Introduction
Ocular trauma is a leading cause of avoidable monocular blindness and visual impairment worldwide.1 The incidence and prevalence of ocular trauma vary based on geographical location, climate and societal factors. Approximately 1.6 million people worldwide are blind due to ocular trauma, 2.3 million being bilaterally visually impaired and 19 million have unilateral loss of vision.2, 3 The reported incidence of ocular trauma in India varies from 1% to 5%.4, 5 5% of all ophthalmic hospitalisation in the developed countries are due to ocular trauma and this figure is much higher in developing countries.6 Despite its public health importance, ocular trauma is most neglected and under-reported disorder.
Severity and extent of ocular injury is determined by the amount of energy transferred to the globe & orbit, characteristic of traumatic agent and location of impact area. Blunt trauma is the commonest form (54.9%) of ocular injury.7 Blunt trauma can occur in almost any setting and circumstances including workplace / domestic accidents, road traffic accidents, sports & recreational activities and physical assaults etc.8
The most common traumatic agent causing blunt ocular trauma are cricket ball, squash ball, fist, bamboo /wooden stick, airbag, cow horn and other projectile objects like stone, brick & Gulli etc.9, 10 The spectrum of blunt ocular injuries ranges from mild non-sight threatening injuries like ecchymosis of eye lid, corneal abrasion, sub-conjunctival haemorrhage to extremely serious blinding consequences such as globe rupture, retinal detachment, intraocular haemorrhage, traumatic optic neuropathy and orbital haemorrhage etc.
Blunt ocular trauma can cause damage of ocular tissue by the coup and countercoup mechanism and anteroposterior compression or horizontal tissue expansion. Coup injury occur at the site of impact (e.g. ecchymosis of lid, sub-conjunctival haemorrhage and corneal abrasion etc). Counter-coup refers to injuries at the opposite side of site of impact like commotio retinae.11
Blunt trauma causes various effects in anterior and posterior segment of the eyeball and its adnexa [eyelid, orbit, conjunctiva]. In this hospital based, observational study we analyze the demographic profile, injury pattern, clinical presentation, visual outcome and prognostic factors of blunt ocular trauma.
Materials and Methods
This was a prospective, hospital based, observational study conducted at the outpatient Department of Ophthalmology and Emergency Services, Sir Sunderlal Hospital, Institute of Medical Sciences, Banaras Hindu University Varanasi, Uttar Pradesh, India. The present study was conducted over a period of four years from March 2012 to February 2016. Out of 402 patients having ocular trauma 226 patients with a definite history of recent blunt trauma to the eyeball and ocular adnexa who were visiting for the first time and willing to give consent were included in the study. Patient with the history of penetrating ocular injury, non-mechanical ocular trauma, old ocular injuries (>1 month), patients operated elsewhere, having pre-existing vision threatening ocular co-morbidity, injury in phthisical eye and patients who were not willing to give consent were excluded from the study.
After getting ethical clearance from research Ethical Committee of Institute of Medical Sciences, Banaras Hindu University Varanasi, Uttar Pradesh and informed, written consent all study subjects underwent detailed history and ocular & systemic examination. A detailed history regarding demographic information such as age, sex, residential area, marital status, occupation and educational status of the patient and specific history of trauma including date, time, place, and mode of injury, circumstances of injury, characteristics of traumatic agent and condition of the victim at the time of injury and information about protective measures taken at the time of injury were recorded.
All patients underwent detailed ocular examination including initial visual acuity assessment, anterior segment evaluation with diffuse torch light and slit lamp examination, gonioscopy (if possible), intraocular pressure measurement (only in closed globe injury) and posterior segment examination with direct ophthalmoscopy and or indirect ophthalmoscopy to assess type, extent and severity of injury and structural and functional loss was noted. Investigation like OCT, X-ray orbit, ultrasonography (USG B Scan), CT scan and MRI were done as per indication.
All patients were managed according to the injury and close follow up was done to assess the treatment outcome / complications. All the information was collected in a predesigned and pretested performa.
Results
Blunt injury is the most frequently observed mode of ocular trauma, in our study, out of 402 patients having ocular trauma, 226 had definite history of recent blunt trauma to the eye. Thus, in our study the extent of blunt mode of ocular trauma was 56.2%.
Demographic profile
Socio-demographic profile of the study subjects is given in Table 1. Out of 226 patients of blunt ocular trauma 181 (80.1%) were males and 45 (19.9%) were females with a male female ratio of 4:1. The mean age was 42.6 ± 18.8 years. The youngest patient was 2 years old and the oldest was of 70 years. Majority of the patients belonged to the 16-25 years (55 patients, 24.3%) and 26-35 years (54 patients, 23.9%) age group. As for the religion, was concerned 80.1% subjects were Hindu and 17.7% were Muslim. Blunt trauma was highest (68.6%) in subjects living in rural areas, whereas the proportion of subjects belonging to Urban and Semi-urban area were 12.8% and 18.6% respectively. Among the injured patients, 25.7% were students, whereas 21.2%, 16.8%, 12.4% and 11.5% were farmer, in service, housewife and laborers, respectively.
