|Year : 2014 | Volume
| Issue : 3 | Page : 141-144
The pattern and visual outcomes of ocular trauma in a large zonal hospital in a non-operational role: A 36 months retrospective analysis
Avinash Mishra1, Ashok Kumar Verma2, Vinod Kumar Baranwal3, Somesh Aggarwal4, Neeraj Bhargava5, Jitender Kumar Singh Parihar6
1 Classified Specialist Ophthalmology, Military Hospital, Ahemdabad, Gujarat, India
2 Commander No 1 Tech Trg Wing, Army Medical Core (AMC) Centre and College, Lucknow, Uttar Pradesh, India
3 Senior Advisor Ophthalmology, Command Hospital, Nothern Command, Udhampur, Jammu and Kashmir, India
4 Associate Professor, M&J Western Regional Institute of Ophthalmology, Byramjee Jeejeebhoy Medical College, Ahmedabad, Gujarat, India
5 Senior Advisor (Ophthalmology), Command Hospital (SC), Pune, Maharashtra, India
6 Professor and HOD, Department of Ophthalmology, Army Hospital (R&R), New Delhi, India
|Date of Submission||26-Aug-2013|
|Date of Acceptance||25-May-2014|
|Date of Web Publication||16-Aug-2014|
Dr. Avinash Mishra
Eye Department, Military Hospital, Hanuman Camp, Shahibag, Ahemdabad, Gujrat, Pin - 380 003
Source of Support: None, Conflict of Interest: None
Aim: To determine the pattern of ocular injuries presenting to the accident and emergency department of a large zonal level hospital in a non operational area. Material and Methods: This retrospective study was conducted from July 2009 to June 2012 in a large, 580 bedded, zonal level military hospital. This hospital caters to serving soldiers, ex-servicemen, and their dependants as well as several large premier military training establishments. It is by far the largest service hospital in its state, and its eye center is the only military eye care facility available for the above-mentioned group of patients. Ocular trauma in our study was defined as any eye injury requiring medical attention. Results: Of the 177 patients included in the study, 153 (86.4%) sustained a closed globe injury while 24 (13.6%) had open globe injuries. One hundred and forty-eight (83.6%) of them presented within 24 hours of injury. One hundred and fifty-one (85.3%) patients required hospital admission. Finally, none of the patients involved were wearing any kind of protective eyewear at the time of injury. Conclusion: This study is unique for the fact that it involves both the military personnel as well as civilians and its analysis provides an insight into the pattern of ocular trauma in our set up. To the best of our knowledge, this is the only study which has been done combining both these entities. The findings indicate that ocular trauma is a significant cause of visual morbidity in this segment of population.
Keywords: Ocular trauma, pattern, visual outcome
|How to cite this article:|
Mishra A, Verma AK, Baranwal VK, Aggarwal S, Bhargava N, Parihar JS. The pattern and visual outcomes of ocular trauma in a large zonal hospital in a non-operational role: A 36 months retrospective analysis. J Clin Ophthalmol Res 2014;2:141-4
|How to cite this URL:|
Mishra A, Verma AK, Baranwal VK, Aggarwal S, Bhargava N, Parihar JS. The pattern and visual outcomes of ocular trauma in a large zonal hospital in a non-operational role: A 36 months retrospective analysis. J Clin Ophthalmol Res [serial online] 2014 [cited 2022 Jul 5];2:141-4. Available from: https://www.jcor.in/text.asp?2014/2/3/141/138856
The eyes occupy only 0.1% of the total and 0.27% of the anterior body surface area; howeve,r ocular trauma is far more commonly seen than what these small figures might indicate. Loss of vision in one or both eyes is so significant that it has been classified as a 24% of whole-person impairment and 85% of whole-person disability, respectively. 
Worldwide eye injuries are responsible for about 1.6 million people being blind and a further 19 million suffering from monocular blindness.  Furthermore, ocular injuries constitute a major cause of visual morbidity, with a significant socioeconomic impact. They are also considered an important, preventable, public health problem the world over. 
These injuries are far more commonly seen in males (the male to female ratio being 4:1) and in them it occurs at a much younger age (average age, 36 years) than in women (average age, 73 years). 
Out of all types of ocular emergencies, ocular trauma is by far the commonest, constituting nearly 75% of all ocular emergencies. 
