February 2019, Volume 69, Issue 1

Research Article

Pattern of ocular injuries in Bangladesh and its surgical management at hospital setting: A retrospective study

Authors: Mohammad Shamsal Islam  ( Dr. Ahmadur Rahman Research Centre, University of Chittagong, Bangladesh, )
Abul Hasnat Golam Quddus  ( Dr. Ahmadur Rahman Research Centre, University of Chittagong, Bangladesh, )
Abbas Rahimi Foroushani  ( Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran. )

Abstract

Objective: To determine the pattern of ocular injuries and their surgical management.
Method: The retrospective study was conducted at the Chittagong Eye Infirmary and Training Complex, Chittagong, Bangladesh, and comprised hospital data of patients with ocular injuries from October 1, 2016, to December 31, 2017. Information gathered related to type and cause of injuries, visual acuity, postoperative complications, follow-up visits, and outcome. SPSS version 22 was used for data analysis.
Results: Of the total injuries, 370 (91%) were classified open globe and 36 (9%) as close globe. In terms of type of injury, 330 (81.4%) were penetrating, 30 (7.3%) ruptured globe, 29 (7.1%) lime burn and 17 (4.2%) injuries were traumatic hyphaema and chemical in nature. Open globe injuries were mostly found in subjects aged 18 years or below. Surgery was the main mode of management in 388
(95.5%) patients.
Conclusion: Preventive measures along with high-quality management should receive priority for reducing monocular blindness.
Keywords: Ocular injury, Open globe, Close globe, Surgical management, Bangladesh.
(JPMA 69: S-17; 2019)

Introduction

Ocular injuries is the most commonly reported cause of unilateral, partial or total loss of vision after cataract of all age groups.1 About 55 million of eye injuries restrict
activities and around 750,000 cases require hospitalisation each year, including some 200,000 open global injuries.2,3 Ocular injuries occur mostly in two
forms: open globe and close globe. Open globe injury (OJI) is one of the most common types and requires immediate operation. Most of the eye injuries fall into
this category that varies from 51% to 92%.4-8 Compared to OJIs, the incidences of close globe injuries (CJIs) is less. The highest CJI occurrence is found around 38% and the lowest around 13%.4,6,8 It is found that the visual acuity (VA) usually improved significantly after surgical management in Iran 9 United States10 and Nigeria 11. There
are numerous studies in developed and semi-developed countries about injury types, rates, causes and surgical management while such studies are limited in developing
countries and more so in Bangladesh. Severe consequences of ocular injuries are well known, but clarity about the types, prevalence rate, causes complications and surgical management for such incidences in Bangladesh is missing. Treatment facilitie are scanty and people end up suffering. In order to prevent and render services to those who need it, there should be enough information with the decision-makersand stakeholders of all shades. The current study was  planned to assess the pattern of ocular injuries and its surgical management in a hospital setting in Bangladesh.

Patients and Methods:

The retrospective study was conducted at the Chittagong Eye Infirmary and Trainin g Complex (CEITC), Chittagong, Bangladesh, and comrised hospital data of patients with ocular injuries from October 1, 2016, to December 31, 2017. Information gathered related to type and cause of injuries, visual acuity, postoperative complications, followup visits, and outcome. All patient files were included and those with incomplete information were later excluded  (Nineteen cases are excluded from the analysis because those were not considered for operation) Table-2. A proforma was generated to take down information from the files. To ensure reliability of data, 20 patient files were initially studied and variables were identified that were properly recorded. Consistency of data was checked by an ophthalmologist and an optometrist for determining content validity. Their comments were incorporated in finalising the research instruments. SPSS version 22 was used for data analysis. A separate analysis of each component of the ocular structure was done to show th abnormalities of each of them (Table-3). Univariate and bivariate tables were used for analysis. Chi-square and Cramer\'s V tests were used where appropriate, and the
level of significance was kept at 0.05.

Results

Children were found to be more vulnerable to ocular injuries as nearly two-thirds of the patients were aged 18 years or younger. Over 69 (68%) female patients were 10
years or below against only 120 (37%) of males. The mean ages of male and female patients were 19.68 (±11.88) years and 13 (±8.42) years, median ages were only 15
years for males and 6 years for females respectively. Patients came from an average distance of 120 (±66) km. On an average there was a gap of 38 (±16) hours between the occurrence of injury and reporting times to the hospital. However, the median hours of reporting were24 hours. Female patients sought medical service on an average within 20 hours against 45 hours by male patients. Vast majority of the injuries were classified as OJIs 370 (91%) against CJIs 36 (9%). In terms of type of injury, 330 (81.4%) were penetrating, 30 (7.3%) ruptured globe, 29 (7.1%) lime burn and 17 (4.2%) injuries were traumatic hyphaema and chemical in nature. The major cause of injury 333 (82%) was strike with sharp objects. Major difference was observed between the injured and the fellow eye as only 14 (12.2%) of the injured eyes had a vision between 6/6 and 6/18 against 101 (87.8%) of fellow eyes. The most threatening part was that 116 (59.5%) injured eyes had vision near close to complete blindness and 57 (29%) injured eyes had poor vision ranging from <6/18 through 3/60. Cross-tabulation showed that age did not significantly relate to VA as 168 (86%) of the patients aged 1-5 years had VA of 3/60 and 54-61% patients of other age groups had similar VA (Table 1).