Injury profile
Table 2 shows the injury profile of the study subjects. It was observed that commonest place of injury was street or road (30.5%) followed by home (27.9%), work place (17.7%), playground or place of recreation (13.3%) and school (9.3%). Maximum injury occurred during summer season (39. 3%). Most common type of injury was non- occupational type in 184 (81·4%) cases, however in 42 (18.6%) cases blunt ocular trauma was related to patient’s occupation.
Common occupational injuries were related to agriculture work (8.8%) followed by building work (4.4%) and engineering work (3.1%). Among the non-occupational injury cases, most common was road traffic accident (RTA) related (26.5%) followed by recreational or sports related (22.6%) and assault related (21.7%). However, in 23 (10.2%) cases injury occurred due to fall or domestic accidents.
Vegetative material and wooden objects (like lathi, gulli-danda, bat, hockey & table/ door etc.) were the most frequent traumatic agents, seen in 59 (26.1%) cases. Other causative agents of blunt trauma were stone / brick (25.2%), metallic objects like iron rod, handle etc. (23.1%), ball (9.7%) fist / hand (4.9%) and animal horn (4.4%). However, in 15 (6.6%) cases agent of blunt trauma was not defined. Collision or impact of objects and projectile object was the commonest mode of blunt ocular trauma in 39.3% and 30.1% study subjects.
Pattern of ocular injury
Table 3 shows the pattern of ocular injury. About 32.3% of patient had isolated ocular injury while rest 67.7% were polytrauma patients. 23.5% of patients had head injury along with ocular trauma, 15.0% cases had oculofacial injuries while 16.4% patients had eye, head and maxillofacial trauma . 211 (93.4%) victims had unilateral ocular involvement and only 15 (6.6%) patients had bilateral injury. Maximum (53.1%) patients had left eye involvement.
Out of 241 injured eyes, 34 (14.0%) had only globe injury and in 59 (24.5%) eyes only ocular adnexae (lid & orbit) was involved. However simultaneous globe and adnexae were injured in 148 (61.4%) eyes. 19.9% eyes had open globe injury while 55.6% had closed globe injury (Table 4).
Clinical presentation
Most common conjunctival finding was congestion & chemosis (73.9% eyes) and sub-conjunctival hemorrhage (47.3% eyes). Among the periocular and lid injuries, 108 (44.8%) eyes had contusion/ ecchymosis (Figure 1), 40 (16.6%) had abrasion and 59 (24.5%) eyes had laceration (Figure 1). Commonest orbital trauma was bony fracture (63.9% eyes) and orbital hemorrhage & emphysema (23.2% eyes). Orbital walls were spared in 87 (36.1%) eyes. Most common orbital wall fracture was floor fracture (26.1%) followed by medial wall fracture (21.6%). Roof of orbit was involved in 15.8% eyes (Figure 3). (Table 5)
Figure 1
A): Young boy having blunt trauma due to fall from height showing both eye both eyelid ecchymosis; B: Clinical photograph of a young girl having blunt trauma of right eye with projectile object showing ecchymosis & edema of both eyelid of right eye
Figure 2
A): Clinical photograph of adult male having assault related blunt trauma right eye showing abrasion of right lower eyelid and temporal sub-conjunctival hemorrhage; B: Clinical photograph of a adult male having RTA related blunt trauma showing abrasion and laceration of right lower eyelid involving lower canaliculi
Out of 241 injured eyes 182 (75.5%) had globe injury. 50 (20.7%) eyes had purely posterior segment injuries, 76 eyes (31.5%) had purely anterior segment injuries and 56 (23.2%) eyes had both anterior & posterior segment injuries. Most common anterior segment finding was corneal abrasion (45.6% eyes) followed by hyphema (44.0%), traumatic mydriasis (35.7%), lens dislocation (22.8%) (Figure 4), corneo-scleral rupture (19.9%), traumatic cataract (17.4%), iridodialysis (16.6%) and lens subluxation (13.7% eyes) (Table 6).
