Acessibilidade / Reportar erro

Profile of pediatric eye trauma at Hospital de Base do Distrito Federal (HBDF), Brasília, Brazil

Perfil do trauma ocular pediátrico no Hospital de Base do Distrito Federal (HBDF), Brasília, Brasil

Summary

Objective:

To describe the epidemiological profile of ocular trauma in children at the HBDF emergency department.

Method:

Descriptive, cross-sectional study. We evaluated 103 cases of ocular trauma in children less than 15 years between July 2012 and January 2013. The factors evaluated through semi-structured questionnaire available online were: age, gender, adult supervision, mechanism, type of trauma, time and place, site and nature of injury, visual acuity, need for hospitalization and/or surgery, type of surgery, mother’s level of education, and family income.

Results:

The average age of patients studied was 7.5 years. Boys (68%) predominate in all age groups. Blunt trauma prevailed (55.3%), followed by open (20%). Most of the cases occurred at home, 14 to 20 hours before seeking hospital care. The most common causes were: wood, stone, bicycle, broken glass, and falls. The cornea was affected in 54%. Visual acuity was ≥20/40 in 68.9%. Primary repair of the eye wall was indicated in 70.37% (p-value=0.022). Open traumas were more severe (p-value=0.005) and had more need for intervention (p-value=0.000). The injuries occurred despite the presence of adult supervision in 54% (p-value=0.002). The most severe injuries predominated in the age range 7-15 years (p=0.001).

Conclusion:

Ocular trauma was more frequent among boys. The mechanisms of injury are the most diverse, and prevail at home. Blunt trauma prevails, but the visual impact is due to open trauma. Programs of prevention and education on child ocular trauma are needed.

Keywords
risk factors; hospital emergency servic; eye injury; child; epidemiology

Resumo

Objetivo:

descrever o perfil epidemiológico do trauma ocular infantil na urgência do HBDF.

Método:

estudo transversal, descritivo. Avaliaram-se 103 casos de trauma ocular em menores de 15 anos entre julho de 2012 e janeiro de 2013, por meio de aplicação de questionário semiestruturado disponível online: idade, sexo, presença de supervisão, mecanismo, tipo do trauma, local e hora, sítio e natureza da injúria, acuidade visual, necessidade de internação e/ou cirurgia, tipo de cirurgia, escolaridade materna e renda familiar.

Resultados:

a média de idade dos pacientes analisados foi 7,5 anos. Os meninos (68%) predominaram em todas as faixas etárias. O trauma fechado prevaleceu (55,3%), seguido do aberto (20%). A maioria dos casos ocorreram em casa, no período de 14 às 20 horas. As causas mais comuns foram: madeira, pedra, bicicleta, caco de vidro e quedas. A córnea foi acometida em 54%. A acuidade visual foi ≥20/40 em 68,9%. Indicou-se sutura primária da parede em 70,37% (p-valor=0,022). O trauma mais grave (p-valor=0,005) e que mais necessitou de intervenção (p-valor=0,000) foi o aberto. As injúrias ocorreram, apesar da presença de supervisão de um adulto, em 54% (p-valor=0,002). Os traumas mais graves predominaram entre 7-15 anos (p-valor=0,001).

Conclusão:

o trauma ocular infantil foi mais frequente nos meninos. Os mecanismos de lesão são os mais diversos e predominaram no domicílio. O trauma fechado prevaleceu; porém, o maior impacto visual decorreu do trauma aberto. São necessários programas de prevenção e educação em trauma ocular infantil.

Palavras-chave
fatores de risco; serviço hospitalar de emergência,; lesões oculares; criança; epidemiologia

INTRODUCTION

Sight is essential for full child development, influencing learning, language for expression and reception, and the ability to interact.11 Nakanami C, Vasconcelos G. Abordagem clínica da criança com baixa visão. In: Série Oftalmologia Brasileira Óptica. Refração e visão subnormal. Rio de Janeiro: Cultura Médica, 2008. p.457-68.

It is estimated that 20 to 50% of eye traumas occur in children,22 Thompson CG, Kumar N, Billson FA, Martin F. The aetiology of perforating ocular injuries in children. Br J Ophthalmol. 2002; 86(8):920-2.,33 Négrel AD, Thylefors B. The global impact of eye injuries. Ophthalmic Epidemiol. 1998; 5(3):143-69. constituting a serious public health problem,33 Négrel AD, Thylefors B. The global impact of eye injuries. Ophthalmic Epidemiol. 1998; 5(3):143-69. which can result in blindness in addition to long-term functional repercussions.33 Négrel AD, Thylefors B. The global impact of eye injuries. Ophthalmic Epidemiol. 1998; 5(3):143-69.

Motor disability, a tendency to imitate adult behavior, relative ignorance regarding risks, and natural curiosity, as well as cultural issues, contribute to children being more susceptible.44 Serrano JC, Chalela P, Arias JD. Epidemiology of childhood ocular trauma in a northeastern Colombian region. Arch Ophthalmol. 2003; 121(10):1439-45.

Despite clinical management being similar to that of cases in adults, child trauma has its own particularities, such as the etiology, surgical recovery and the major socioeconomic impact due to the long life expectancy of children.22 Thompson CG, Kumar N, Billson FA, Martin F. The aetiology of perforating ocular injuries in children. Br J Ophthalmol. 2002; 86(8):920-2.

In addition, the prognosis of these injuries in children is worse, because there is a greater tendency to ocular atrophy in puncture wounds and a serious problem of amblyopia, which is understood as the failure in the consolidation of visual acuity, resulting from lack of stimuli or inappropriate stimuli during the critical period of development, when the brain is labile to adjust to changes in visual experience, which occurs up to the eighth year of life.11 Nakanami C, Vasconcelos G. Abordagem clínica da criança com baixa visão. In: Série Oftalmologia Brasileira Óptica. Refração e visão subnormal. Rio de Janeiro: Cultura Médica, 2008. p.457-68.

