Research Article
Pediatric Open Globe Injuries Occurring at Home: A 12- Year Case Series
Sebastian P. Lesniak1, Xintong Li2*, Alain Bauza2, Jung H. Son2, Marco A. Zarbin2, Paul Langer2 and Neelakshi Bhagat2*
1Department of Ophthalmology, Matossian Eye Associates, USA
2Department of Ophthalmology, Rutgers New Jersey Medical School, USA
*Corresponding author: Xintong Li, Department of Ophthalmology, Rutgers New Jersey Medical School, Newark, 15 Setter Place Kendall Park, NJ 08824, USA
Published: 07 Dec, 2016
Cite this article as: Lesniak SP, Li X, Bauza A, Son JH,
Zarbin MA, Langer P, et al. Pediatric
Open Globe Injuries Occurring at
Home: A 12-Year Case Series. Clin
Surg. 2016; 1: 1220.
Abstract
Objectives: In children, ocular trauma occurs disproportionately in the home. The purpose of this study is to evaluate the epidemiology, characteristics, and outcomes of pediatric traumatic Open
Globe Injuries (OGI) occurring at home, and to compare the observed final Visual Acuity (VA) to
the Ocular Trauma Score (OTS) expected VA.
Methods: Retrospective chart review of pediatric (ages 0-19) patients with traumatic OGI that
presented to University Hospital, Newark and Rutgers New Jersey Medical School between 1997-
2008.
Results: Eighty-nine pediatric OGI were identified of which 42 (47%) occurred at home (mean age
5.8 years [range 1-19], 64% male). Penetrating injuries represented 79% of cases, while ruptures
comprised the remaining 21%. The most common cause of injury was poking with a sharp object
(38%). The most common objects involved in these injuries included broken glass, pens, furniture,
knives, screwdrivers, wooden sticks, and toys. Self-injury occurred in 57% cases; siblings were
involved in 19% of cases. Retinal detachment occurred in 9 (21%) cases. A comparison with 47
pediatric OGIs that occurred outside of home revealed that injuries at home are more likely to occur
in younger children, have better initial and final VA, and are more likely to be penetrating injuries.
Conclusion: Nearly half of the pediatric OGI in this study occurred at home. Self-injury was the
most common cause (57% cases), which emphasizes the need for close supervision of young children.
Visual prognosis for pediatric OGI remains poor. The final VA predicted by OTS correlated with
the observed final VA.
Keywords: Eye injuries; Ocular trauma; Open globe injury; Vision; Pediatric
Introduction
Open Globe Injury (OGI) is defined as a full-thickness wound of the eye wall, [1] the most common cause of monocular blindness [5]. 2.4 million Eye injuries occur annually in the United States [3-5] with 13.2 hospitalizations for eye trauma per 100,000 [5]. Over 7,500 hospitalizations costing more than $88 million occur annually for pediatric eye trauma [2]. Visual prognosis after OGI depends on factors such as wound location, extent, and severity; and infection. Eye trauma classification systems, especially the Ocular Trauma Score (OTS), [1] can be used to predict final visual outcome. Only 4 pediatric studies have been published since 2000 describing U.S. populations with OGI. Farr et al. [5] reported on 180 eyes treated from 1970-1993; Hill et al. [4] on 59 eyes from 1990-2002; Acuna et al. [3] on 13 eyes with delayed presentation from 2002-2007, and Lesniak et al. [9] on 89 eyes at our institution from 1997-2008. Narang et al. [6] reported on OGI in India that occurred at home versus outside. Armstrong et al. [10] described characteristics of over a million eye injuries presenting to U.S. emergency departments from 2001-2007; this study included mainly closed globe injuries without separate analysis of OGIs (termed “laceration/puncture,” noted in 3%). Our study evaluates the epidemiology, characteristics, and outcomes of pediatric traumatic OGIs sustained at home, and compares observed final Visual Acuity (VA) to that predicted by the OTS.