The aim of this study was to determine the pattern of ocular injuries presenting to the accident and emergency department of a large zonal level hospital in a non operational area.
| Materials and Methods|| |
After obtaining the necessary clearance from the ethics committee, a study was conducted, retrospectively, from July 2009 to June 2012 in a large, 580 bedded, zonal level military hospital. This hospital caters to serving soldiers, ex-servicemen, and their dependants as well as the personnel serving in several large premier military training establishments. It is by far the largest service hospital in the state, and its eye center is the only military eye care facility available for the above mentioned group of patients.
These patients either presented directly to this hospital or were referred from other peripheral hospitals/polyclinics. All patients with varying degrees of ocular injuries were taken into consideration in this study. Ocular trauma in our study was defined as any eye injury requiring medical attention. The injuries were classified using The Birmingham Eye Trauma Terminology (BETT) system  [Table 1]. All patients underwent a comprehensive ocular examination including visual acuity (using Snellen chart), torch light examination, slit lamp biomicroscopy including fluorescein staining, and direct ophthalmoscopy. During the initial examination, we also evaluated the ocular trauma score (OTS) of each and every injured eye using the Ocular Trauma Scoring system, developed by Kuhn et al., since it provides prognostic information regarding the final visual outcome post-eye injury. It is a scoring system that takes into account six variables [Table 2]. Higher OTS scores tend to indicate a better visual prognosis.  Though there is no doubt that computed tomography (CT) is the best initial mode of imaging,  specially wherein a retained intra ocular foreign body is suspected; however, this facility was not available at this center till as late as September 10 and we had to make our diagnosis on the basis of history, clinical assessment as well as the basic radiological investigations like radiographs and ultrasound.
|Table 1: The Birmingham Eye Trauma Terminology (BETT) system of classification of ocular injuries|
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| Results|| |
A total of 177 patients of ocular trauma were managed in this hospital. Age-wise distribution of these cases [Figure 1], reflects that more than 50%, i.e., 89 of the patients involved were young, i.e., between 10-29 years of age. Majority of our patients were males 134 (75.7%). A large majority of the patients, i.e., 148 (83.6%) had presented within 24 hours of injury. The most common cause of injury, 34 cases (19.2%) was sports and recreational activities. Road traffic accidents (20), falls (9), and assault (14) were together responsible for 43 (24.3%) of cases. We also noted that 24 of these three causes, i.e., more that 50%, were intoxicated due to excess alcohol consumption at the time of presentation, implying that alcohol-related injury was significantly high in our study.
The various clinical finding on presentation to this center is shown in [Table 3]. The most common presentation was with subconjunctival hemorrhage, i.e., 27 (15.3%) followed by laceration wounds involving the conjunctiva/cornea/sclera seen in 24 (13.6%) of the cases. The OTS evaluation of the patient revealed 23 (13%) had a score of 1 (extremely bad visual prognosis) while 109 (61%) had a score of 5 (relatively good visual prognosis). The remaining 45 patients had a score from 2-4. Though, some of the patients were managed conservatively, however many of them, i.e., 111 (62.7%) required a surgical intervention. Out of these, a total of 92 cases, i.e., (52.9%) of them were operated at our center [Figure 2]. The most common surgical procedure we performed was repair of the cornea/sclera/conjunctiva. There was no statistically significant difference as far as which eye was injured with only the right eye being involved in 83 (46.9%) and only the left eye being involved in 85 (49.1%) of the patients. Both the eyes were involved in 9 (5.1%) of the patients. Visual acuity of the patients recorded on presentation as well as the final visual acuity after treatment [Table 4] reflects that most of the patients were discharged with a significant improvement in their vision, with 136 (76.8%) of them achieving a vision of 6/12 or better.
|Table 4: Visual acuity at presentation and the final visual acuity after treatment|
Click here to view
A total of 24 (13.6%) eyes had open globe injuries. In our study, open globe injuries, like by definition, included all cases with a full thickness defect in the cornea and or sclera. Eight of these cases were due to road traffic accidents (RTA), six were due to assault, and five occurred during military training exercises. The remaining five cases were due to various causes like sports, falls, and due to accidents at home or school.