Currently the majority of studies are conducted in developed countries;33 Négrel AD, Thylefors B. The global impact of eye injuries. Ophthalmic Epidemiol. 1998; 5(3):143-69. however, local epidemiology is essential for the development of preventive strategies.66 Liu M, Chang Y, Tseng S, Cheng H, Huang F, Shih M. Major pediatric ocular trauma in Taiwan. J Pediatr Ophthalmol Strabismus. 2010; 47(2):88-95.

The aim of this study is to describe the epidemiological profile of emergency pediatric eye trauma at the Hospital de Base do Distrito Federal (HBDF), Brazil, a trauma reference center for the greater federal district area, contributing to the planning and implementation of preventive measures for this injury.

METHOD

A cross-sectional, descriptive study was carried out, based on the evaluation of cases of incidents of acute eye trauma among children from 0 to 15 years admitted to the ophthalmology emergency service at the HBDF, Brasília, Distrito Federal (DF), from July 2012 to January 2013.

The HBDF is a teaching hospital, and is included in the hierarchical health care network, with the mission of providing high complexity care. It is considered a trauma reference center for the greater Brasília area, as well as receiving cases from neighboring states.

The survey included all cases of acute eye trauma, of whatever nature, in children under 15 years of age, with no cases of abstention. The exclusion criteria were: age of over 15 years, admissions for chronic sequelae from eye trauma or cases due to other acute or chronic degenerative causes, for example: conjunctivitis, hordeolum, keratoconus, pterygium, and more.

The data were collected from a semi-structured questionnaire developed for the purpose of research, based on the literature review, and made available in an online platform (Google Drive) for completion in real time. We assessed the age (in full years), sex, presence of adult supervision at the time of the trauma, mechanism and type of trauma, time and place of the trauma, site and nature of the injury, visual acuity without correction, the need for hospitalization and/or surgery, type of surgery, household income and the mother’s level of education.

To evaluate the type of trauma the classification of the Birmingham Eye Trauma Terminology (BETT) was used, which is recommended by the International Society of Ocular Trauma, and classifies trauma of mechanical nature.77 Kuhn F, Morris R, Witherspoon CD, Mester V. The Birmingham Eye Trauma Terminology system (BETT). J Fr Ophtalmol. 2004; 27(2):206-10. The BETT defines eye bulb as a whole as a reference element; thus it proposes that the trauma with involvement of the entire thickness of the wall (cornea/sclera), with or without involvement of the retina and choroid, is classified as an open trauma. Closed or blunt trauma, on the other hand, would be classified as one in which the eye wall remains intact.77 Kuhn F, Morris R, Witherspoon CD, Mester V. The Birmingham Eye Trauma Terminology system (BETT). J Fr Ophtalmol. 2004; 27(2):206-10. Trauma with eyelid involvement, chemical trauma and burns were added to this classification.44 Serrano JC, Chalela P, Arias JD. Epidemiology of childhood ocular trauma in a northeastern Colombian region. Arch Ophthalmol. 2003; 121(10):1439-45.

The eye exam of the child assessed the parameters of: visual acuity (without correction), external inspection with or without the aid of a flashlight, pupillary light reflex, ocular motility, biomicroscopy with slit lamp and ophthalmoscopy, whenever possible, in accordance with the age of the child and respecting the limitations arising from the moment of stress caused by the trauma.

The evaluation of visual acuity was standardized, with the fixation and following test held in pre-schoolers (0-6 years), and visual acuity measured by the Snellen chart in schoolchildren (7-15 years).

The statistical analyses were performed using SPSS 18.0 software. Bivariate analysis, chi-square test, Student’s t-test and Fisher’s exact test were used, considering statistical significance p-value<0.05.

The research was approved and conducted with the consent of the Research Ethics Committee CEP/FS at Universidade de Brasília under registration number 138/12, and met the requirements of the Declaration of Helsinki, including obtaining informed consent in writing (from the legal guardians of the participants of the study), ensuring the right to non-participation and confidentiality of the information obtained.

RESULTS

Of the 103 cases evaluated, 68%, were male and 32% were female; with a ratio of 2.12 boys for every girl and an average age of 7.5 years.

Most of the cases sought hospital care on the same day as the accident (43.7%).

The accidents occurred mainly between 2 pm and 8 pm (51%), at home (62.1%) and with adult supervision (54%), being caused by the child itself in 54.4% of cases. In one case shaken baby syndrome was suspected, and the patient was promptly forwarded to be followed up by the Social Service sector of the hospital.

The causative agents varied, with the most common being: wood (11.7%), stone (8.7%), falls (5.8%), cycling (3.9%) and pieces of glass (3.9%). The less common agents included: cement, nails, fingernails and clothesline with 2.9% each; wire, being run over, balls, physical contact, knives, irons, pencils, mobile phones, with 1.9% each; and other agents such as stairs, soap, party explosives, glue, dog bite, ammonia, plastic, alcohol, among others, with 1% of cases.

The most prevalent sites of ocular injury were the conjunctiva (54%), cornea (54%) and eyelid (53%), while lens (11%), scleral (5%) and posterior pole injuries (1%) were rare.

To analyze the involvement of each eye structure separately, it was observed that in purely corneal injuries there was a prominence of keratitis and corneal laceration (12 cases each, 16.43%), and corneal abrasion (10 cases, 13.69%).

In eyelid injuries edema and excoriation (14 cases, 19.17%) were the most common, followed by eyelid laceration (13 cases, 17.80%), bruising (3 cases, 4.10%), burns (2 cases, 2.73%) and one case of eyelid ptosis (1.36%).

The majority of injuries to the conjunctiva were cases of hyposphagma (13 cases, 17.80%), followed by hyperemia (4 cases, 5.47%) and laceration (3 cases, 4.10%). There were three cases of scleral laceration (4.10%) and one case (1.36%) of isolated involvement of the lens (phacodonesis).

