INTRODUCTION:

The ability to see, commonly known as "Vision", is a valuable gift from God that is essential for daily functioning and can only be achieved with healthy eyes. While the eyeball is a well-protected tissue in the body, even a minor trauma can cause significant damage that may result in more severe morbidity than any other organ. The eyes are safeguarded by anatomical and physiological factors such as elastic fatty tissue, the bony orbit, head-turning reflexes, blink reflexes, and lacrimation.¹ Despite these natural defence mechanisms, eye trauma is still prevalent and often results in ophthalmic emergencies. The anterior segment, including the conjunctiva, cornea, angle of anterior chambers, iris, and lens, is frequently affected by an injury's impact, although the posterior segment may also be involved.²

The consequences of eye trauma can be devastating, often leading to complete loss of vision due to the delicate nature of the eye's structures. This holds immense social and economic importance, resulting in significant human suffering and economic loss or insufficiency.³ Ocular injuries pose a significant threat to vision in various settings such as homes, workplaces, schools, playgrounds, and sports.⁴

The history of ocular injuries began when one primitive man fought with another when he first walked through forest and chipped a piece of flint to make his primitive tool. At a much later date that is about the year 1200 B.C. one artist painted a picture of removal of foreign body from the eye of a workman on a tomb.⁵Sir William Tindall Lister (1868-1944) has contributed most richly to the knowledge of ocular injuries. The earliest statistics of the incidence of ocular injuries of all types among ophthalmic patients were correlated by Zander and Geissler (1864). They found the estimate to vary from 1.8 to 9 % of all eye disease.^6,7In subsequent studies the figure has varied according to the degree of industrialization. Weldmann (1888) among 30,000 ophthalmic patients found a total incidence of 10.4%. Again, Prawn in 1889 among 4,44,819 ophthalmic patients found a total incidence of 4.89%.⁷As regards the age incidence, the highest incidence is in adult life because of growing industrialisation. But children are also in special danger because they are less aware of hazards and child’s eye is relatively less well protected because of the smaller orbit.^6,7 Worldwide, ocular trauma is an important cause of eye morbidity and is a leading cause of non-congenital monocular blindness in children. The severity of trauma is directly proportional to morbidity and affects the socioeconomic loss; however, this loss can be prevented if certain precautions are taken.

Intrauterine Injuries: The effects of injuries sustained during foetal life are not yet fully understood, but there are various potential damages that can occur due to genetic and environmental factors. Teratogenic agents such as intrauterine molding, trauma, and embryo mutilation can cause ocular deformities, while variations in amniotic fluid volume may be debatable. Ionizing radiation, ultrasonic energy, low temperatures, and atmospheric changes are some physical agents that can act as teratogens, with ionizing radiation being the most significant. Maternal infections such as syphilis, toxoplasmosis, and rubella can also cause deformities ranging from enophthalmos to cataract. Drug and chemical exposure during pregnancy has gained increasing attention since the thalidomide disaster, with thalidomide causing gross and widespread congenital deformities, including ocular defects in 25% of cases. The use of these substances during pregnancy should be carefully controlled.

Birth Injuries: The article discusses the occurrence of ocular injuries during childbirth, which may involve the eye itself, the lids, the orbit, the skull, and the visual neural apparatus. These injuries are more common than previously thought, occurring in 20 to 25% of normal births, which can rise to 40 or 50% when delivery is prolonged or aided by instrumental means. Most injuries are mild, and their effects are transient, and they are difficult to diagnose without specialist examination at an early stage. The only adequate method of dealing with the problem is prophylactically through ante-natal supervision, which should be supplemented by care and discrimination when instrumental interference is necessary. The article emphasizes the importance of recognizing and preventing ocular injuries during childbirth. The more common of these injuries will be discussed as they affect the eyeball, the ocular adnexa and the central nervous system.