One hundred and fifty-one (85.3%) patients required in patient care. One hundred and eleven (62.3%) of the cases also required surgical intervention. Out of these 92 cases, i.e., 82.9 % of them were operated at our center while the remaining 19 cases, i.e., 17.1% needed to be referred to a higher center after stabilizing the eye and providing the necessary initial management [Figure 2]. The various causes of referral to higher centers are shown in [Table 5]. Most of these cases involved the posterior segment of the eye, the facilities as well as the expertise of their management was not present at this center. Unresolving vitreous hemorrhage and retinal detachment were the two most common causes for a further referral.
| Discussion|| |
Vision is one of the most valued and powerful of the senses, with an intact binocular vision playing an important role in development, independence, and improving the very quality of life. Ophthalmic trauma is a major public health problem and immediate and comprehensive medical care is mandatory for all ocular trauma patients. Several studies have been carried out concerning ocular injuries in solely military personnel , and also those involving only the civilian populations;  however, this study is unique because it involves both the military personnel, serving as well as those who have retired from active service. It also involved all their dependants, i.e., civilians. To the best of our knowledge, this is the only study which has been done combining both these entities. This study is also unique for the fact that most of the earlier studies have been carried based on the available hospital data.  However our study was carried out involving both the hospitalized patients as well as the mild cases, which did not need hospitalization, most of our patients affected were in the young economically productive age group. Similar findings were also noticed in our study as well as other studies carried out worldwide. , Sports and recreational activities were most commonly responsible for the injuries. Other studies too have portrayed a similar finding. , Cricket, football, boxing, hockey, basket ball, all types of racquet sports, and full contact martial arts were most commonly the culprits. All these games are very popular in the services as well as among children. Playing with bow and arrow, and gullidanda are a unique and common cause of ocular injury in our country  and we too received our share of these. Military exercises too were responsible for a significant number of injuries, 25 (14.1%). These occurred during jungle training, field exercises, organized war games, or counter insurgency acting exercises as well as firing, handling explosives, and skill training. Similar findings have been shown in other studies too. 
The number of open globe injuries in our study was 24 (13.6 %), which was much lower than seen in other studies, some of which showed them to be as high as 80.4%. ,
Similarly, the percentage of patients requiring surgical intervention was lower in our study as compared with some earlier studies which have shown that nearly 77% of these cases require one or more surgical procedures. 
A significant improvement in vision was seen on discharge among most patients. These results are far better than some other previous studies wherein the best corrected visual acuity on discharge has been reflected to be as low as 1/60 in over 77% of cases.  We feel that an early presentation post injury, as well as a lesser number of open globe injuries played an important role in our achieving such good results. However, 17 (9.6%) patients were discharged with a best corrected vision of 6/60 or less. Out of these, 2 eyes had to undergo enucleation. One of these had had come after a severe RTA and a practically auto enucleated eye and the other had presented 3 months after the injury, with a painful blind eye. Involvement of the posterior segment was a significant factor responsible for a poor visual outcome. Retinal detachment and endophthalmitis were specially found to be associated with a bad visual prognosis. Other risk factors related to bad visual prognosis were extremes of age and injury caused by assault or road traffic accidents. Conversely, young age, contusion, and a good vision on presentation signalled a better outcome.
The most important strength of this study is that the ophthalmological examination and recording of clinical findings in all cases was carried out by a single examiner. Another major strength was that it being a military set up, all the patients were easily available for examination and follow-up till their final disposal. Also all patients in the study group per force had to report to this center only, so underreporting of injuries was never an issue. Another plus point about this study was that it included both the patients who required admission as well as those who were managed on an outpatient basis, unlike most other studies which are just based on the medical records of the admitted patients.
The major limitation of this study was that the demographics of the population studied are unique, and extrapolation to other populations may not be accurate. Another limitation was the fact that this study is retrospective and non-randomized in nature. Ocular injury is frequently a preventable cause of visual impairment. Since 100% prevention is the goal in all cases of eye injuries, attention should be directed to potential causes of injury on the playfield, at home, and the workplace. In our study, a large number of cases were alcohol related. Excess alcohol consumption is well known to be associated with serious and sometimes even fatal accidents. The troops as well as the officers commanding them along with the community as a whole should be educated about the possible dangerous and sometimes even fatal adverse effects of excessive alcohol consumption. We recommend strict administrative action to be enforced against those found to be indulging excessively and then attempting to drive or getting into uncalled for fights.
Public health education aimed at increasing awareness among parents, guardians, and school teachers regarding the need for supervision of children, and institution of prevention programs, especially for the vulnerable groups, is urgently needed in order to reduce ocular morbidity due to ocular trauma.
Since none of the patients were wearing any kind of eye protection we recommend wearing protective eye gear while engaged in potentially dangerous tasks, not only at work but also during recreational activities. Many of the sports-related eye injuries could have been prevented by wearing the recommended protective equipment. 
We also recommend a long-term database of all ocular injuries on a larger scale, to aid in research, and to develop new and effective preventive strategies.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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