To evaluate joint injuries of multiple ocular structures a wide range of abnormalities were found, such as: 14 cases of corneal laceration associated with the traumatic cataract and/or iridian impairment or otherwise (46.7%), and one case of extensive corneal-scleral laceration (3.4%), in addition to an association between eyelid and corneal injuries (laceration and/or eyelid edema with keratitis) in six cases (20%), and also five cases (16.7%) of injury to the conjunctiva and cornea (keratitis with hyposphagma).

There were three cases (10%) of intraocular foreign body associated with corneal laceration (2 caused by wood and 1 by glass) and one case (3.4%) of severe trauma with the association of eyelid laceration, corneal laceration, cataract, iridodialysis, vitreous hemorrhage, and retinal detachment.

There was no significant difference in relation to laterality (45.6% right eye and 47.6% left eye), and 6.8% showed bilateral injury.

Closed trauma predominated (55.3%), followed by open (20%), eyelid (18.4%) and chemical trauma (3.9%) and burns (2.9%) (Table 1).

TABLE 1
Factors related to severity of trauma (n=100).

The largest number of closed traumas (42.10%) occurred between 2 to 6 years of age. In relation to open trauma, 55% occurred between 11 to 15 years, although there is no significant association between the variables (Table 2).

TABLE 2
Variables correlated to age range (n=103).

The most serious traumas predominated between 7 and 15 years of age (24%) (p-value=0.001) (Table 1).

Most cases (68.9%) showed good visual acuity after the trauma. However, 21 (20.4%) patients suffered severe loss (Table 1).

When correlating visual acuity with the classification of the trauma (BEET), open traumas proved to be more severe (p-value=0.000) (Table 1).

Hospitalization occurred in 28.2%, while in 26.2% there was surgical intervention (p-value=0.000) (Table 3). The severity of the injury correlated with the type of surgery (p-value=0.022), the most common being primary closure of the eye wall (Table 1).

TABLE 3
Relation among surgical indication, trauma classification and need for hospital admission (n=103).

When analyzing the classification of the trauma, visual acuity and the need for surgery, it was noted that open trauma (p-value=0.000) (Table 3), as well as patients with worst visual acuity upon admission (p-value=0.000) (Table 1) were those most in need of intervention.

In relation to socioeconomic characteristics, most mothers completed primary education (39.8%) and family income was up two minimum wages (58%), with income (p-value=0.270) and level of education (p-value=0.278) having no influence on the severity of the injury. However, severe traumas were more frequent in children whose mother’s level of education was primary education (17.7%), and with household income of up to two minimum wages (21.7%) (Table 1).

There is an association between age and presence or absence of supervision (p=0.002). Children under six years old had a higher probability of being supervised and suffered fewer accidents compared to those over the age of seven years (Table 2).

DISCUSSION

This was the first work in the Emergency Department of the HBDF with the intention of describing the epidemiology of pediatric eye trauma.

We decided to carry out an exploratory study with the goal of providing first contact for investigation, because the knowledge and understanding about the phenomenon under study were insufficient or non-existent.

Despite all the physical limitations and the large volume of treatments at the ophthalmic emergency service, special time was dedicated to these patients because they were cases of eye trauma in the pediatric population, a fact which, by itself, mobilizes the entire medical team on duty.

At times it was not possible to perform the complete examination due to stressful circumstances associated with the trauma, rendering the child uncooperative, and making it impossible to assess visual acuity in three cases and perform the ophthalmoscopy in nine cases. These cases, and all others that required return and monitoring were later assessed routinely in the ophthalmic emergency department, depending on the severity of the injuries.

It was observed that boys were most affected, perhaps for engaging in activities of higher risk compared to girls.88 Armstrong GW, Kim JG, Linakis JG, Mello MJ, Greenberg PB. Pediatric eye injuries presenting to United States emergency departments: 2001-2007. Graefes Arch ClinExp Ophthalmol. 2013; 251(3):629-36.

9 Mowatt L, McDonald, Ferron BD. Paediatric ocular trauma admissions to the University Hospital of the West Indies 2000-2005. West Indian Med J. 2012; 61(6):598-604.

10 Cascairo MA, Mazow ML, Prager TC. Pediatric ocular trauma: a retrospective survey. J Pediatr Ophthalmol Strabismus. 1994; 31(5):312-7.

11 Labrada Rodrigues YH, Flores Pérez D, González Hess L. Trauma ocular en niños. Rev Cub Oftalmol. 2003; 16(2):3.

12 Rostomian K, Thach AB, Isfahani A, Pakkar A, Pakkar R, Borchert M. Open globe injuries in children. J AAPOS. 1998; 2(4):234-8.
-1313 Mensah A, Fany A, Adjorlolo C, Touré ML, Kasieu M, Mihluedo KA, et al. Épidémiologie des traumatismes oculaires de l’enfant à Abidjan. SANTE. 2004; 14(4):239-43. For this reason, gender is considered to be a strong risk factor.22 Thompson CG, Kumar N, Billson FA, Martin F. The aetiology of perforating ocular injuries in children. Br J Ophthalmol. 2002; 86(8):920-2.,44 Serrano JC, Chalela P, Arias JD. Epidemiology of childhood ocular trauma in a northeastern Colombian region. Arch Ophthalmol. 2003; 121(10):1439-45.

5 Hosseini H, Masoumpour M, Fatemeh KF, Razeghinejad M, Salouti R, Nowroozzadeh M. Clinical and epidemiologic characteristics of severe childhood ocular injuries in Southern Iran. Middle East Afr J Ophthalmol. 2011; 8(2):136-40.
-66 Liu M, Chang Y, Tseng S, Cheng H, Huang F, Shih M. Major pediatric ocular trauma in Taiwan. J Pediatr Ophthalmol Strabismus. 2010; 47(2):88-95.,88 Armstrong GW, Kim JG, Linakis JG, Mello MJ, Greenberg PB. Pediatric eye injuries presenting to United States emergency departments: 2001-2007. Graefes Arch ClinExp Ophthalmol. 2013; 251(3):629-36.,1414 Lee CH, Su WY, Lee L, Yang ML. Pediatric ocular trauma in Taiwan. Chang Gung Med J. 2008; 31(1):59-65.

