ORIGINAL ARTICLE

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PATTERN OF OCULAR TRAUMA IN KUCHING, MALAYSIA

PS Mallika¹, MS; AK Tan1, MD; T Asok², MMed; HA Faisal ², MS; S Aziz², MS; G Intan², MS.

¹Department of Ophthalmology, Faculty of Medicine and Health Sciences, University Malaysia Sarawak, Kuching, Sarawak, Malaysia (Mallika Premsenthil)
²Department of Ophthalmology, Sarawak General Hospital, Kuching, Sarawak, Malaysia (Asokumaran Thanaraj, Humayun Akter Faisal, Mohamad Aziz Salowi, Tan Aik Kah, Intan Gudom)

Address for correspondence: Dr. Mallika Premsenthil, Lecturer, Ophthalmology unit, Faculty of Medicine and Health Sciences, University Malaysia Sarawak, Lot 77, Sekysen 22 Kuching Town Land District, Jalan Tun Ahmad Zaidi Adruce, 93150 Kuching, Sarawak, Malaysia. Tel: +6082-416550, Fax: + 6082-422564, Email: pmallika@fmhs.unimas.my

Conflict of interest: None

INTRODUCTION

Ocular injuries still remain a significant global health problem. The epidemiological data for ocular injuries are scarce or totally lacking unlike other major blinding conditions such as cataract, trachoma, xerophthalmia, where epidemiological studies have contributed much.¹ It has been recognized that ocular trauma is a leading cause of monocular blindness.² The annual incidence of ocular trauma is 55 million, of which 750,000 cases require hospitalization each year, including some 200,000 open globe injuries.³ Ocular trauma is one of the preventable causes of visual impairment.⁴

In Malaysia, Study from the National Health and Morbidity Survey II in 1996, revealed that the national prevalence of blindness  is 0.29% and the prevalence of low vision  is 2.44%.⁵ Cataract remains the single largest cause of blindness in the country (39.1%), followed by retinal diseases (24.5%) and uncorrected refractive error (4.1%).⁶ Sarawak, the largest state in Malaysia, has a higher number of blind people, approximately 0.33% of the population.⁷ The incidence of ocular trauma is under-reported in Malaysia, and not many studies have been done on ocular trauma. This study was undertaken to gather information on the epidemiology of ocular injuries in East Malaysia. This study can also provide some references to the future researchers who want to do more research on ocular trauma in this part of the country.

METHODS

This was a prospective study done over a period of 12 months (January 2006 to December 2006), at the Ophthalmology Department of Sarawak General Hospital, Kuching. All ocular injuries patients seen in the Ophthalmology Department for the first time were included in this study. Patients treated elsewhere and patients on follow-up were excluded from the study. The demographic details and details about the ocular injury were entered into a specially designed proforma, based on the US Trauma Registry questionnaire.⁸ Patients with severe form of ocular trauma were hospitalized and others treated as outpatients. The demographic details included name, age, gender, and ethnicity. The details about injury included the date of injury, eye affected, place, intent, source and type of injury. All ocular injuries were divided into either work related or non- work related. The nature of occupation and the use of personal protective devices were elicited in the work-related group.

The different ethnic groups were divided into categories 1-5, which included Iban, Bidayuh, Malays, Chinese and others. Age group was stratified into 10-year intervals. Place of occurrence of the injury were classified as follows: Industrial premises (any injury related to work), home, sports-related, street, public building and others. Type of the injury was classified under the following: unintentional, assault, self-inflicted and abuse (child, spouse, elder, unknown). Alcohol or drug abuse leading to ocular injury was noted. The source of ocular injury was classified as follows: sharp object, blunt object, fall, motor-vehicle accidents, fireworks, burns and eye injuries related to superficial foreign bodies were put under miscellaneous groups. The preliminary data entry was followed by detailed eye examination. Tissues involved were documented and any previous ocular abnormality was also recorded. Visual acuity was categorized as follows: 6/6 to 6/9, 6/12 to 6/36, 6/60 to CFCF (counting finger close to the face), HM (hand movement), and PL (perception of light) and NPL (no perception of light). Ocular injuries associated with other organ injury were also noted.

RESULTS

Our study involved 257 eye injuries in 233 patients. Of these 233 patients 46.8% (n=109) required outpatient management whereas 53.2% (n=124) of them needed hospitalization due to the severe nature of the ocular injury. Out of 233 patients, 85.8% (n=200) of them were males and only 14.2% (n=33) were females. The male to female ratio was 6:1. Right eye was involved in 46.4% (n=108), the left eye was involved in 43.3% (n=101) and bilateral involvement was seen in 10.3% (n=24) of the patients.

