Journal of Pediatric Ophthalmology and Strabismus

Original Article 

Pediatric Ocular Injuries: A 3-Year Follow-up Study of Patients Presenting to a Tertiary Care Clinic in Canada

Cyril Archambault, MD; Assia Mekliche; Jordan Isenberg, MD; Nicole Fallaha, MD, FRCSC; Patrick Hamel, MD, FRCSC; Rosanne Superstein, MD, FRCSC

Abstract

Purpose:

To identify age groups or activities at risk for ocular injuries to provide parents, sports teams, schools, and hospitals with the appropriate tools for prevention strategies.

Methods:

A retrospective chart review was conducted of all trauma-related cases from 2013 to 2015 and data were obtained with the use of an electronic medical record. All patients younger than 18 years who presented to the ophthalmology clinic with traumatic ocular injuries were included.

Results:

A total of 409 patients met the inclusion criteria and all were included in this study. The mean age was 7.74 years. Boys were injured more frequently than girls (60.4%). Most ocular injuries occurred between the ages of 2 and 9 years (51.8%). The most common sport was soccer, followed by ball/ice hockey, which differs from previous study findings. This may highlight the increasing popularity of soccer and the risk it may entail. Injuries occurred at home in 23.2% of cases. Final visual acuity was 20/40 or better in 77% of patients.

Conclusions:

These findings are comparable to the authors' previous data and to those of the only other Canadian study done on this subject, with the exception of an increased incidence of soccer-related injuries in the current cohort, highlighting an area important to future prevention strategies.

[J Pediatr Ophthalmol Strabismus. 2020;57(3):185–189.]

Abstract

Purpose:

To identify age groups or activities at risk for ocular injuries to provide parents, sports teams, schools, and hospitals with the appropriate tools for prevention strategies.

Methods:

A retrospective chart review was conducted of all trauma-related cases from 2013 to 2015 and data were obtained with the use of an electronic medical record. All patients younger than 18 years who presented to the ophthalmology clinic with traumatic ocular injuries were included.

Results:

A total of 409 patients met the inclusion criteria and all were included in this study. The mean age was 7.74 years. Boys were injured more frequently than girls (60.4%). Most ocular injuries occurred between the ages of 2 and 9 years (51.8%). The most common sport was soccer, followed by ball/ice hockey, which differs from previous study findings. This may highlight the increasing popularity of soccer and the risk it may entail. Injuries occurred at home in 23.2% of cases. Final visual acuity was 20/40 or better in 77% of patients.

Conclusions:

These findings are comparable to the authors' previous data and to those of the only other Canadian study done on this subject, with the exception of an increased incidence of soccer-related injuries in the current cohort, highlighting an area important to future prevention strategies.

[J Pediatr Ophthalmol Strabismus. 2020;57(3):185–189.]

Introduction

In the pediatric population, ocular trauma represents the most common cause of non-congenital blindness.1 In Canadian children younger than 14 years, sports-related injuries rank second.2 Large organizations such as the American Academy of Pediatrics and the American Academy of Ophthalmology have released policy statements recommending that all children enrolled in organized sport activities wear adjusted ocular protective equipment.3 In addition to ocular protection, better education and supervision may prevent up to 90% of traumatic injuries.4 Research conducted in the United States,4–10 United Kingdom,1,11 and many other countries12–16 has shown that injuries related to sports or sports equipment represent a major cause of pediatric trauma, most in children older than 10 years. However, as has been postulated previously,11 sports and other activities differ according to a country's culture and climate, indicating probable regional variation of traumatic mechanisms and causes.

Recently, we published data from the province of Quebec, Canada, regarding the epidemiology of sports-related trauma.17 However, many trauma patients present directly to the ophthalmology clinic, thus bypassing the emergency department. To obtain a more complete picture of the causes of injuries, we undertook this follow-up study to gather data from a tertiary care ophthalmology clinic in Montreal, Canada, to determine high-risk age groups, sports, or other activities and to compare our findings with the data from those patients who presented directly to the emergency department.

Patients and Methods

Our university ophthalmology clinic uses an electronic medical record to keep track of patient data. Using the search engine within the electronic medical record, we were able to identify trauma-related cases between 2013 and 2015, using the following search terms: trauma, hyphema, accident, burn, injury, rupture, fracture, erosion, abrasion, hemorrhage, and perforation. Basic demographic data were obtained (age, gender, and telephone area code), in addition to visual acuity at presentation and discharge from the ophthalmology service, delay before presentation to the hospital, use of ocular protection, mechanism and type of injury, type of sport (if applicable), geographical location of injury, and necessity for ocular surgery. Parents or legal guardians were contacted by telephone when there was missing data about injuries. Consent was obtained verbally to use the shared information. Internal review board approval was obtained for the chart review and the subsequent telephone follow-up. Data analysis was performed to examine at-risk groups, causal factors, and morbidity, which was determined by the final visual acuity.