Materials and Methods
Rutgers Health Sciences, Newark Campus Institutional Review Board approval was obtained for
retrospective chart review of patients aged ≤19 years presenting with OGI to University Hospital and
Rutgers New Jersey Medical School, Newark, NJ, USA from January
1997 – December 2008. OGI diagnosis was made upon clinical or
intraoperative finding of a full-thickness break in the globe. Data
extracted from charts included age, race, gender, wound location,
injury mechanism, trauma classification, initial and final VA, ocular
examination, time from injury to first surgery, and additional
surgeries performed. Cases with missing variables were omitted
from analysis of that variable. Ocular examination variables included
Afferent Pupillary Defect (APD), lens status, Retinal Detachment
(RD), Vitreous Hemorrhage (VH), choroidal detachment, injury
zone, intraocular foreign body (IOFB), endophthalmitis, and
Sympathetic Ophthalmia (SO).
OTS was calculated [3] while assuming presence of APD in eyes
with no light perception (NLP). Briefly, VA was grouped into NLP,
light perception (LP)/hand motion (HM), 1/200 – 19/200, 20/200 –
20/50, or ≥20/40. Scoring based on prognostic factors then assigned
each eye into an OTS category. Final observed VA outcomes in each
OTS category were compared to expected VA outcomes using the
Fisher’s exact test. Statistical significance was defined as p < 0.05. For
statistical calculation, VA was converted into logMAR from Snellen
VA or as follows: counting fingers (CF)=1.6, HM=2.0, LP=2.5, and
NLP=3.0 logMAR units [7]. Inclusion criteria for this analysis were
complete data on the OTS variables and ≥3 months of follow-up.
Zone 1 of injury included the cornea and limbus, zone 2 within
5 mm beyond the limbus, and zone 3 as anywhere posterior to
zone 2 [1]. OGI was further classified as penetration (sharp object:
single wound), perforation (sharp object: separate entrance and exit
wounds), IOFB, and rupture (blunt object) [1 and 3].
Table 1
Table 2
Table 2
Comparison of pediatric open globe injury cases sustained at home
versus outdoors that presented to at our institution from 1997-2008.
Results
One hundred and three (14%) of 757 total OGIs treated at
University Hospital from 1997 – 2008 occurred in patients aged ≤19
years. 89 (86%) of these charts were complete with 42 occurring at
home [47%, mean age: 5.8 years (range: 1-19); 64% male]. African-
American patients represented 33%, Hispanics 21%, and Caucasians
12% of the study population. Penetrating injuries comprised 71%
of cases and ruptures the remaining 29%, with no perforations or
IOFBs. 57% of injuries occurred in zone 1, 29% in zone 2, and 14% in
zone 3. Traumatic cataract was noted in 25 cases (60%), with all eyes
phakic at injury. Lens was dislocated in 2 cases (5%) and extruded in
1 case (2%). Cataract extraction was performed with primary globe
repair in 3 cases (7%), while 18 (72%, mean age 5.7 years) had it as a
subsequent procedure averaging 78 days after primary repair. 4 eyes
(10%) underwent intraocular lens (IOL) implant.Posterior segment
complications noted < 10 days after presentation included VH in 11
cases (26%), hemorrhagic choroidals in 7 (17%), and RD in 6 (14%).
≤6 months of injury, there were a total of 9 (21%) RD cases. OGI
was most commonly due to poking by a sharp object (16 eyes, 38%),
followed by 12 falls onto object (29%), 6 projectile injuries (14%),
5 falling object injuries (12%), and 3 blunt hits (7%). Self-injury
occurred in 57% of cases, while sibling-perpetrated injury comprised
19%. Table 1 presents age group-specific causes of injury and final
VA.