15 Sharifzadeh M, Rahmanikhah E, Nakhaee N. Pattern of pediatric eye injuries in Tehran, Iran. Int Ophthalmol. 2013; 33(3):255-9.
-1616 Diniz CM, Tzelikis PFM, Alvim HS, Gonçalves RM, Rodrigues Jr A, Trindade FC. Trauma ocular em crianças abaixo de 15 anos: prevenção baseada em estatísticas. Rev Bras Oftalmol. 2003; 62(2):96-101. The male:female ratio varies according to the population and age group, reaching 5.2:1.1313 Mensah A, Fany A, Adjorlolo C, Touré ML, Kasieu M, Mihluedo KA, et al. Épidémiologie des traumatismes oculaires de l’enfant à Abidjan. SANTE. 2004; 14(4):239-43. However, in most studies22 Thompson CG, Kumar N, Billson FA, Martin F. The aetiology of perforating ocular injuries in children. Br J Ophthalmol. 2002; 86(8):920-2.,44 Serrano JC, Chalela P, Arias JD. Epidemiology of childhood ocular trauma in a northeastern Colombian region. Arch Ophthalmol. 2003; 121(10):1439-45.

5 Hosseini H, Masoumpour M, Fatemeh KF, Razeghinejad M, Salouti R, Nowroozzadeh M. Clinical and epidemiologic characteristics of severe childhood ocular injuries in Southern Iran. Middle East Afr J Ophthalmol. 2011; 8(2):136-40.
-66 Liu M, Chang Y, Tseng S, Cheng H, Huang F, Shih M. Major pediatric ocular trauma in Taiwan. J Pediatr Ophthalmol Strabismus. 2010; 47(2):88-95.,88 Armstrong GW, Kim JG, Linakis JG, Mello MJ, Greenberg PB. Pediatric eye injuries presenting to United States emergency departments: 2001-2007. Graefes Arch ClinExp Ophthalmol. 2013; 251(3):629-36.,1414 Lee CH, Su WY, Lee L, Yang ML. Pediatric ocular trauma in Taiwan. Chang Gung Med J. 2008; 31(1):59-65.

15 Sharifzadeh M, Rahmanikhah E, Nakhaee N. Pattern of pediatric eye injuries in Tehran, Iran. Int Ophthalmol. 2013; 33(3):255-9.
-1616 Diniz CM, Tzelikis PFM, Alvim HS, Gonçalves RM, Rodrigues Jr A, Trindade FC. Trauma ocular em crianças abaixo de 15 anos: prevenção baseada em estatísticas. Rev Bras Oftalmol. 2003; 62(2):96-101. the ratio is between 2 to 3:1, which corroborates with this study.

Children between 2 and 6 years were most susceptible, a similar finding to other studies,22 Thompson CG, Kumar N, Billson FA, Martin F. The aetiology of perforating ocular injuries in children. Br J Ophthalmol. 2002; 86(8):920-2.,44 Serrano JC, Chalela P, Arias JD. Epidemiology of childhood ocular trauma in a northeastern Colombian region. Arch Ophthalmol. 2003; 121(10):1439-45.,1212 Rostomian K, Thach AB, Isfahani A, Pakkar A, Pakkar R, Borchert M. Open globe injuries in children. J AAPOS. 1998; 2(4):234-8.,1717 El-Sebaity DM, Soliman W, Soliman AM, Fathalla AM. Pediatric eye injuries in upper Egypt. Clin Ophthalmol. 2011; 5:1417-23. probably due to immaturity of the motor system, limited sense of risk assessment and the natural curiosity of childhood.44 Serrano JC, Chalela P, Arias JD. Epidemiology of childhood ocular trauma in a northeastern Colombian region. Arch Ophthalmol. 2003; 121(10):1439-45.

The lack of standardization in the definition of childhood and categorization of age groups hinders a comparative analysis between studies.33 Négrel AD, Thylefors B. The global impact of eye injuries. Ophthalmic Epidemiol. 1998; 5(3):143-69.

The injuries with greater visual impairment mostly affect children over 6 years; however, when seeking to define the age group at greatest risk there is divergence between studies,1818 Cariello AJ, Moraes NSB, Mitne S, Oita CS, Fontes BM, Melo Jr LAS. Epidemiological findings of ocular trauma in childhood. Arq Bras Oftalmol. 2007; 70(2):271-5.,1919 MacEwen CJ, Baines PS, Desai P. Eye injuries in children: the current picture. Br J Ophthalmol. 1999; 83(8):933-6. which reinforces the need for regional epidemiological research.33 Négrel AD, Thylefors B. The global impact of eye injuries. Ophthalmic Epidemiol. 1998; 5(3):143-69.

The group of special interest from the point of view of prevention are children under the age of 8 years at risk of amblyopia, an injury that should be treated and monitored regardless of the involvement of the trauma itself, as it may cause persistent and irreversible visual loss, which has a great impact when it comes to children who still have a long life expectancy.11 Nakanami C, Vasconcelos G. Abordagem clínica da criança com baixa visão. In: Série Oftalmologia Brasileira Óptica. Refração e visão subnormal. Rio de Janeiro: Cultura Médica, 2008. p.457-68.

