ORIGINAL ARTICLE

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PATTERN OF OCULAR TRAUMA IN KUCHING, MALAYSIA

Figure 1. The Birmingham Eye Trauma Terminology System (BETT) for severeocular trauma

DISCUSSION

The incidence of ocular injuries is more in developing countries than in developed countries. In developed countries the incidence seems to be higher in industrialized areas than non-industrialized areas. Zander & Giessler¹⁰ first reported the incidence of ocular injuries in (1864), as 1.8 to 9%. Desai et al¹¹ in a prospective study involving 415 patients reported the incidence to be 8.14%. Wong et al¹² in a population-based study in Singapore reported the incidence as 12.6%. However the annual incidence rates (per 100,000 populations per year) for eye injury patients are: 13.2 (Sweden) ¹³; 15.2 (United States);¹⁴ our study involved 233 patients and 257 eyes. We could not report the incidence of ocular injuries in our study, as our sample size was small and it was a hospital-based study and not a population-based study.

Many hospital and population based studies indicate a large preponderance of injuries affecting males,¹⁵ approximately 70 to 85%.¹⁶ The greater tendency for men to sustain eye injury is multifactor which includes aggressive behaviour, work-related, sports related, assault related, alcohol and drug abuse and reluctance to use protective devices at work. In our study also, men were more involved in ocular injuries 85.8% (n=200) than women, a ratio of 6:1.

The age of occurrence of ocular trauma is bi-modal, with the maximum incidence occurring in young adults and a second peak in elderly.¹⁷ The cause for high incidence of ocular injuries in young adult males has already been highlighted. The increase incidence of ocular injuries among elderly could be because of poor vision as a result of various ocular conditions like cataract, glaucoma, age related macular degeneration and previous ocular surgeries. Schrader ¹⁸ reported that the incidence of open globe injuries in Germany was high in the elderly during early 1990’s, which he attributed to an increase rate of cataract surgeries performed during that year. Wong and Tielsch12 have shown bi-modal age pattern of ocular injury in a population-based study in Singapore. Our study did not show a bi-modal pattern, which could be due to small sample size, but showed a predominant involvement of young males. In our series ocular injuries were common in the age group of 21-30 years, followed by 41-50 years. Shukla et al¹⁹ in their prospective study involving 400 patients has shown that the commonest age group of people involved was in the third decade. A study done in Baluchistan by Qureshi²⁰ also showed similar age group involvement (21-30 years).

Malays were the predominant ethnic group indulged in ocular injuries 32.2% (n=75) in our study followed by Chinese 25.3% (n=59). Wagener et al²¹ also reported racial differences in ocular injuries; they have shown that working blacks had fewer ocular injuries than working whites. Wong et al¹² reports that the risk of ocular injuries were twice in Indian men than Chinese or Malay men in Singapore.

Bilateral involvement of the eyes usually occurs in severe form of ocular trauma, which is often associated with polytrauma. Bilateral eye injuries are usually the result of bomb blasts, anti-personal mines and motor vehicle accidents. Karaman et al²² has given figures of 3.7% for bilateral trauma and Khan et al²³ in a 12 years review of ocular trauma has given figure of bilateral trauma as 4.9%. We had 10.3% (n=24) patients with bilateral ocular involvement. Both eyes were involved mainly in patients with chemical injuries.

Work related injuries occurred in 36.9 % (n=86) of patients. The common occupations among these groups were mechanics, welders, labourers and general workers who were involved in high-powered tools activities like hammering, grinding, welding and cutting metals. None of these patients gave history of wearing protective devices while working. Though there was a high risk of ocular injury in these occupations, the use of personal protective devices was totally absent in this group. Legislation to use protective eye devices is implicated only in the major industries, whereas in small scale industries it is totally ignored. These small industries should be brought under strict legislation to implement protective eye wear. The preventive strategies should also be more focused on these areas to reduce the incidence of ocular injuries.

The causes of ocular trauma have changed continuously over the course of this century in the UK.²⁴ Almost 100 years ago, more than 70% of all serious ocular injury occurred in the work place. In 1960-1970 motor vehicle accidents, predominated the cause. Sports injury dominated in 1980’s, and now home has been recognized as the common location for ocular injury. This fact is further supported by the study done by Desai et al ¹¹ who showed that home is the frequent place of ocular injury in his study. The most common settings in which injury occurred in our series were home 34.3 % (n=80), followed by work place 31.8 % (n=74), street and highway 21.5 % (n=50). Accidents are preventable and they occur as a result of ignorance, haste, negligence, carelessness and lack of knowledge. Our series shows similar findings. Ninety-two percent (n=215) of ocular injuries were accidental and 7.7 % (n=18) were due to assault.

There was evidence of definite or possible alcohol use in 6.9 %( n=16) of the injured persons. Almost all the alcohol-related injuries were associated with motor vehicle accidents. Sports-related injuries were seen in 2.5% (n=6) patients. Blunt trauma with shuttlecock was the predominant sports injury noted in our study and we had one patient with rugby related ocular injury.

Serious eye injuries involving the orbit and intra-ocular structures are usually classified into those caused by blunt objects, large sharp objects, small flying particles and burns.²⁴ The common causes of ocular injuries in our study were blunt objects 30 % (n=70) followed by sharp objects 23.2 % (n=54).

Visual loss following ocular injury depends on the type of injury, mechanism and extent of damage sustained by the eye and the use of any protective devices. Penetrating injuries carry a poorer prognosis than contusion injuries. In our series 26.4% (n=68) had mild to moderate visual impairment (visual acuity 6/12 to 6/36) and 34.2% (n=88) suffered severe visual loss (vision 6/60 and worse). The initial visual loss was more in penetrating than contusion injuries.

Karaman et al²² in their retrospective analyses of 383 patients found 67.3% of ocular injuries were closed globe and 32.7% were open globe injuries. MacDonald ²⁵ found perforating injuries in 51.6% and contusions in 41.7% patients in study. In our analysis closed globe injuries were 125 cases (61.1%) and open-globe injuries were 67 cases (34.8%).

Chemical injuries were seen in 17 patients in our study. Acid injuries were more common than alkaline injuries, and mostly due to automobile battery explosion. Intraocular foreign body constituted 11 cases and globe rupture occurred in five cases. Motor vehicle accidents were the common mode of injury in patients with globe rupture.

Majority of ocular injury cases occur in isolation and are associated with injuries of other organs only in sever ocular trauma, especially if it is due to motor vehicle accidents. Ocular injuries are usually not given priority if it is accompanied with multiple system injuries. After identifying major organ injury and stabilizing the general condition of the patient, ocular injuries should be given preference to simple fractures, because visual loss can be a great morbidity for the patient once he recovers from the minor ailment if the ocular condition is neglected. Facial injuries may be associated with severe ocular trauma. In our study we had 7.3% cases (n=17) with injuries elsewhere in the body, but majority of the cases 92.3 % (n=216) were isolated ocular injuries.

CONCLUSION

Contusion injuries were common in young males. Home and industrial premises were the common location of ocular injuries. Public awareness and strict legislation to use personal protective devices can help to reduce the occurrence of ocular injury. Our study can be an eye opener for any further study in the field of ocular injuries in this part of the world.

ACKNOWLEDGMENTS

Thanks to Erica Kueh Yee Cheng, Statistician, for the statistical help.

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