There were multiple abnormalities in patients. As for the status of ocular components, 6 (2.6%) patients had eyeball contour-related abnormalities, such as soft eye, phthisical eye and proptosed eyeball. About 18 (8%) of the patients had abnormality in the lid and lacrimal system, 31 (14%) had sclerouveal abnormality due to ruptured sclera, 31(14%) had abnormality in anterior chamber due to inflammatory response, 20 (9%) patients had shallow angle issues and 11 (5%) patients had traumatic cataract. Three most affected components of the injured eyes were conjunctiva 240 (59%), cornea 369 (91%) and iris and pupil 195 (48%). Surgery was the main means of management in 388 (95.5%) cases. General and local anaesthesia were given to 217 (53.4%) and 181 (44.5%) patients, respectively. Each patient received 3 to 4 types of drugs at a time along with the surgery. A total of 14 types of surgical interventions were performed for the management of ocular injuries (Table 2).


For the first follow-up out of 406 patients 331 showed up. Of them visual acuity records of only 115 patients were found. Difficulty of measuring visual acuity of children below 5 years of age was possibly the main cause of fewer records. There was no explanation why visual acuity of adults was not recorded. Initially we thought we would compare first report with the follow-up reports to determine the changes that took place over a time period after management but that became difficult as the number of patients started dropping in subsequent followup visits and time gap between visits was uneven. The reason for dropouts and irregular follow-up visits could be for improvement of the condition or seeking alternative treatment or frustration with the treatment. Since the number and patients were different between follow-ups and reasons of dropouts were unknown we thought it would be unwise to compare the changes, if any, due to the management. In view of these difficulties we have simply made a presentation of status of visual acuity of only those patients who came for follow-up at different points of time irrespective of their attendance in the earlier follow-up/follow-ups. At the time of first follow-up 19 (16.5%) patients had VA within a range of 6/6 to 6/18, followed by 25 (21.8%) between <6/18 and 3/60. The remaining 71 (61.8%) patients had VA of extreme low vision or near blindness or completely blind <3/60. Nearly 90 (78%) patients made their first follow-up visit to the hospital and 98 (77%) of them did it within 15 days of their first report to the hospital. Among those patients who came for follow-up visits there were 95 (66%) of females and114 (79%) of males (p<0.05). Near blindness or blindness (<3/60) increased from 59.5% to 65.3% from the first to the second follow-up, declined from 56.4% to 49.6% at the third to the fourth follow-up after the management of ocular injury. About 13% patients had either infection or inflammation in the injured eye during the first followup, which reduced to 4% during the second follow-up but increased to 10% during the third follow-up and again dropped down to zero at the four th follow-up Over 103 (82%) of orbit and periobita, 107 (85%) of lid and larcrimal system, and 103 (82%) of conjunctiva injuries were found normal. About6 (4.8%) and 10 |(8.7%|) of the eyes of all above mentioned components had phthisical eye and enucleated eye, respectively. The most affected  site was cornea, as 66 (52%) of the eyes were not found normal and 49 (39%) of which had corneal opacity. There were few other minor problems that were not more than 3 (2%) in each component (Table 3).


Discussion

There was a gender disparity regarding incidences of ocular injury as 68% of girls of 10 years or below came to the hospital against only 37% of boys of the same age.
This means more girls at young age are involved with activities that carry risk of ocular injury. Since children are more vulnerable to severe injuries due to their involvement with various games and innovative activities, they possibly constituted the major patient population of ocular injuries at the hospital. Most of the patients (81%) came with penetrating injury. Injuries were mostly OJIs (91.0%). Different studies have also reported that overwhelming majority of the injuries was open globe (52-92%).5,7-10 Penetrating injuries were found in 81% patients. Studies in other countries also found strike by sharp objects as the major cause of ocular injury.10,11 Treatment options of this condition are few and there are limited numbers of qualified surgeons for it. Preventive measures should be encouraged so that those at risk should take proper protection during their professional work. This study has identified assault as a growing cause of ocular injury for women. About 20% of ocular-injured women were assaulted by their husbands and 5% by others. This problem has to be solved through informal education and empowerment of women in addition to medical services. Hospital data showed that only 12% of the ocular-injured patients who came first time to the
hospital had normal vision, followed by 30% poor vision and 58% near or complete blind. This is to point out that most of the time this blindness is irreversible and convertsinto enucleated and phthisical eye. This is a great cosmetic blemish for the victim and the family. In view of the severe consequences, preventive measures along with better treatment facilities are needed. In terms of limitations, patient files did not always have the required information for study purposes. This phenomenon possibly is true for all hospitals of the country and needs to be rectified. In the absence of complete data across the board, comparison with current
literature was not possible in all the cases.

Conclusion

Preventive measures along with high-quality management should receive priority for reducing monocular blindness. Agriculture-related ocular traumas have declined
significantly possibly due to mechanisation of agriculture. A new fact about the ocular injury of married women is husbands\' physical assault. The assaulted women even can\'t seek treatment owing to restriction of movement imposed by their families.

Acknowledgement: We are grateful to all volunteers, to the author of the School of Public Health, Tehran University of Medical Sciences, Iran, and to Dr. Ahmadur Rahman Research Centre, University of Chittagong, Bangladesh.

Sources of Funding: None.
Conflict of interests: None.
Disclaimer: None.

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