Results

Characteristics

A total of 409 patients met the inclusion criteria and all were included in this study. The mean age was 7.74 years (median age: 7.58 years). Boys were injured more frequently than girls (60.4%). Most ocular injuries occurred between the ages of 2 and 9 years (51.8%) (Figure 1).

Age distribution of pediatric ocular injuries.

Figure 1.

Age distribution of pediatric ocular injuries.

Timing

There was a seasonal peak in the early summer months. June (n = 50), July (n = 46), and May (n = 42) were the months with the most injuries. January and February had the fewest injuries (n = 23) (Figure 2).

Month when ocular injury occurred.

Figure 2.

Month when ocular injury occurred.

Activities

Most injuries were caused by blunt objects (Figure 3). “Free play” injuries were the most prevalent among all age groups (20.4%) and in children younger than 10 years (23.7%). In older children (10 to 18 years), sports-related injuries were more prevalent than all other categories (35.3%) (Table 1). The most common sport was soccer (32.8%), followed by ball/ice hockey (20.9%) (Figure 4). Injuries occurred at home in 23.2% of cases.

Etiology of pediatric ocular injuries.

Figure 3.

Etiology of pediatric ocular injuries.

Activities Leading to Injury According to Age Group

Table 1:

Activities Leading to Injury According to Age Group

Sports-related pediatric ocular injuries.

Figure 4.

Sports-related pediatric ocular injuries.

Morbidity

Visual acuity at presentation was variable (20/20 to light perception). Final visual acuity was 20/40 or better in 77% of patients. Surgery (including foreign body extraction and periocular laceration repair) was required for 37 patients (9.1%), 9 of whom needed more extensive vision-preserving surgery (Table 2).

Ocular Injuries Requiring Surgery

Table 2:

Ocular Injuries Requiring Surgery

Contacting Families

After analyzing data of all 409 patients, 59 charts were found to have missing data regarding the circumstances of trauma. Families were called by telephone to gather more detailed information. Of these, 29 parents or legal guardians were successfully reached. Those who could not be contacted either did not answer after three consecutive attempts, had an out-of-service number, or left no contact information. One parent declined to give any additional information.

Discussion

This is the second epidemiological study examining causes and outcomes of pediatric ocular trauma in the province of Quebec. Our first study17 looked at data of patients who presented directly to the emergency department between 2007 and 2010. However, patients who had presented directly to the ophthalmology clinic were not included in our prior analyses, and due to poor documentation information was missing in the charts as to the cause of the injury. Given that electronic medical records were implemented in 2013, a more thorough review was done by reviewing all patients who were seen in the ophthalmology clinic regardless of how they were referred between 2013 and 2015. Telephone calls were made to gather missing data to ascertain as much data as possible.

Compared with the previous data, the demographic characteristics of our cohort of patients remained similar, with boys being more affected than girls and at an average age of 7.7 years. Younger children (age 0 to 9 years) were at higher risk of injury, most often during free play (23.7%) or in unknown circumstances where the child may have been left without supervision (20.4%). These young children are postulated to be at higher risk because of decreased maturity and awareness of dangerous behaviors that may lead to trauma.

In the sports-related injury category, our findings were also demographically similar, with older children more often involved in these types of activities. However, we had previously found that un-organized ball/ice hockey injuries were more prevalent among the Quebec population. In our current sample, soccer was responsible for 33% of sports injuries, whereas unorganized hockey was responsible for only 20% (Figure 3). This trend may be related to an increased number of summertime injuries in this study, or could indicate that soccer is increasing in popularity in Canada, as seen in studies done in the United Kingdom.1,11 This could also reflect that soccer trauma injuries are more often blunt or minor and that children may not present to the emergency department directly. In fact, they may only present later to the optometrist or directly to the clinic complaining of visual disturbance or ocular pain. Children playing soccer are at particularly high risk of being injured due to use of the head to direct the ball in play and the lack of ocular protection. This also reveals the increasing need for ocular protection in a sport such as soccer.

The distribution of injuries according to month showed a trend in early summertime injuries, which has also been a consistent finding in other studies in Canada2 and Australia.15 Injuries occurring outdoors are frequent and most prevalent during warmer summer days. We did not observe an increased rate of ocular trauma during winter as we had observed previously. In terms of morbidity, 77% of patients had a final visual acuity of 20/40 or better, which means that more than 20% of patients had significant visual loss from injuries. As previously mentioned, 8 patients required extensive vision-preserving surgery, with an additional ninth patient (patient 7) requiring life-saving surgery that led to significant visual loss. Only 4 of the 11 severely injured eyes retained a visual acuity of 20/30 or better. Although accidental and rare, these traumatic injuries often have a poorer visual prognosis.

