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.
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.
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.
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.
Activities Leading to Injury According to Age Group
Sports-related pediatric ocular injuries.
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
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.
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.
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.
- MacEwen CJ, Baines PS, Desai P. Eye injuries in children: the current picture. Br J Ophthalmol. 1999;83(8):933–936. doi:10.1136/bjo.83.8.933 [CrossRef]
- Podbielski DW, Surkont M, Tehrani NN, Ratnapalan S. Pediatric eye injuries in a Canadian emergency department. Can J Ophthalmol. 2009;44(5):519–522. doi:10.3129/i09-093 [CrossRef]
- American Academy of Pediatrics, Committee on Sports Medicine and Fitness American Academy of Ophthalmology, Eye Health and Public Information Task Force. Protective eyewear for young athletes. Ophthalmology. 2004;111(3):600–603. doi:10.1016/j.ophtha.2003.12.027 [CrossRef]
- Larrison WI, Hersh PS, Kunzweiler T, Shingleton BJ. Sports-related ocular trauma. Ophthalmology. 1990;97(10):1265–1269. doi:10.1016/S0161-6420(90)32421-1 [CrossRef]
- Haring RS, Sheffield ID, Canner JK, Schneider EB. epidemiology of sports-related eye injuries in the United States. JAMA Ophthalmol. 2016;134(12):1382–1390. doi:10.1001/jamaophthalmol.2016.4253 [CrossRef]
- Grin TR, Nelson LB, Jeffers JB. Eye injuries in childhood. Pediatrics. 1987;80(1):13–17.
- SooHoo JR, Davies BW, Braverman RS, Enzenauer RW, McCourt EA. Pediatric traumatic hyphema: a review of 138 consecutive cases. J AAPOS. 2013;17(6):565–567. doi:10.1016/j.jaapos.2013.07.007 [CrossRef]
- Strahlman E, Elman M, Daub E, Baker S. Causes of pediatric eye injuries: a population-based study. Arch Ophthalmol. 1990;108(4):603–606. doi:10.1001/archopht.1990.01070060151066 [CrossRef]
- Moren Cross J, Griffin R, Owsley C, McGwin G Jr, . Pediatric eye injuries related to consumer products in the United States, 1997–2006. J AAPOS. 2008;12(6):626–628. doi:10.1016/j.jaapos.2008.07.005 [CrossRef]
- Matsa E, Shi J, Wheeler KK, McCarthy T, McGregor ML, Leonard JC. Trends in US emergency department visits for pediatric acute ocular injury. JAMA Ophthalmol. 2018;136(8):895–903. doi:10.1001/jamaophthalmol.2018.2062 [CrossRef]
- Abbott J, Shah P. The epidemiology and etiology of pediatric ocular trauma. Surv Ophthalmol. 2013;58(5):476–485. doi:10.1016/j.survophthal.2012.10.007 [CrossRef]
- Al Wadeai EA, Osman AA, Macky TA, Soliman MM. Epidemiological features of pediatric ocular trauma in Egypt. J Ophthalmol. 2016;2016:7874084. doi:10.1155/2016/7874084 [CrossRef]
- Cao H, Li L, Zhang M, Li H. Epidemiology of pediatric ocular trauma in the Chaoshan Region, China, 2001–2010. PLoS One. 2013;8(4):e60844. doi:10.1371/journal.pone.0060844 [CrossRef]
- Haavisto AK, Sahraravand A, Holopainen JM, Leivo T. Paediatric eye injuries in Finland-Helsinki Eye Trauma Study. Acta Ophthalmol. 2017;95(4):392–399. doi:10.1111/aos.13327 [CrossRef]
- Hoskin AK, Yardley AM, Hanman K, Lam G, Mackey DA. Sports-related eye and adnexal injuries in the Western Australian paediatric population. Acta Ophthalmol. 2016;94(6):e407–e410. doi:10.1111/aos.12911 [CrossRef]
- Puodziuviene E, Jokubauskiene G, Vieversyte M, Asselineau K. A five-year retrospective study of the epidemiological characteristics and visual outcomes of pediatric ocular trauma. BMC Ophthalmol. 2018;18(1):10. doi:10.1186/s12886-018-0676-7 [CrossRef]
- Archambault C, Gabias C, Fallaha N, Bélanger C, Superstein R. Pediatric ocular injuries: a 3-year review of patients presenting to an emergency department in Canada. Can J Ophthalmol. 2019;54(1):83–86. doi:10.1016/j.jcjo.2018.02.006 [CrossRef]
Activities Leading to Injury According to Age Group
|Activity||Age Group [n (%)]|
|0 to 9 Years (n = 270)||10 to 18 Years (n = 139)||Total (N = 409)|
|Sports||18 (6.7)||49 (35.3)||67 (16.4)|
|Free play||64 (23.7)||20 (14.4)||84 (20.5)|
|Unknown||55 (20.4)||22 (15.8)||77 (18.8)|
|Fall||28 (10.4)||4 (2.9)||32 (7.8)|
|Assault/fighting||6 (2.2)||10 (7.2)||16 (3.9)|
|Other||99 (36.7)||34 (24.5)||133 (32.5)|
Ocular Injuries Requiring Surgery
|Case||Patient Age, Sex, OD/OS||Location of Injury||Details of Injury||Diagnosis According to BETT||Final Visual Acuity|
|1||11 years, male, OS||Tennis court||Retinal dialysis and detachment; injury with tennis ball||Closed globe laceration, contusion||20/25−1|
|2||2 years, male, OS||Unknown||Corneal laceration and traumatic cataract; unknown cause of injury||Open globe laceration, penetrating injury||20/150|
|3||15 years, male, OD||Unknown||Traumatic cataract and vitreous hemorrhage, in addition to iridodialysis and hyphema with secondary ocular hypertension; injury with wood stick||Closed globe injury, contusion||20/20−1|
|4||13 years, male, OS||School||Corneal laceration and traumatic cataract; injury with ruler in school||Open globe injury, penetrating injury||20/50|
|5||3 years, male, OS||Home||Corneal laceration; injury from glass shards (broken window)||Open globe injury, penetrating injury||20/20−2|
|6||1 year, female, OD||Home||Corneoscleral laceration with iris and vitreous extrusion; injury from falling holding a glass||Open globe laceration, penetrating injury||NA|
|7||16 years, male, OU||Unknown||Severe penetrating head trauma with secondary posterior ischemic optic neuropathy||NA||Hand motions OD, 20/100−1 OS|
|8||1 month, female, OU||Unknown||Shaken baby syndrome, secondary retinal hemorrhages, lens subluxation and traumatic cataract||Closed globe injury, contusion||20/40 OD, 20/30 OS|
|9||6 years, female, OS||Golf course||Lateral orbital fracture, macula-off retinal detachment, commotio retinae and choroidal rupture; injury with golf club||Closed globe injury, contusion||20/50|