Ocular trauma is an under-recognised and under-reported cause of vision loss; moreover, while bilateral ocular trauma is comparatively uncommon, it can lead to severe visual impairment and long-term disability. [2, 3, 7] Unfortunately, little information is currently available regarding the magnitude, epidemiology and injury patterns of this condition. To our best knowledge, this is the third study to report clinical and epidemiological data regarding cases of simultaneous bilateral ocular trauma. These findings provide insight into the epidemiology, clinical characteristics and outcomes of cases of simultaneous ocular injuries presenting to the largest tertiary referral hospital in Eastern Uttar Pradesh, India.
The incidence of bilateral ocular injuries depends on a wide variety of factors, including geographical location, climate, culture, social values, common occupations, rates of crime and violence and common types of trauma and traumatic agents. In our study, simultaneous bilateral injuries occurred in 8.46% of patients presenting with ocular trauma over a six-year period. Sabaci et al. reported bilateral involvement in 16 (7.55%) of 212 patients with weapon-related OGIs.[8] In a previous study carried out at the Sir Sunderlal Hospital, 22.9% of university students with ocular injuries were affected in both eyes, with ocular injuries most commonly attributed to assault, RTAs and recreational activities.[4] In contrast, other studies have reported lower rates of bilateral ocular injuries(0.69–3.0%).[5, 9, 10] In contrast, according to an interview-based survey in Nepal, the prevalence of trauma-related bilateral blindness was 20%.[7]
There was a male predominance in the current study, with the male-to-female ratio being 2.4:1. This finding is comparable to that reported in other studies [6, 10]. Moreover, young adults (i.e. 16–25 and 26–35 years old) and older children and adolescents (i.e. 6–15 years old) represented the most vulnerable age groups. In general, young men tend to spend more time outdoors, are often employed in occupations involving manual labour and are more likely to be involved in violence or risky behaviours, factors which place them at greater risk of injury and trauma.[11, 12] In this study, the majority of patients resided in rural areas, demonstrated poor literacy and were of low socioeconomic status; furthermore, such patients were more likely to have poor outcomes due to a lack of eye protection and delays in seeking medical care. These individuals should therefore be considered a high-risk group in terms of prognosis.
The majority of bilateral ocular injuries in our study occurred during summer and the rainy season; similar results have been reported by other researchers.[13, 14] In contrast, Canavan et al. reported that ocular injuries in Ireland usually transpired during the winter season as a result of the increased prevalence of dangerous sporting activities and domestic accidents.[15] Several reasons are proposed for the high incidence of injury in summer and low incidence in the winter season noted in the present study. Many college and university students engage in outdoor games and activities during their summer holidays, potentially making them more injury prone. Secondly, summer is culturally considered marriage season in India and people are therefore often exposed to fireworks and travel-related injuries. Finally, the cold, foggy climate and the occurrence of annual college examinations in the winter season would limit involvement in outdoor activities.
In this study, most patients were injured in the afternoon between 12:00 and17.59 hours (50.00%); this is to be expected given that this interval represents the peak time for outdoor activities. In addition, the most common place of injury was away from home (64.71%), including in the street, at school/college and in the playground. This is consistent with results reported in other studies. [5, 8, 9, 16] In comparison, the commonest place for monocular injuries is reportedly at home, particularly among children and women. [17–21]. However, Tok et al. reported that paediatric ocular injuries were less prevalent at home compared to elsewhere [22].
In our study, mechanical injuries (47.05%) accounted for the majority of simultaneous bilateral ocular injuries, with most cases being non-occupational in nature (91.18%). The most common cause of injury was assault (26.47%), including physical assault, acid attacks and gunshots. Similar incidence rates of assault-related ocular trauma have been previously reported (22–30%).[5, 23, 24] However, other researchers have reported much higher incidence rates of assault-related ocular injury(34–53%).[17, 25, 26] Other common causes of ocular injuries in the present study included RTIs (20.59%), sports/recreational activities (17.65%) and cracker blasts (17.65%). Blomdahl et al. reported similar findings [27]. In order to avoid or prevent severe eye injuries, MacEwen et al. recommended that children wear appropriate protective eyewear while taking part in sporting activities.[19] Babar et al. recorded bilateral involvement in 46 (2.9%) of 1,551 hospitalised ocular trauma patients in Pakistan, with the most common cause being landmine blasts (54.3%), dynamite blasts (10.8%) and firearms (6.5%), with RTIs and physical assault being responsible in only 4.3% and 2.1% of cases, respectively.[2]
Traumatic agents in the present study were mostly solid in nature (41.18%), with the most common mode of injury being collision/impact (41.18%), followed by blast/gunshots (20.59%). Over one-third of the victims (38.24%) were under the influence of alcohol at the time of injury. Moreover, 82.35% were not using a protective device, a major risk factor for severe ocular injury. When analysing the period of time elapsed between injury and seeking medical care, the majority of the patients presented one day after injury (41.17%). Of the 14.71% of victims who reported to hospital several days after the traumatic incident, the majority came from rural backgrounds and were of low socioeconomic status. Previous studies have indicated that delayed hospital presentation is a major risk factor for poor visual outcomes in patients with serious ocular injuries.[28, 29]
The majority of our patients had polytrauma (58.82%),while 41.18% had isolated ocular trauma, thus indicating that the management of bilateral ocular trauma requires a multidisciplinary approach. In particular, assault, RTIs and falls were common causes of polytrauma; similar findings have been reported previously [25, 30]. In our study, the most common ocular structure involved was the periocular tissues and eyelid (63.24%), followed by the globe (44.12%). Periocular burns with or without foreign bodies occurred in 29.11% of patients, while chemical burns accounted for 8.83% of cases. The commonest type of globe injury were CGIs (29.41%) in zones I, II and III, while OGIs were present in 14.71% of cases, most commonly in zone II.
Bilateral ocular OGIs area rare occurrence (1.6–5.4%).[31, 32] Jovanovic et al. reported that 66.7% of 36 cases of simultaneous bilateral ocular injuries due to RTIs were OGIs.[6] In particular, globe ruptures in zone III are associated with poor initial visual acuity, while poor final visual acuity is likely in cases of OGIs with wound sizes of > 10 mm.[29] Our results demonstrated that zone III OGIs, poor initial visual acuity, the presence of associated intraocular haemorrhage (i.e. hyphaema and vitreous haemorrhage), injury to the lens or uveal tissue, retinal detachment and low OTS values (categories I or II) were poor prognostic factors. Similar observations have been reported in other studies.[22, 33–39].
The results of this study should be considered in light of certain limitations. The study was retrospective in nature and not randomised, with data collection limited to the information available in the patients’ medical records. Moreover, the sample size was relatively small for the purposes of subgroup comparison. Finally, it is likely that the findings underestimated the actual incidence of bilateral ocular injuries given that the study was restricted to cases treated at a single teaching hospital in North India. Nevertheless, this study provides important demographic, clinical and epidemiological information regarding the frequency, presentation and outcomes of cases of simultaneous bilateral ocular trauma.