Fig.1: Lid Oedema with ecchymosis

Fig. 2: Hyphema

The eye is protected from blunt trauma by the natural configuration of the orbit around the eye and the instincts of a man making him wary of any injury. The orbital cavities are placed on either side of the mid-vertical line of the skull between the cranium and the skeleton of the face. The fact that the widest part of the orbit lies behind the orbital margins and not at the orbital margins, along with the structurally heavier configuration of the orbital rim, makes it impossible for missiles having a greater radius of curvature that 2 inches to traumatise the eye. On the other hand, a high-speed hockey puck, having a radius of curvature of 1.5 inches may penetrate the orbital opening with frequently blinding devastations.⁸ The orbital margin overhung superiorly and inferiorly with the nose providing protection medially. Thus, the eye is most exposed laterally, leaving it most vulnerable to injuries from this aspect. The floor of the orbit is thin (0.5-1 mm) and can fracture from a blunt object hitting the eye. This relieves pressure and may prevent sclera rupture. The instinctive response to an object aimed at the eye is to move the head to avoid impact.

With an increase in the number of cases of vehicle accidents and sports-related ocular injuries in the paediatric age group, a study was conducted at Krishna Hospital, Karad, to evaluate the clinical profile of ocular injuries, estimate visual prognosis using the Paediatric Ocular Trauma Score, and assess visual prognosis following appropriate treatment.

MATERIALS AND METHODS>

This is a single-center study conducted at Krishna Hospital in Karad, which included patients with ocular trauma who visited the hospital for treatment. This is the prospective study on the source of paediatric age group patients suffering from Ocular Trauma visiting and getting treated at Krishna Hospital, Karad. The study period is of 18 months from November 2019 to May 2021.The sample size of the study taking the value as 25%. According to the study of “Paediatric ocular Trauma” the sample size was calculated suing formula:

4pq

[n] = ----------- ... (1)

Where, P is 25%, L (allowable error) is 10%, Q is 100 – p = 75% and N (sample size) = 75.

The selection inclusion criteria refers to all instances of ocular trauma in individuals who are 15 years of age or younger and receive treatment at Krishna Hospital in Karad. The exclusions were patients not willing for examination, age group more than 15 years of age, previous ocular trauma, cognitive disability patients and cases associated with congenital anomalies.

EXPERIMENTAL:

During the assessment, informed written consent was obtained from the patient or their guardian. A detailed history was taken, including the time, place, and mode of injury. Specific details were noted, such as a history of head injury, vomiting, and loss of consciousness. Other relevant details, such as a history of seizures and ENT bleeding, were also recorded. Previous ocular trauma or ocular surgery was also noted, as well as the patient's birth history and history of NICU admission. Immunisation history, specifically for tetanus, was also documented, as well as a history of systemic illness and bleeding disorders. A general examination was conducted, followed by a thorough ocular examination, which included visual acuity, torchlight examination, and, wherever possible, slit-lamp examination and fundoscopy. Radiological investigations, such as X-rays, CT scans (if required), MRI (if required after ruling out metallic foreign body), and B-scans (if required), were also performed. Routine investigations, such as a complete blood count, blood sugar levels, urine and routine microscopy, HIV, HbsAg, and HCV, were also conducted. Medical management and/or surgical repair were performed as required, and the patient was followed up as needed depending on the type of injury. Final vision was assessed six months after follow-up. The Paediatric Ocular Trauma Score was calculated during the assessment process.

Baseline Treatment^9,10:

During the examination of patients with conjunctival congestion and subconjunctival haemorrhage, careful examination was done to rule out underlying scleral involvement. Patients were given local antibiotic drops and ointment, and vitamin C was prescribed for 15 days. In cases of conjunctival foreign bodies, careful inspection of the upper fornix by double eversion was done, and foreign bodies were removed under topical anaesthesia using 4% lignocaine as the anaesthetic agent. Local antibiotic drops and ointment (moxifloxacin) for 3-4 days were given for controlling infection. For small conjunctival tears with no underlying scleral involvement, conservative treatment was given, and local ointment was prescribed along with an eye pad for 3 days. Conjunctival tears requiring suturing were sutured with 8.0 silk under local infiltration anaesthesia, and sutures were removed after 7 days. In cases of corneal foreign bodies, they were removed under topical anaesthesia with 4% lignocaine using a disposable Needle No. 26 1⁄2. Homatropine eye drops and chloramphenicol ointment were put on, and an eye pad was applied for 24 hours. For lamellar (sealed) corneal tear, conservative treatment was given. Local antibiotic and cycloplegic eye drops were prescribed with pressure eye pads. The lamellar flaps here got well opposed with haziness initially due to oedema. Overall, the management strategies varied depending on the type and severity of the eye injury.

RESULTS:

The data represents the age and gender distribution of a sample population, Table 1. Out of the total sample size of 75, 48 individuals (64%) are male, and 27 individuals (36%) are female. In the age group of 0-5 years, there are 6 individuals, of which 4 (8.33%) are male and 2 (7.41%) are female. In the age group of 6-10 years, there are 41 individuals, of which 25 (52.08%) are male and 16 (59.26%) are female. Finally, in the age group of 11-15 years, there are 28 individuals, of which 19 (39.58%) are male and 9 (33.33%) are female.

Table 1: Case Distribution in the study according to age and sex

Age	Male	Male (%)	Female	Female (%)	Total	Age (%)
0 - 5	4	8.33 %	2	7.41 %	6	8.0 %
6 - 10	25	52.08 %	16	59.26 %	41	54.67 %
11 - 15	19	39.58 %	9	33.33 %	28	37.33 %
Total	48	100 %	27	100 %	75	100 %

The data in Table 2 represents the distribution of eye conditions in a sample of 75 individuals. Out of the total sample size, 32 individuals (42.67%) have a condition in their right eye, 34 individuals (45.33%) have a condition in their left eye, and 9 individuals (12.0%) have a condition in both eyes.

Table 2: Distributing of patients on the basis of eye trauma side and Gender

on the basis of eye trauma side				Gender
Right Eye	Left Eye	Both	Total	Gender	Number Of Patients	%
32	34	9	75	Male	48	64.0 %
42.67 %	45.33 %	12.0 %	100 %	Female	27	36.0 %
				Total	75	100 %

The data in Table 3 represents the gender distribution of a sample of 75 patients. Out of the total sample size, 48 patients (64.0%) are male and 27 patients (36.0%) are female. It's important to note that the percentages for each gender group add up to 100%, as they represent the total percentage of the sample that belongs to that particular gender.

Table 3: Distribution of cases according to type of injury to eye

Type Of Injury	Number Of Patients	Percentage
Sports and Play	28	37.33 %
RTA	17	22.67 %
Domestic	12	16.00 %
Firecracker	18	24.00 %
Total	75	100.00 %

The data represents the type of injury distribution in a sample of 75 patients. Out of the total sample size, 28 patients (37.33%) suffered from sports or play-related injury, 17 patients (22.67%) suffered from an injury caused by a road traffic accident (RTA), 12 patients (16.00%) suffered from a domestic injury, and 18 patients (24.00%) suffered from an injury caused by fireworks.

Table 5: Distribution of cases according to ocular damage to eye

Ocular Damage	Number Of Patients	Percentage
Anterior Segment	49	65.33%
Posterior Segment	18	24.00%
Both	8	10.67%
Total	75	100%

The data represents the distribution of anterior segment injuries in a sample of 75 patients. Out of the total sample size, 17 patients (22.67%) suffered from a conjunctival tear, 13 patients (17.33%) suffered from a corneal abrasion, 8 patients (10.67%) suffered from a corneal tear, 12 patients (16.00%) suffered from a hyphema, 8 patients (10.67%) suffered from iris involvement, 7 patients (9.33%) suffered from lens involvement, 2 patients (2.67%) suffered from a relative afferent pupillary defect (RAPD), and none of the patients suffered from endophthalmitis.

