Ocular trauma is a major problem faced in Karachi that results from disobeyance to laws, weak security status, domestic violence, lack of education and awareness and a care-free attitude toward handling hazardous objects. These could occur at the workplace, at home, including falls, door injuries and accidental injuries.; be related to road traffic accidents, assault and to leisure activities and festivals, fireworks, blast injuries, etc. Domestic accidents and assaults make nearly one-third of injuries. [2, 7, 8] Apart from the various eye disorders causing blindness, as seen in a US eye disease statistics survey, ocular trauma is also a major cause. 
Various studies have shown varied orders of incidence of trauma according to the socioeconomic and cultural circumstances at the site of the event. Zakrzewski et al showed that workplace incidents were the most common, followed by domestic causes.  In the study of Ying Qi, work-related injuries accounted for 31.5%, followed by household injuries (27.4%), firework injuries (24.5%), electric bicycles (15.1%), animal-related injuries (8.4%) and sports injuries (7.3%). 
Many times the patient, the attendant or a quack manages the injury initially, but when the trauma is severe or becomes complicated, it is then brought to an eye clinic. The state of hospitality and medical supplies of eye clinics in rural and urban areas is another detrimental factor. Patients suffering ocular trauma in rural areas do not either find a qualified optometrist or ophthalmologist or do not receive appropriate management from the available medical personnel. Factors that formulate the final visual and structural outcome include mode, velocity severity and site of injury, duration spent since trauma, age of patients, co-occurrence of any systemic illnesses, primary or secondary infections, duration of exposure to the traumatizing object and the duration spent until commencement of appropriate treatment. 
Our study was based on data collection of ocular trauma patients who presented at three large tertiary care hospitals in Karachi: the Al Ibrahim Eye Hospital/Isra Postgraduate Institute of Ophthalmology (IPIO), the Jinnah Postgraduate Medical Centre (JPMC) and the Dow International Medical College and Hospital (DIMC).
The numbers of patients at JPMC and IPIO were nearly the same. Fewer patients presented at DIMC versus the other two tertiary care institutions. Possible reasons could be that it is located considerably away from the city center and is not easily approachable to the vast majority of the population. Services offered are paid; hence, nonaffording patients do not visit this center. The eye department is fairly new with limited faculty members compared to the other two institutes and is still in its development stages.
Males outnumbered females in all three centers because they still worked in larger numbers outside than females. Many national and international studies have shown this male preponderance to be 83.87%, 84.2%, 81.6%. [12, 13, 14] In a large study conducted by Ying Qi et al, the male to female ratio was 2.8:1. 
In our study, the most common age of patients was between 20-50 years, which is the prime working age in Pakistan. Adolescents are taken out of school and put to work at a younger age. Being at a vulnerable age with a lack of education, financial instability and socially ill-developed individuals are at an increased risk of injuries. The lower limit of age of working females is decreasing rapidly as more girl kids now mainly working in the service sector start working at a younger age.
Various studies have shown the most common age of presentation to be between 45-59 years, 17 and 39 years and 18 - 35 years [11,12, 13, 15].
It was noted that the incidence of the different modes of injury were different at the three centers. At JPMC, adult cases of road traffic accident and assault topped the list. JPMC is the largest tertiary care center built on Sharea Faisal, which is a main street connected to multiple areas of Karachi. Multidisciplinary management is effectively possible here for patients who present with multiple injuries, as the hospital has all medical and surgical departments. Medicolegal cases are accepted here. Forty-four patients presented with injury from assault and 29 with RTA. This mainly reflects the high frustration level of society, disobedience of traffic rules and the prevalent fearless attitude to readily indulge in assault and encounter.
In various studies, the incidence of RTA-related injuries was 24.2%, 25.2% cases and 20.5% patients. [11,13,14] In the West, the incidence of RTA and assault are also considered to be associated with alcoholism and substance use. 
Fourteen cases at JPMC presented with chemical injury, of which 4 occurred at the workplace, 4 as a result of assault and 6 related to accidental exposure to agents such as sanitizer, thinner, perfume, caustic soda and commonly available adhesives such as Elfy. The overc-counteravailability of acids, alkalis and kerosene oil has consistently kept a number of cases of assault from chemical injury, high, mostly in young and middle-aged ladies. Cases of sanitizer splash into eyes rose during this study’s duration because of its increased use during this coronavirus pandemic.
Koh et al showed that the workplace presents the greatest risk of chemical injuries.  Alkali is a more common cause than acid in workplace settings. These include ammonia, lye (sodium hydroxide), potassium hydroxide, magnesium hydroxide, and lime, which are found in fertilizers, refrigerants, and cleaning solutions drain cleaners. Lime is the most common cause of workplace chemical injuries overall and is found in plaster, mortar, cement, and whitewash.  In the study of Quesada et al, ocular chemical burns were the second most common workplace eye injury, with 68.54% of men and 31.45% of females being affected.  The largest proportion of chemical eye injuries are seen in women in cleaning and kitchen jobs, which results from splashing and spraying of liquids . The cause has been attributed to, limited training. 