Sarawak state is a multi-racial community having nearly 29 different ethnic groups. The percentage distribution of these different ethnic groups in Sarawak is as follows: Iban 28.9%, Chinese 25.5%, Malay 22.2%. Bidayuh 8%, other indigenous population 5.7%, Melanau 5.5%, and Others 4.1%. Ocular injury was commonly noticed in Malays (32.2 %) followed by Chinese, (25.3%).

The age distribution of the patients is shown in (Table:1). The average age was 30 years, with a range of 1-72 years. Injuries were more frequent in the 21-30 years group and 41-50 year group.

Table 1. Distribution of eye injuries according to age group

Age group (Years)	No of patients (frequency)	Percentage (%)
<10	33	14.1
11-20	33	14.1
21-30	61	26.1
31-40	41	17.5
41-50	44	18.8
51-60	12	5.1
>60	9	3.8
Total	233	100

In our study 36.9% (n=86) of ocular injuries were work-related and 63.1% (n = 147) were not work-related. The type of work associated with injury is shown in (Table: 2)

Table 2. Occupations of patients with eye injuries

Occupation	Number (%)
Labourer	38 (44.2)
Mechanic	19 (22.1)
Welder	8 (9.3)
Construction worker	5 (5.8)
Farmer	4 (4.7)
General worker	4 (4.7)
Self-employed	3 (3.5)
Other occupations*	5 (5.8)
Total	86

*Include one each of the following: teacher, carpenter, crane Operator, land surveyor, driver

The different settings in which ocular injuries occurred are shown in (Table:3). The commonest location for eye injury to occur was in the home 34.3% (n=80) and industrial premises 31.8% (n=74).Injuries at school were uncommon (1.7%).

Table.3 Location of patients at the time of eye injury

Place of injury	No of patients (frequency)	Percentage (%)
Industrial premesis	74	31.7
Farm	6	2.5
Home	80	34.3
School	4	1.7
Sports and recreation centres	11	4.7
Street and highway	50	21.4
Public building	5	2.14
Others	2	0.85
Unknown	1	0.42
Total	233	100

In our series most of the patients had sustained eye injuries accidentally 92.3 %( n=215), however, 7.7% (n=18) of them sustained injuries as a result of assault. Ocular injuries in young males (20-30 years) were significantly more work-related 61% (n=33) and more assault-related 38.8% (n=7) (p = 0.01). Alcohol-related ocular injuries 6.9% (n=16) were more observed in motor-vehicle accidents.

The different modes of ocular injury in this study is shown in (Table: 4). The commonest source of injury were from blunt objects 30% (n=70) and sharp objects 23.2% (n=54).

Table. 4 Mode of eye injury

Source	Number (%)
Sharp object	54 (23.2)
Nail	15 (6.4)
Fall	11 (4.7)
Blunt object	70 (30.0)
Gunshot	2 (0.9)
Motor vehicle accident	28 (12)
Firework	2 (0.9)
Burns	14 (6.0)
Explosion	5 (2.1)
Unknown	1 (0.4)
Others	31 (13.3)
Total	233

In patients with severe ocular trauma, the initial presenting visual acuity was better in patients with contusion injuries (closed globe injury) than penetrating injuries (open globe injury). Visual acuity in patients with contusion injury and penetrating injury at presentation and after follow-up is given in (Table: 5). Visual acuity of patients better than 6/60 in contusion injuries was 70.1% (n=80) and in penetrating injury 37.25% (n=19). Follow-up visual acuity at 3 months duration showed 73.68% (n=84) and 43.13% (n=22) cases in the contusion and penetrating injury group was better than 6/60. Long term follow-up of these patients was not possible as most of the referred patients were asked to follow in the respective hospitals.

Table 5. Visual acuity at initial presentation and at 3 months follow-up

Visual acuity	Contusion Initial presentation    3-month follow-up		Penetrating injury Initial presentation   3-month follow-up
6/6 to 6/9	39	61	9	11
6/12 to 6/36	41	23	10	11
6/60 to CFCF	11	14	11	12
HM	17	12	11	8
PL	3	1	4	3
NPL	3	3	6	6
Total cases	114	114	51	51

In our series the anterior segment was involved more 79.3% (n=185) than the posterior segment 12% (n=28), however lids and adnexal structures were involved in 8.5% (n=20) of the patients.

We adopted the Birmingham’s Eye Trauma Terminology classification ⁹ to categorize our patients with severe eye injury, however patients with superficial corneal foreign body and ocular burns were grouped separately (figure 1).We had 23 patients with superficial corneal foreign bodies and 18 patients with ocular burns (chemical and thermal injury). In patients with severe ocular trauma, contusions were the commonest closed globe injury (n=114) and penetrating injuries were the commonest open globe injury (n=51) seen. In the polytrauma group 13 patients out of 17 had injury involving the face, whereas 4 patients had associated limb fractures.