DISCUSSION:

The study aimed to evaluate paediatric ocular trauma clinically with a special focus on the Paediatric Ocular Trauma Score (POTS). The study included 75 patients of paediatric age group (15 years or below) with ocular trauma who visited the Ophthalmology Department at Krishna Hospital, Karad, a tertiary healthcare hospital. A detailed history of each patient was recorded, followed by a general examination of the patients and an ocular examination, along with the initial visual acuity assessment. If possible, the fundus was evaluated with direct and indirect ophthalmoscope. For patients with an open globe injury, wound exploration and primary wound suturing under sedation SOS general anaesthesia after surgical fitness from the paediatric and medicine department was performed. There were no cases of intraocular foreign bodies in the study. In addition, necessary procedures were performed according to the complications, and a written informed consent was obtained from each patient's parents or guardian before surgical intervention.

Follow-up of patients was done as required depending on the type of injury, and the final visual acuity was assessed at six months of follow-up. The final results obtained were statistically analysed. The study conducted by Vishal Katiyar et al.⁽¹¹⁾ on ocular trauma in India yielded comparable results. The paediatric population, in which male children between the ages of 6 and 10 years constituted the largest group, accounted for 41.1% (80/191) of total patients. The mean age of patients in the current study was 9.31 ± standard deviation 3.01 years. Out of 75 patients, 32 patients (42.67%) had trauma to the right eye, 34 patients (45.33%) to the left eye, and 9 patients (12%) were traumatised in both eyes. In contrast, in a study by Huda S. Al-Mahdi et al. ⁽¹²⁾, the right eye was affected more than the left eye, with no bilateral involvement. Out of 75 patients, 48 patients (64%) were male patients, and 27 (36%) were female patients. A study by Huda S. Al-Mahdi et al. ⁽¹²⁾ on paediatric ocular trauma in a fast-developing country had the majority of male patients (77.4%, n = 82). The distribution of patients according to the aetiology of trauma to the eye showed that 18 out of 75 patients had firecracker injury (24%), followed by injury due to a stone in 14 patients (18.67%). Wooden stick and chemical aetiologies were present in 11% and 10% of patients, respectively.

The number of 75 patients was classified according to the segments damaged in the eye, with maximum involvement seen in the anterior segment (65.33%), followed by 24% in the posterior segment. 10.67% of patients had involvement in both segments. Conjunctival tear was seen in most of the patients (22.67%), corneal abrasion was observed in 17.33% of patients, and 17.33% of patients had hyphaema. Majority of patients with posterior segment injuries to the eye had Berlins oedema (16%), followed by retinal haemorrhage (9.33%) and vitreous haemorrhage in (8%). Both retinal detachment and traumatic optic neuropathy were seen in 2.67% of patients. Out of 75 patients, 61 patients (81.33 %) had mechanical injury, and 14 patients (18.67%) had chemical injury. The majority of patients had closed globe injuries in the form of contusion seen in hyphaema.

CONCLUSIONS:

The study highlights the prevalence of ocular injuries in children, particularly during sports and play, and the devastating impact it can have on a child's vision and overall well-being. Preventive measures such as proper supervision and the use of safety gear can significantly reduce the incidence of such injuries. The study emphasizes the need for health education on eye protection in schools, educational health centers, and sports academies, along with the development of standardized documentation systems and the promotion of safety procedures through mass media. The collaborative effort between parents, teachers, and doctors is crucial in preventing and managing ocular trauma in paediatric patients, and it is essential to recognize the value of vision and take necessary precautions to prevent any injuries that may result in its loss. It is also important to note that the results of this study could be used by ophthalmologists to provide parents or guardians with a brief explanation of the expected visual outcome, but the POTS is just a prediction and cannot guarantee the visual outcome.

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Received on 09.02.2023 Modified on 11.03.2023

Research J. Pharm. and Tech 2023; 16(5):2359-2363.

DOI: 10.52711/0974-360X.2023.00388