Posterior segment damage was seen in 106 (44.0%) eyes. Commonest posterior segment finding was vitreous hemorrhage (33.2% eyes) followed by retinal detachment (20.3% eyes), retinal hemorrhage (15.8% eyes) retinal tear / hole (11.6% eyes) and traumatic optic neuropathy (2.9% eyes). Post traumatic endophthalmitis was observed in 13 (5.4%) eyes. (Table 6)
Figure 3
A: Young male having blunt trauma of right orbit with cricket bat showing ecchymosis both eyelid, periocular swelling & lower lid laceration; B: 3 D-reformated CT Scan image showing multiple displaced fracture of maxillary & zygomatic bone involving right floor & lateral wall of orbit
Figure 4
A: Blunt ocular trauma causing scleral rupture with total hyphema; B: Cow horn injury causing Phacocele with Hyphaema
At the time of initial presentation vision was good (VA > 6/12) in 80 (33.2%) eyes, visual impairment (VA 6/18- 6/60) was observed in 69 (28.6%) eyes and blindness (< 6/60 - NOPL) in 86 (35.7%) eyes while visual acuity could not be assessed in 6 (2.5%) eyes (Table 7).
As extent of globe injury was concerned, Zone-III injuries were more common in eyes with closed globe injury (35, 14.5% eyes) as compared to open globe injury (12, 5.0% eyes) (Figure 5) while Zone-II injuries were almost equal in eyes with open globe injury (19, 7.9%) to that of closed globe injuries (18, 7.5%) (Table 8, Table 9). 46 injured right eyes had ≤ 3 ocular structure involvement and 36 eyes had ≥ 4 structure involved while 72 injured left eyes had ≥ 4 ocular structure involvement.
Treatment outcome and visual prognosis
Maximum (n=115, 50.9%) patients were managed by conservative / medical treatment, 46 (20.4%) underwent for only ocular surgery (Figure 5), however 65 (28.8%) patients required multidisciplinary treatment. Table 10 represents final visual outcome. After 6 months, vision was good in 138 eyes (57.3%), impaired vision in 48 (19.9%) eyes and blindness in 51 eyes (21.2%). However, Final visual outcome could not be assessed in 4 (1.7%) eyes due to lack of final follow-up. Table 11 showed important prognostic factor (ocular trauma score) in injured eyes. Ocular trauma score was in category I (<45) in 36 (14.9%) eyes (RE=6, LE=30). OTS was in category II (45-65) in 4.1% of right eye and 2.9% of left injured eye. OTS was in category III (66-80) in 24 (9.9%) eyes and in category V (92-100) in 70 (29.0%) eyes. However, OTS could not be determined in 20 (8.3%) eyes. Most of the eyes with globe rupture had lower level (category I & II). Lower OTS level tends to indicate poor prognosis.
Figure 5
A: Assault related Blunt trauma causing scleral rupture (Zone-III) with corneal edema & hyphema; B: Repaired scleral rupture
Visual impairment and blinding outcome were more common in left injured eyes. Visual outcome was poor in eyes having zone-III open globe injury/ posterior segment involvement including vitreous hemorrhage & retinal detachment etc. Six months after the treatment, 176 (77.8%) of victims had improvement, 14 (6.2%) were unchanged and 30 (13.3%) were deteriorated while 4 (1.8%.) were absent from last follow-up. Outcome was poor in eyes having ≥ 3 ocular structure involvement.
Table 1
Demographic profile of study subjects
Table 2
Injury profile of the study subjects
Table 3
Pattern of injury
Table 4
Distribution of eyes according to ocular structure involved
Table 5
Distribution of eyes according to adnexal injury
Table 6
Distribution of eye according to ocular findings
Table 7
Initial grade of visual acuity (N=241 Eyes)
Table 8
Distribution of injured eyes according to zone of closed globe injury
Table 9
Distribution of injured eyes according to zone of open globe injury
Table 10
Final visual outcome after 6 months (N=241 Eyes)
Table 11
Distribution of injured eyes according to ocular trauma score
Discussion
Blunt objects are most common source of mechanical ocular trauma. In our series of 402 ocular injury cases 56.2% had blunt trauma. We analyzed 226 patients with 241 eye injuries caused by blunt traumatic agents. Our study concurs with MacEwen et al. (65%),12 Adamu et al. (77.8%),13 Titiyal GS et al. (32.7%)14 and Mark YZ Wong (32.6%)15 who reported higher Incidence of blunt ocular trauma. In contrast to this study Okoye OI (61%),16 Kaur et al. (73.7%),17 and Krishnan et al (69.2%)18 reported more of penetrating ocular injuries caused by sharp object.
In this study about 50% blunt ocular injuries occurred in the most productive age group (16-45 years of age). Males (80.1%) more commonly sustained blunt ocular trauma as compared to females (19.9%). This was consistent with the study done by Nayagam G et al.,19 Saxena R. et al.,20 Titiyal GS et al.14 and Oluyemi F et al.21 This male predominance seems to be due to outdoor activity, nature of occupational exposure, participation in dangerous recreational activities & sports, risk-taking behaviors, alcohol use and increase interpersonal conflicts.
