusion due to blunt trauma in 62
(55.4%), and 12 (10.6%) had superficial
foreign body. 18(16.1%) had small corneal
laceration. 8 (7.1%) had eye lid injury,
4 (3.5%) had chemical injury, 7 (6.3%) had
rupture globe, and 1 (0. 9%) had penetrating
eye injury. Table 2
shows the types of ocular trauma.
82 (73.2%) of the cases were treated as
outpatients. 30 (26.8%) were admitted to
the hospital, of these 21 (18.8% of the
total) stayed in the hospital less than
5 days while 9 (8% of the total) stayed
longer than 6 days. 16 (53%) of the cases
who were admitted had hyphaema.
The causes of injury
were many and variable but air gun toys
were the most common especially between
the ages of 5-14 years.
Other causes were during
sporting activities, or due to falling down,
sticks, domestic chemicals, glass and tree
leaves. The injury causes are shown in Table
3.
The final visual acuity
was taken at time of final discharge from
the clinic. The child who lost his vision
in the affected eye had been exposed to
a penetrating injury.
The visual acuity at presentation and the
final visual acuity are shown in Table
4.
Good final visual acuity
was related to good initial visual acuity,
to non penetrating injuries and early presentation,
while poor final vision was related to poor
initial visual acuity, multiple eye structure
injury and penetrating injury.
There is an excess risk of severe trauma
among the very young which has been recognized
in many studies, with more than one third
of all injuries occurring in the pediatric
age group [4,5] which is the same finding
as in our study.
Other studies have
identified that boys tend to be affected
more commonly than girls [6,7,8] which is
in keeping with our findings. School aged
children are more susceptible than younger
age groups, because they are more independent
and adventurous, which may make them more
vulnerable [7].
In this study blunt
injuries predominate. Most children were
admitted because of hyphaema. This represents
further incidence that there is a trend
of increased incidence of blunt trauma in
children7 compared with perforating injuries
which were more common in the past. [4]
In our study we
have found that toys are a common cause
of ocular injury in children, and air gun
toy injuries have a poor prognosis because
of the damage caused by the high velocity
pellets and often result in loss of vision
or even enucleation 9, so safety standards
should be considered for the manufacturers
of such toys.
Sports have frequently been reported as
a source of major ocular trauma in all age
groups, but especially in the young [10,11].
Penetrating eye
injury contributes to poor visual outcome
and ocular survival [5,8]. Poor visual outcome
is also related to multiple ocular structure
injury and severity of initial injury [12,
13], and still ocular trauma in children
is a major cause of monocular blindness
and a common cause of enucleation in children
[14].
In this study most
of the ocular injuries were contusions due
to blunt trauma with good initial visual
acuity, and the early presentation to the
eye clinic because of parental awareness,
reflects the good final visual outcome.
In conclusion,
pediatric ocular trauma is a major cause
of ocular morbidity in children and requires
special care. There is a strong need for
adult supervision of children at play or
at home, and also there is a need to encourage
early attendance to the hospital.
Young children
are uncooperative in examinations like assessing
the visual acuity, and examination of the
post segment which may have to be done under
general anesthesia. Post-operative managemen't
like correction of unilateral aphakia, and
proper management of amplyopia require cooperative
parents. Prevention of ocular trauma in
children should remain a priority to reduce
ocular morbidity.
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