A recently published study from the United States10 found that the rate of emergency department ocular injuries due to any cause is decreasing in the pediatric population, possibly secondary to proper prevention and redistribution of care outside of emergency care facilities (eg, ambulatory ophthalmology clinics). However, sports-related injuries were found to have increased in children during this period, indicating that there might be prevention strategies yet to be developed that may decrease injuries related to sports.

In this study, we evaluated patients who presented directly to the ophthalmology clinic, whether by walking in or with a referral from an optometrist or the emergency department. This addressed an important limitation of our previous study that only included patients who presented to the emergency department. However, we may still be underestimating the proportion of trauma in this population because periocular injuries such as eyelid lacerations or contusions may be dealt with in the emergency department without ever being seen by the ophthalmology service. Also, this analysis was conducted 3 years after the previous study,17 which may affect the comparison of our results. Finally, our hospital serves a large population for subspecialty care and trauma, but may not be fully representative of the full Quebec population because there are two other large hospital centers for children in the province.

Conclusion

Our demographic findings are comparable to our previous data and to those of the only other Canadian study done on this subject.2 We found an increased trend of injuries in the early summer months of the year. Soccer was the most prevalent sport associated with trauma, mirroring published data from the United Kingdom. One of the main goals of this study was to analyze data on all ocular injuries regardless of the referral method (emergency department, walk-in, or optometrist), therefore including all patients who would require specialty care. We attempted to gather all pertinent details on events, calling families when information was missing from the chart. We propose that this may give more accurate and complete epidemiological data on ocular trauma in Canada and North America.

References

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Activities Leading to Injury According to Age Group

ActivityAge Group [n (%)]

0 to 9 Years (n = 270)10 to 18 Years (n = 139)Total (N = 409)
Sports18 (6.7)49 (35.3)67 (16.4)
Free play64 (23.7)20 (14.4)84 (20.5)
Unknown55 (20.4)22 (15.8)77 (18.8)
Fall28 (10.4)4 (2.9)32 (7.8)
Assault/fighting6 (2.2)10 (7.2)16 (3.9)
Other99 (36.7)34 (24.5)133 (32.5)

Ocular Injuries Requiring Surgery

CasePatient Age, Sex, OD/OSLocation of InjuryDetails of InjuryDiagnosis According to BETTFinal Visual Acuity
111 years, male, OSTennis courtRetinal dialysis and detachment; injury with tennis ballClosed globe laceration, contusion20/25−1
22 years, male, OSUnknownCorneal laceration and traumatic cataract; unknown cause of injuryOpen globe laceration, penetrating injury20/150
315 years, male, ODUnknownTraumatic cataract and vitreous hemorrhage, in addition to iridodialysis and hyphema with secondary ocular hypertension; injury with wood stickClosed globe injury, contusion20/20−1
413 years, male, OSSchoolCorneal laceration and traumatic cataract; injury with ruler in schoolOpen globe injury, penetrating injury20/50
53 years, male, OSHomeCorneal laceration; injury from glass shards (broken window)Open globe injury, penetrating injury20/20−2
61 year, female, ODHomeCorneoscleral laceration with iris and vitreous extrusion; injury from falling holding a glassOpen globe laceration, penetrating injuryNA
716 years, male, OUUnknownSevere penetrating head trauma with secondary posterior ischemic optic neuropathyNAHand motions OD, 20/100−1 OS
81 month, female, OUUnknownShaken baby syndrome, secondary retinal hemorrhages, lens subluxation and traumatic cataractClosed globe injury, contusion20/40 OD, 20/30 OS
96 years, female, OSGolf courseLateral orbital fracture, macula-off retinal detachment, commotio retinae and choroidal rupture; injury with golf clubClosed globe injury, contusion20/50
Authors

From the Department of Ophthalmology (CA, JI, NF, PH, RS) and the Faculty of Medicine (AM), University of Montreal, Quebec, Canada.

The authors have no financial or proprietary interest in the materials presented herein.

Correspondence: Cyril Archambault, MD, Department of Pediatric Ophthalmology, Centre Hospitalier Universitaire (CHU) Ste-Justine, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC H3T1C5, Canada. E-mail: cyril.archambault@umontreal.ca

Received: December 28, 2019
Accepted: February 19, 2020

10.3928/01913913-20200326-01

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