The present study confirmed that accidents occur most often at home,22 Thompson CG, Kumar N, Billson FA, Martin F. The aetiology of perforating ocular injuries in children. Br J Ophthalmol. 2002; 86(8):920-2.,44 Serrano JC, Chalela P, Arias JD. Epidemiology of childhood ocular trauma in a northeastern Colombian region. Arch Ophthalmol. 2003; 121(10):1439-45.,66 Liu M, Chang Y, Tseng S, Cheng H, Huang F, Shih M. Major pediatric ocular trauma in Taiwan. J Pediatr Ophthalmol Strabismus. 2010; 47(2):88-95.,88 Armstrong GW, Kim JG, Linakis JG, Mello MJ, Greenberg PB. Pediatric eye injuries presenting to United States emergency departments: 2001-2007. Graefes Arch ClinExp Ophthalmol. 2013; 251(3):629-36.,1515 Sharifzadeh M, Rahmanikhah E, Nakhaee N. Pattern of pediatric eye injuries in Tehran, Iran. Int Ophthalmol. 2013; 33(3):255-9.

16 Diniz CM, Tzelikis PFM, Alvim HS, Gonçalves RM, Rodrigues Jr A, Trindade FC. Trauma ocular em crianças abaixo de 15 anos: prevenção baseada em estatísticas. Rev Bras Oftalmol. 2003; 62(2):96-101.

17 El-Sebaity DM, Soliman W, Soliman AM, Fathalla AM. Pediatric eye injuries in upper Egypt. Clin Ophthalmol. 2011; 5:1417-23.
-1818 Cariello AJ, Moraes NSB, Mitne S, Oita CS, Fontes BM, Melo Jr LAS. Epidemiological findings of ocular trauma in childhood. Arq Bras Oftalmol. 2007; 70(2):271-5. diverging from other research, where 67.3% occurred on the street.1717 El-Sebaity DM, Soliman W, Soliman AM, Fathalla AM. Pediatric eye injuries in upper Egypt. Clin Ophthalmol. 2011; 5:1417-23.

In relation to time, most injuries occurred between 2 pm and 8 pm (51%), which corroborates with the literature.22 Thompson CG, Kumar N, Billson FA, Martin F. The aetiology of perforating ocular injuries in children. Br J Ophthalmol. 2002; 86(8):920-2.,1515 Sharifzadeh M, Rahmanikhah E, Nakhaee N. Pattern of pediatric eye injuries in Tehran, Iran. Int Ophthalmol. 2013; 33(3):255-9.,1616 Diniz CM, Tzelikis PFM, Alvim HS, Gonçalves RM, Rodrigues Jr A, Trindade FC. Trauma ocular em crianças abaixo de 15 anos: prevenção baseada em estatísticas. Rev Bras Oftalmol. 2003; 62(2):96-101.

A Nigerian study2121 Ashaye AO. Eye injuries in children and adolescent: a report of 205 cases. J Natl Med Assoc. 2009; 101(1):51-6. indicated that 24.9% of accidents were caused by an adult. In a study published in Thailand,66 Liu M, Chang Y, Tseng S, Cheng H, Huang F, Shih M. Major pediatric ocular trauma in Taiwan. J Pediatr Ophthalmol Strabismus. 2010; 47(2):88-95. the patient was responsible in 18.6% of cases, followed by classmates (16%) and siblings (6.7%), similar to this research.

The number of cases without supervision outweighs the those supervised.44 Serrano JC, Chalela P, Arias JD. Epidemiology of childhood ocular trauma in a northeastern Colombian region. Arch Ophthalmol. 2003; 121(10):1439-45.,1616 Diniz CM, Tzelikis PFM, Alvim HS, Gonçalves RM, Rodrigues Jr A, Trindade FC. Trauma ocular em crianças abaixo de 15 anos: prevenção baseada em estatísticas. Rev Bras Oftalmol. 2003; 62(2):96-101.,1717 El-Sebaity DM, Soliman W, Soliman AM, Fathalla AM. Pediatric eye injuries in upper Egypt. Clin Ophthalmol. 2011; 5:1417-23. However, our research and other studies indicate a larger number of cases where there is a responsible adult1616 Diniz CM, Tzelikis PFM, Alvim HS, Gonçalves RM, Rodrigues Jr A, Trindade FC. Trauma ocular em crianças abaixo de 15 anos: prevenção baseada em estatísticas. Rev Bras Oftalmol. 2003; 62(2):96-101.,2020 Salvin JH. Systematic approach to pediatric ocular trauma. Curr Opin Ophthalmol. 2007; 18(5):366-72.,2121 Ashaye AO. Eye injuries in children and adolescent: a report of 205 cases. J Natl Med Assoc. 2009; 101(1):51-6. and a possible low quality of supervision in relation to the hazardous circumstances.1616 Diniz CM, Tzelikis PFM, Alvim HS, Gonçalves RM, Rodrigues Jr A, Trindade FC. Trauma ocular em crianças abaixo de 15 anos: prevenção baseada em estatísticas. Rev Bras Oftalmol. 2003; 62(2):96-101. Thus, the difficulty of those responsible to perceive hazardous circumstances in the day to day environment and removing the child from danger should be considered.

Demographic characteristics have an influence on the multifactorial mechanism of trauma.1010 Cascairo MA, Mazow ML, Prager TC. Pediatric ocular trauma: a retrospective survey. J Pediatr Ophthalmol Strabismus. 1994; 31(5):312-7.,1111 Labrada Rodrigues YH, Flores Pérez D, González Hess L. Trauma ocular en niños. Rev Cub Oftalmol. 2003; 16(2):3.,1717 El-Sebaity DM, Soliman W, Soliman AM, Fathalla AM. Pediatric eye injuries in upper Egypt. Clin Ophthalmol. 2011; 5:1417-23.,2222 Garcia TA, McGetrick BA, Janik JS. Ocular Injuries in children after major trauma. J Pediatr Ophthalmol Strabismus. 2005; 42(6):349-54. Sports activities such as badminton, squash, tennis and darts,2323 Abbott J, Shah P. The epidemiology and etiology of pediatric ocular trauma. Surv Ophthalmol. 2013; 58(5):476-85. as well as injuries from fireworks55 Hosseini H, Masoumpour M, Fatemeh KF, Razeghinejad M, Salouti R, Nowroozzadeh M. Clinical and epidemiologic characteristics of severe childhood ocular injuries in Southern Iran. Middle East Afr J Ophthalmol. 2011; 8(2):136-40.,2323 Abbott J, Shah P. The epidemiology and etiology of pediatric ocular trauma. Surv Ophthalmol. 2013; 58(5):476-85. or circumstances of war55 Hosseini H, Masoumpour M, Fatemeh KF, Razeghinejad M, Salouti R, Nowroozzadeh M. Clinical and epidemiologic characteristics of severe childhood ocular injuries in Southern Iran. Middle East Afr J Ophthalmol. 2011; 8(2):136-40. are rare in Brazil.44 Serrano JC, Chalela P, Arias JD. Epidemiology of childhood ocular trauma in a northeastern Colombian region. Arch Ophthalmol. 2003; 121(10):1439-45.,1818 Cariello AJ, Moraes NSB, Mitne S, Oita CS, Fontes BM, Melo Jr LAS. Epidemiological findings of ocular trauma in childhood. Arq Bras Oftalmol. 2007; 70(2):271-5.