Present study showed higher prevalence of blunt ocular trauma in rural population (68.6%) as compared to urban one (12.8%) in contrast to findings of Sujatha, MA et al who reported 78.% of blunt trauma in urban population.22 Dandana et al and Nirmalan et al also. reported higher prevalence in rural population.23, 24
In the current study, commonest place of injury was street / road (30.5%) followed by home (27.9%), work place (17.7%) and playground (13.3%). While in previous studies work place was found to be the commonest place of trauma.1, 25, 26 We observed that female subjects, were more likely injured at home while men were likely suffered by road traffic accidents and at work place trauma which is the similar to the results found in the study by Oum et al, Maurya R P et al. and Syal E. et al.27, 28, 25
In this study most common cause of blunt ocular trauma was RTA (26.5%) followed, by sports or recreational activities (22.6%) and physical assaults (21.7%). Previous studies also reported RTA as a commonest cause of blunt ocular trauma.29, 30, 31
In our study, commonest source of ocular trauma was wooden object (26.1%) like lathi, branch of tree, hockey, cricket bat etc. followed by stone / brick (25.2%) and metallic objects (23.1%) like metal rod, nail, handle etc. Rest sources of blunt trauma were ball (9.7%), hand & fist (4.9%) and animal horn (4.4%). Syal E et al was found most common traumatic agent as metallic objects (28.5%) followed by vegetative materials (11.0%).25 Pearlman et al. reported blunt ocular trauma caused by airbags.9
Majority (93.4%) of victims had unilateral blunt ocular trauma with predominance of left eye involvement (53%). However only 6.6% victims had bilateral involvement. Previously we reported overall bilaterally 8.5%.3, 32 Low bilaterality was reported in several studies e.g. Bucan et al (1%),33 MacEwen (2%),12 Babar et al (2.9%)34 and Jahagir et al (3%).6 We observed maximum bilaterally and left eye involvement in victim’s having RTA and assault related ocular trauma. About 32.3% of patient had isolated ocular trauma and rest 67.7% had associated polytrauma. Most common associated polytrauma was head injury (52.7%) and maxillo-facial trauma (31.4%). Ababneh et al (75%)35 was also reported head and neck trauma as most frequent associated body injuries with ocular trauma.
In the present study the most common ocular part involved was ocular adnexa in 85.9% eyes followed by globe injury in 75.5% eyes. 24.5% injured eyes had only adnexal injury. However 61.4% eyes had simultaneous globe and adnexal injuries Syal E et al. reported combined injury of adnexa and globe in 15% cases.25
In current study commonest adnexal injury was contusion / ecchymosis of eyelid (44.8%) followed by eyelid edema (71.4%), orbital fractures (63.9%) and sub-conjunctival hemorrhage (47.3%). Syal E et.al reported 46% contusional injury.25 Pai SG et al. reported lid edema / ecchymosis in 62.5% patients and 37.5% patients had sub-conjunctival hemorrhage.29 Comparable percentage reported by Ababneh et al (eyelid hematoma in 52.7% and SCH in 33.9% patients)35 and Soni et al (eyelid hematoma in 46.0% and SCH in 23.0% patients).36
We noticed that 56.6% eyes had closed globe injury and rest 19.9% eyes had globe rupture. Mishra A et al reported rupture globe in 13.6% of all ocular injuries.37 Mishra However closed globe injuries were found to be more common in several studies eg Marudhamuthu et al (95.3%),38 Syal E et al (60.5%)25 and Oum et al.27
In present study 182 eyes had globe injury. 76 eyes had purely anterior segment injury and 50 eyes had purely posterior segment injury while 56 eyes had both anterior and posterior segment injuries. Syal E et al found isolated posterior segment injury in 10% patients.25
In our study commonest type of anterior segment finding observed were corneal abrasion (45.6%), hyphema (44.0% eyes) and traumatic mydriasis (35% eyes). Traumatic cataract was most common type lens injury seen in 17.4% eyes. Liggett PE et al found that hyphema was present in 50% of the patients having blunt ocular trauma.39, 40
The most recorded posterior segment finding in our study was vitreous hemorrhage (33.2%) followed by retinal detachment (20.3%). Upon initial presentation 86 (35.7%) eyes were blind. 69 (28.6%) eyes had visual impairment. On final follow-up the number of visually impaired eyes had fallen to 48 (19.9%) and blind eye to 51 (21.2%).
In this study ruptured globe have worse prognosis than closed globe injury. Similar findings were reported by other researchers.41 Our finding suggests that poor visual outcome depends on initial visual acuity, extent of injury, presence of intraocular hemorrhage, lens injury, uveal prolapse and retinal detachment.
Conclusion
We can conclude from our study that blunt trauma is the commonest mode of ocular injury. RTA, physical assault and sport related injuries are common causes of blunt ocular trauma. Young adult males are more vulnerable. Intraocular hemorrhage (hyphema & vitreous hemorrhage), zone III injury, posterior segment involvement and low ocular trauma score (category I & II) are poor prognostic factors.