IPIO cases of corneal injury and keratitis resulting from foreign body exposure presented the most. This is mainly because this center is located in the outskirts of Karachi surrounded by villages and farms. While traveling through dusty lands and working on farms, they are exposed to dust, stones and vegetative matter. Industrial workers, vehicle mechanics and welders fell next and reported exposure to metallic particles, wires or rods. Blunt objects were found to be the most common causative agent. They often work without abiding by to any appropriate handling measures. In the study of Ying Qi et al, 21.4% of cases resulted from metals, knives and scissors. Construction sector workers reported exposure to stones, sand and pebbles. Chemical injuries reported from exposure to bleach, used for cleaning in homes and from acid use, resulting from car or UPS (uninterruptable power supply) battery explosion. Ying Qi showed that 51.9% of the cases were farmers and workers.  Tan HH’s study revealed that 53% of the workers included cleaners, workers and technicians. . Bhupally et al showed chemical injuries to be the second most common (13%) in their study. 
At DIMC, cases of accidental injury resulting from various foreign bodies followed by welding and grinding ranked high. There are many workplaces of welders and iron mongers in the vicinity. Quesada et al.’s study showed foreign bodies to be the top most common cause of ocular injury (43.42%). A total of 29.4% of cases were affected by metallic foreign bodies in the study of Khaqan et al.
In the study of Bhupally et al, the most common mode of ocular trauma was blunt trauma (77.6%) 
Children overall suffered trauma with varied objects easily accessible at home and on streets. During the COVID-19 pandemic, children were mostly out of school and staying at home. This increased their chance of being exposed to various inciting agents, such as rooster and bird beaks, matchsticks, adhesives (elfy), pencils, knife, screw driver, scissors, etc. Increased use of gadgets also impacted the cartoons shown on the various kids’ channels, which show trauma as fun. In our study we got most kids of age 7 years. This reflects lack of parental supervision. Kids are freely allowed to play on streets, which further predisposes them to various forms of trauma. Child labor in Pakistan also exposes children to hazardous agents.  In the study of Malik I.Q. Seventy percent of cases occurred in the age group less than 10 years. The male:female ratio was 1.6:1, which incremented to 10:1 after the age of 10 years.  In the study by Khaqan H. A. A total of 28.8% of patients were less than 10 years old, and the mean age of the children was 8.09 years.  In the study of Ying Qi, patients aged younger than 2 y comprised 5.3%.  Commonest causes of ocular trauma have been found to be household items, RTA and physical abuse in various studies. [24,25]
Commonest signs at presentation at DIMC were impacted foreign bodies; at JPMC, lid and corneal tears were observed, followed by cases of chemical trauma. At the IPIO corneal foreign body, keratitis, corneal tear, corneal opacity, iris prolapse, pupillary irregularity, hema and cataract were found in decreasing order. Since children made a large part of the sample size, traumatic endophthalmitis was found in 15 cases. These signs were clearly related to the type of inciting trauma.
Other studies showed nearly similar results. In one study Open Globe Injuries occurred in 53.4%.  In yet another study, intraocular foreign bodies (IOFBs) were found in 15%, corneal tears in 75%, corneoscleral tears in 24%, cataract formation in 61.6% and retinal detachment in 9.81%.  In the study of Ying Qi, the most common signs were traumatic cataracts (25.0%), endophthalmitis (16.8%), intraocular foreign bodies (16.6%), and retinal detachment (15.0%) 
Worldwide, however, due to the ongoing pandemic, an overall decrease in the incidence of trauma has been reported. Christey et al. reported a 43% reduction in injury-related hospitalization.  Pellegrini et al reported a 68.4% reduction in the number of eye trauma cases during the first month of the pandemic compared to the same period of the previous year. They found that a massive decrease occurred in sport-related ocular injuries (from 6.5% to 0.9%) [27, 32]. However, an increase in household-related ocular injuries was observed. [28, 29, 33]
Most of the patients from all 3 centers fell at grade 5 of the OTS, and their visual acuity ranged mostly between 6/6 and 6/18. It was between PL+ and 6/60 in the study by Khaqan et al. This corelated with the high number of RTA cases. 
According to an international survey, 200,000 open-globe injuries occur annually, resulting in 1.6 million blind, 2.3 million bilaterally and 19 million unilaterally.  Ocular trauma results in an inability to continue jobs and chores at home and the workplace. It increases the financial and physical burden on the patient and attendants. [10, 30]. As seen by Quesada et al, 6 patients suffered permanent partial disability.  Quesada et al found that the total cost of the initial emergency consultation, follow-up consultations, nursing appointments, consultations with the ophthalmologist, medical transport and medication and treatment costs were very high. 
We recommend, in coherence with other studies, that at the workplace, personal protective equipment (PPE) must be provided by authorities and religiously used by workers. Laws be made and their abidance made mandatory. In our part of the world taking care of traffic rules and by enacting punishment for illegal acts, the cases of RTA and assault, especially domestic violence and child abuse, would be immensely reduced. Child labor and overt-the-counteravailability of chemicals will be checked sternly. The care-free attitude toward handling sharps at home is addressed via awareness sessions including pictorials and videos showing the possible consequences of ocular injuries via various common household objects. [19, 33]
We also recommend adhering to the standardized classification of ocular trauma.