In the present study there were no cases arising from traffic accidents, which can be explained by the positive action of Brazilian legislation.2424 Brasil. Presidência da República, Casa Civil, Subchefia para Assuntos Jurídicos (BR). Código de Trânsito Brasileiro. Lei n. 9.503, 23 de setembro de 1997.

In relation to the involvement of eye structures, the literature corroborates with this research, with the cornea being the most affected site.22 Thompson CG, Kumar N, Billson FA, Martin F. The aetiology of perforating ocular injuries in children. Br J Ophthalmol. 2002; 86(8):920-2.,55 Hosseini H, Masoumpour M, Fatemeh KF, Razeghinejad M, Salouti R, Nowroozzadeh M. Clinical and epidemiologic characteristics of severe childhood ocular injuries in Southern Iran. Middle East Afr J Ophthalmol. 2011; 8(2):136-40.,66 Liu M, Chang Y, Tseng S, Cheng H, Huang F, Shih M. Major pediatric ocular trauma in Taiwan. J Pediatr Ophthalmol Strabismus. 2010; 47(2):88-95.,1212 Rostomian K, Thach AB, Isfahani A, Pakkar A, Pakkar R, Borchert M. Open globe injuries in children. J AAPOS. 1998; 2(4):234-8.,1717 El-Sebaity DM, Soliman W, Soliman AM, Fathalla AM. Pediatric eye injuries in upper Egypt. Clin Ophthalmol. 2011; 5:1417-23.

In relation to laterality, there was no significant predominance of one eye over the other, and bilateral involvement is rare.22 Thompson CG, Kumar N, Billson FA, Martin F. The aetiology of perforating ocular injuries in children. Br J Ophthalmol. 2002; 86(8):920-2.,1212 Rostomian K, Thach AB, Isfahani A, Pakkar A, Pakkar R, Borchert M. Open globe injuries in children. J AAPOS. 1998; 2(4):234-8.,1414 Lee CH, Su WY, Lee L, Yang ML. Pediatric ocular trauma in Taiwan. Chang Gung Med J. 2008; 31(1):59-65.,1919 MacEwen CJ, Baines PS, Desai P. Eye injuries in children: the current picture. Br J Ophthalmol. 1999; 83(8):933-6.

Closed trauma predominated in general;44 Serrano JC, Chalela P, Arias JD. Epidemiology of childhood ocular trauma in a northeastern Colombian region. Arch Ophthalmol. 2003; 121(10):1439-45.,1111 Labrada Rodrigues YH, Flores Pérez D, González Hess L. Trauma ocular en niños. Rev Cub Oftalmol. 2003; 16(2):3.,1414 Lee CH, Su WY, Lee L, Yang ML. Pediatric ocular trauma in Taiwan. Chang Gung Med J. 2008; 31(1):59-65.,1616 Diniz CM, Tzelikis PFM, Alvim HS, Gonçalves RM, Rodrigues Jr A, Trindade FC. Trauma ocular em crianças abaixo de 15 anos: prevenção baseada em estatísticas. Rev Bras Oftalmol. 2003; 62(2):96-101.,1818 Cariello AJ, Moraes NSB, Mitne S, Oita CS, Fontes BM, Melo Jr LAS. Epidemiological findings of ocular trauma in childhood. Arq Bras Oftalmol. 2007; 70(2):271-5.,1919 MacEwen CJ, Baines PS, Desai P. Eye injuries in children: the current picture. Br J Ophthalmol. 1999; 83(8):933-6. however some studies disagree, with a predominance of open trauma,22 Thompson CG, Kumar N, Billson FA, Martin F. The aetiology of perforating ocular injuries in children. Br J Ophthalmol. 2002; 86(8):920-2.,1212 Rostomian K, Thach AB, Isfahani A, Pakkar A, Pakkar R, Borchert M. Open globe injuries in children. J AAPOS. 1998; 2(4):234-8.,1717 El-Sebaity DM, Soliman W, Soliman AM, Fathalla AM. Pediatric eye injuries in upper Egypt. Clin Ophthalmol. 2011; 5:1417-23. which is most prevalent among those older than 7 years,44 Serrano JC, Chalela P, Arias JD. Epidemiology of childhood ocular trauma in a northeastern Colombian region. Arch Ophthalmol. 2003; 121(10):1439-45.,1616 Diniz CM, Tzelikis PFM, Alvim HS, Gonçalves RM, Rodrigues Jr A, Trindade FC. Trauma ocular em crianças abaixo de 15 anos: prevenção baseada em estatísticas. Rev Bras Oftalmol. 2003; 62(2):96-101.,2121 Ashaye AO. Eye injuries in children and adolescent: a report of 205 cases. J Natl Med Assoc. 2009; 101(1):51-6. while chemical trauma and burns were rare.44 Serrano JC, Chalela P, Arias JD. Epidemiology of childhood ocular trauma in a northeastern Colombian region. Arch Ophthalmol. 2003; 121(10):1439-45.,1616 Diniz CM, Tzelikis PFM, Alvim HS, Gonçalves RM, Rodrigues Jr A, Trindade FC. Trauma ocular em crianças abaixo de 15 anos: prevenção baseada em estatísticas. Rev Bras Oftalmol. 2003; 62(2):96-101.,2121 Ashaye AO. Eye injuries in children and adolescent: a report of 205 cases. J Natl Med Assoc. 2009; 101(1):51-6.