Forty-one patients (98%) underwent primary open globe
repair, while 1 patient (2%) underwent primary enucleation due to
irreparable anatomy. Thirty (71%) patients underwent surgery within
24 hours of injury, while 39 (93%) underwent surgery within 48. In
3 (7%) cases, the initial surgery occurred 7 days post-trauma due to
delayed presentation. Twenty-one (50%) patients required additional
surgeries following initial repair: 15 (36%) underwent 1 additional
surgery, 5 (12%) had 2 additional surgeries and 1 (2%) underwent
3 additional surgeries. Secondary surgeries included 9 Pars Plana
Vitrectomies (PPV), 11 Cataract Extractions (CE), 8 Pars Plana
Lensectomies (PPL), 1 Penetrating Keratoplasty (PKP), and 1 open
globe revision. Seven of 9 RD patients (78%) underwent PPV, 1 (11%)
was enucleated, and 1 (11%) was lost to follow-up. Five of 7 (71%)
patients who underwent PPV for RD achieved anatomic success,
averaging 1.6 PPVs. No cases of endophthalmitis or SO were noted
in this series.
Initial and final VA recorded ≥3 months post-trauma was
available in 26 cases. Mean initial VA was 1.73 logMAR (Snellen
equivalent 20/1074); mean final VA was 1.16 logMAR (Snellen
equivalent 20/289). 8 patients were excluded from OTS calculation
(final n=18). In each category, the number of expected patients closely
predicted actual observations (p >0.05 for each).
Table 2 compares this series with 47 cases of OGI occurring
outside the home from the same population; these two groups were
previously reported together [14].
Discussion
To our knowledge, this is the first study to focus specifically on
the epidemiology, characteristics, and visual outcomes of OGI in
children that happened at home. Pediatric OGI occurred in 13.6% of
all OGI cases at our institution; approximately half occurred at home.
Narang et al. [6] reported that only 14% of pediatric OGIs occurred at
home, while Armstrong et al. [10] reported that 66% of pediatric open
and closed globe injuries occurred at home.
Self-injury occurred in 57% of cases here, while 19% of cases
were sibling-perpetrated. Most cases involved penetration with sharp
objects such as broken glass (mostly from broken light bulbs), pens,
furniture, knives, screwdrivers, wooden sticks, and toys. These objects
are easily accessible to young children, emphasizing the need to
ensure a safe home environment with supervision of young children
and limiting access to both sharp household items and potentially
dangerous toys.
In our study, 64% of OGIs occurred in males, which is slightly
lower than previously reported rates (74-83%) [4-6]. This rate is,
however, very close to the overall rate of closed and open eye injuries
among males at 66% [10]; boys may be more likely to engage in
activities leading to eye injuries.
Pediatric OGIs sustained at home averaged 5.8 years old versus
13.2 years among those with injuries occurring elsewhere, which
likely reflects the tendency for older children to spend more time
outdoors than younger children. Most OGIs that occurred at home
were penetrating injuries (71%), while ruptures (29%) comprised the
rest. Outdoor injuries were more evenly split between penetrating
injuries (40%) and ruptures (38%), while also including perforations
(13%) and IOFBs (9%).
Infants were most commonly injured as a result of falls and
toddlers were more likely to be poked by sharp objects, underscoring
the importance of safeguarding cribs and keeping sharp objects away
from toddlers. Children >10 years old were most likely to be injured
by projectiles. The youngest children had the worst final VA, possibly
due to amblyopia.
Most injuries involved zone 1 (57%), yet only 1 eye underwent
subsequent PKP. In our study, mean follow-up was 22 months.
No eyes developed infectious endophthalmitis or SO. One patient
underwent primary enucleation during initial surgery due to
irreparable anatomy.
Mean final VA was poor, which may be due to aphakia (90% of
patients), persistent RD (5%), and/or amblyopia (difficult to quantify
in this study).
Final VA predicted by the OTS correlated well with observed final
VA; OTS was reliable in predicting final VA in this series of pediatric
OGI at home from our urban institution.
Limitations in this study originate from the inherent difficulty
in obtaining complete variables in retrospective analyses. OTS was
computed in 18 of 42 eyes (43%), mainly due to difficulty assessing
VA in young patients.
Visual prognosis in eye injuries in children remains guarded,
even after prompt surgical intervention. Prevention may lie in greater
awareness of the common causes of ocular injury occurring at home
and frequent inspection of the environment.
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