The presence of open trauma and visual acuity are prognostic factors for eye trauma.2121 Ashaye AO. Eye injuries in children and adolescent: a report of 205 cases. J Natl Med Assoc. 2009; 101(1):51-6. Most cases presented visual acuity greater than or equal to 20/40.44 Serrano JC, Chalela P, Arias JD. Epidemiology of childhood ocular trauma in a northeastern Colombian region. Arch Ophthalmol. 2003; 121(10):1439-45.,1818 Cariello AJ, Moraes NSB, Mitne S, Oita CS, Fontes BM, Melo Jr LAS. Epidemiological findings of ocular trauma in childhood. Arq Bras Oftalmol. 2007; 70(2):271-5.,2525 Uysal Y, Mutlu FM, Sobaci G. Ocular trauma score in childhood open-globe injuries. J Trauma. 2008; 65(6):1284-6. However, studies have reported a higher prevalence of visual acuity between light perception and 20/100,2626 Cao H, Li L, Zhang M, Li H. Epidemiology of pediatric ocular trauma in the Chaoshan Region, China, 2001-2010. PloS One. 2013; 8(4):e60844.,2727 Aghadoost D, Fazel MR, Aghadoost HR. Pediatric ocular trauma in Kashan. Arch Trauma Res. 2012; 1(1):35-7. which may be related to the reported prevalence of cases of open trauma.44 Serrano JC, Chalela P, Arias JD. Epidemiology of childhood ocular trauma in a northeastern Colombian region. Arch Ophthalmol. 2003; 121(10):1439-45.,2828 Nelson LB. Ocular injuries in childhood: an ongoing trauma. J Pediatr Ophthalmol Strabismus 2002; 39(1):3.

Open trauma required more specialist intervention, and primary suturing of the eye wall was the procedure conducted the most.44 Serrano JC, Chalela P, Arias JD. Epidemiology of childhood ocular trauma in a northeastern Colombian region. Arch Ophthalmol. 2003; 121(10):1439-45.,66 Liu M, Chang Y, Tseng S, Cheng H, Huang F, Shih M. Major pediatric ocular trauma in Taiwan. J Pediatr Ophthalmol Strabismus. 2010; 47(2):88-95.,2626 Cao H, Li L, Zhang M, Li H. Epidemiology of pediatric ocular trauma in the Chaoshan Region, China, 2001-2010. PloS One. 2013; 8(4):e60844.

Family income and mother’s level of education do not relate to a worse visual prognosis, unlike the literature.1717 El-Sebaity DM, Soliman W, Soliman AM, Fathalla AM. Pediatric eye injuries in upper Egypt. Clin Ophthalmol. 2011; 5:1417-23.,2929 Moreira Jr CA, Debert-Ribeiro M, Belfort Jr R. Estudo epidemiológico das lesões oculares em crianças brasileiras. Arch Ophthalmol. 1988; 106(6):781-4.

In relation to level of education, there was a concentration of cases in two categories in the sample, as most of the respondents did not complete primary education, but also a large part completed high school or had incomplete higher education, which demonstrates an evolution to the average level of education in Brazil cited in a previous study.2929 Moreira Jr CA, Debert-Ribeiro M, Belfort Jr R. Estudo epidemiológico das lesões oculares em crianças brasileiras. Arch Ophthalmol. 1988; 106(6):781-4.

In relation to family income, only two categories were used, as most patients were included in a wage bracket of up to 2 minimum wages, which may be related to the fact that the study was aimed at a population served in the public sector, and the study did not include child trauma care at private hospitals, with other studies needed to clarify the impact of socioeconomic aspects of child eye trauma.

CONCLUSION

Trauma in childhood is a public health problem. In this study it was observed that the male gender was the most affected. There are multiple trauma mechanisms, and injuries at home predominate, despite supervision. Closed trauma is most common in all ages, but the greatest impact on sight is caused by open trauma. Severe trauma is more frequent in those aged over 7 years. Level of education and family income did not influence the severity of the injury.

Therefore, it is clear that eye trauma has a major impact on visual acuity in the population studied, with the promotion and prevention of eye health being essential tools to address that.

Awakening knowledge about the risks especially in the educational, sports and home spheres during childhood and adolescence through practicing safer activities under the supervision of parents or responsible adults is the best way of preventing eye trauma.

Accordingly, educational campaigns in public health are needed, as well as recognition and prevention of potentially damaging factors and health education strategies covering both the home environment and the streets, for example: control of the toy industry, rules on the use of personal protective equipment at work and in certain sports (glasses, helmets), compulsory use of seat belts in vehicles, legislation on fireworks, etc.2626 Cao H, Li L, Zhang M, Li H. Epidemiology of pediatric ocular trauma in the Chaoshan Region, China, 2001-2010. PloS One. 2013; 8(4):e60844.

These measures are only possible from the moment in which the profile of the problem is established, which helps to understand the difficulties to be faced and, from this point, to endorse protection, promotion and prevention actions aimed at better visual health of children and adolescents.

  • Study conducted at Hospital de Base do Distrito Federal (HBDF), Brasília, DF, Brazil

References

  • 1
    Nakanami C, Vasconcelos G. Abordagem clínica da criança com baixa visão. In: Série Oftalmologia Brasileira Óptica. Refração e visão subnormal. Rio de Janeiro: Cultura Médica, 2008. p.457-68.
  • 2
    Thompson CG, Kumar N, Billson FA, Martin F. The aetiology of perforating ocular injuries in children. Br J Ophthalmol. 2002; 86(8):920-2.
  • 3
    Négrel AD, Thylefors B. The global impact of eye injuries. Ophthalmic Epidemiol. 1998; 5(3):143-69.
  • 4
    Serrano JC, Chalela P, Arias JD. Epidemiology of childhood ocular trauma in a northeastern Colombian region. Arch Ophthalmol. 2003; 121(10):1439-45.
  • 5
    Hosseini H, Masoumpour M, Fatemeh KF, Razeghinejad M, Salouti R, Nowroozzadeh M. Clinical and epidemiologic characteristics of severe childhood ocular injuries in Southern Iran. Middle East Afr J Ophthalmol. 2011; 8(2):136-40.
  • 6
    Liu M, Chang Y, Tseng S, Cheng H, Huang F, Shih M. Major pediatric ocular trauma in Taiwan. J Pediatr Ophthalmol Strabismus. 2010; 47(2):88-95.
  • 7
    Kuhn F, Morris R, Witherspoon CD, Mester V. The Birmingham Eye Trauma Terminology system (BETT). J Fr Ophtalmol. 2004; 27(2):206-10.
  • 8
    Armstrong GW, Kim JG, Linakis JG, Mello MJ, Greenberg PB. Pediatric eye injuries presenting to United States emergency departments: 2001-2007. Graefes Arch ClinExp Ophthalmol. 2013; 251(3):629-36.
  • 9
    Mowatt L, McDonald, Ferron BD. Paediatric ocular trauma admissions to the University Hospital of the West Indies 2000-2005. West Indian Med J. 2012; 61(6):598-604.
  • 10
    Cascairo MA, Mazow ML, Prager TC. Pediatric ocular trauma: a retrospective survey. J Pediatr Ophthalmol Strabismus. 1994; 31(5):312-7.
  • 11
    Labrada Rodrigues YH, Flores Pérez D, González Hess L. Trauma ocular en niños. Rev Cub Oftalmol. 2003; 16(2):3.
  • 12
    Rostomian K, Thach AB, Isfahani A, Pakkar A, Pakkar R, Borchert M. Open globe injuries in children. J AAPOS. 1998; 2(4):234-8.
  • 13
    Mensah A, Fany A, Adjorlolo C, Touré ML, Kasieu M, Mihluedo KA, et al. Épidémiologie des traumatismes oculaires de l’enfant à Abidjan. SANTE. 2004; 14(4):239-43.
  • 14
    Lee CH, Su WY, Lee L, Yang ML. Pediatric ocular trauma in Taiwan. Chang Gung Med J. 2008; 31(1):59-65.
  • 15
    Sharifzadeh M, Rahmanikhah E, Nakhaee N. Pattern of pediatric eye injuries in Tehran, Iran. Int Ophthalmol. 2013; 33(3):255-9.
  • 16
    Diniz CM, Tzelikis PFM, Alvim HS, Gonçalves RM, Rodrigues Jr A, Trindade FC. Trauma ocular em crianças abaixo de 15 anos: prevenção baseada em estatísticas. Rev Bras Oftalmol. 2003; 62(2):96-101.
  • 17
    El-Sebaity DM, Soliman W, Soliman AM, Fathalla AM. Pediatric eye injuries in upper Egypt. Clin Ophthalmol. 2011; 5:1417-23.
  • 18
    Cariello AJ, Moraes NSB, Mitne S, Oita CS, Fontes BM, Melo Jr LAS. Epidemiological findings of ocular trauma in childhood. Arq Bras Oftalmol. 2007; 70(2):271-5.
  • 19
    MacEwen CJ, Baines PS, Desai P. Eye injuries in children: the current picture. Br J Ophthalmol. 1999; 83(8):933-6.
  • 20
    Salvin JH. Systematic approach to pediatric ocular trauma. Curr Opin Ophthalmol. 2007; 18(5):366-72.
  • 21
    Ashaye AO. Eye injuries in children and adolescent: a report of 205 cases. J Natl Med Assoc. 2009; 101(1):51-6.
  • 22
    Garcia TA, McGetrick BA, Janik JS. Ocular Injuries in children after major trauma. J Pediatr Ophthalmol Strabismus. 2005; 42(6):349-54.
  • 23
    Abbott J, Shah P. The epidemiology and etiology of pediatric ocular trauma. Surv Ophthalmol. 2013; 58(5):476-85.
  • 24
    Brasil. Presidência da República, Casa Civil, Subchefia para Assuntos Jurídicos (BR). Código de Trânsito Brasileiro. Lei n. 9.503, 23 de setembro de 1997.
  • 25
    Uysal Y, Mutlu FM, Sobaci G. Ocular trauma score in childhood open-globe injuries. J Trauma. 2008; 65(6):1284-6.
  • 26
    Cao H, Li L, Zhang M, Li H. Epidemiology of pediatric ocular trauma in the Chaoshan Region, China, 2001-2010. PloS One. 2013; 8(4):e60844.
  • 27
    Aghadoost D, Fazel MR, Aghadoost HR. Pediatric ocular trauma in Kashan. Arch Trauma Res. 2012; 1(1):35-7.
  • 28
    Nelson LB. Ocular injuries in childhood: an ongoing trauma. J Pediatr Ophthalmol Strabismus 2002; 39(1):3.
  • 29
    Moreira Jr CA, Debert-Ribeiro M, Belfort Jr R. Estudo epidemiológico das lesões oculares em crianças brasileiras. Arch Ophthalmol. 1988; 106(6):781-4.

Publication Dates

  • Publication in this collection
    July 2016

History

  • Received
    05 Nov 2014
  • Accepted
    19 Feb 2015
Associação Médica Brasileira R. São Carlos do Pinhal, 324, 01333-903 São Paulo SP - Brazil, Tel: +55 11 3178-6800, Fax: +55 11 3178-6816 - São Paulo - SP - Brazil
E-mail: ramb@amb.org.br