Open-globe injuries, which are caused by a traumatic breakdown in the integrity of the eyewall, are of particular importance in the pediatric age group of patients due to its high incidence as well as the difficulties in assessment and treatment. The condition constitutes a serious public health problem in children with destructive lifelong impact on their quality of life as well as devastating psychological and sociological effects in their adult life. Therefore, a better understanding of the characteristics of this condition is essential in building up preventive measures as well as establishing better management strategies.
The predominance of boys over girls with a ratio of 1.67:1 was consistent with the literature as demonstrated in many studies before with similar ratios from all over the world from different countries (France, United Kingdom, Sydney, Thailand, India, Tunisia etc.) as well as our country5,7,11,12,14−17. This finding is frequently attributed to the fact that boys are more likely to get involved in dangerous games/sports or high-risk activities, which is observed commonly across different cultures8,17. On the other hand; the most frequent range of age exposed to ocular trauma, the setting of the injury and the most frequent objects causing injury are reported variably in the literature. Our study demonstrated the most frequent age range as 0–6 years (46.4%), the most common setting of injury as home (62.5%), and the most common traumatizing object as knife (10.7%) and fork (8.9%). We think that these findings are consistent with each other since children aged 0–6 years are at home for most of their times, and kitchen utensils are frequent objects for home injuries. Other two studies reporting the highest incidence of ocular injury in older children (6–10 years, 39.3%12 and 11–16 years 49.0%8) found the most common traumatizing object as wooden sticks; which is consistent as well since older children spend more time outdoors and subject to trauma with wood. In another study from our country with the peak age of ocular injury in 3–7 years (53%)11 reported the most common causative object as scissors/knives, similar to our findings. Moreover, in a different report from our country studying perforating ocular injuries in all age groups, the most frequent age group was 0–7 years (48.2%)18. The higher rate of ocular injury in pre-school children in our country points out to the importance of educating the parents and caregivers regarding close supervision and preventive measures at home.
All of the patients in our study were unilateral trauma cases with almost equally affected right and left eyes. These findings are in accordance with the literature, as in Boret et al.16 and Batur et al.11 stated in their studies as well. The frequency of bilateral trauma in children are rarely experienced with a reported rate of 0% in several studies8,19,20. This lower rate of bilaterality in the pediatric group compared to adults can be attributed to the lower possibility of children to be exposed to severe traumas like traffic accidents or gunshots which can result in bilateral ocular injuries. Also consistent with the literature, the majority (60.7%) of the ocular traumas were zone 18,19,21−23.
Although measuring the VA at the presentation time is one of the most challenging parts of the open-globe injury assessment in children; it should be performed to the extent the child’s cooperation allows since it has a prognostic value as shown in the former studies11,17,23−26. Consistently, our study demonstrated a positive correlation between initial and final visual acuity values which can provide helpful information about the visual prognosis of the patient. Another prognostic factor about the final visual acuity was found to be the presence of lens injury in this study. Liu et al. and AlDahash et al. presented a similar relationship in their studies, as well5,6. According to the findings of Liu et al., however, the presence of a vitreous hemorrhage was also found to be a poor prognostic factor; about which we did not record any significant relationship in the present study5. Likewise, the presence of a retinal detachment did not display a statistically significant influence on the postoperative visual prognosis in our study while Choovuthayakorn et al. claimed that it predicted a significantly worse visual outcome according to their findings8. Although the previous studies reported the most common concomitant intraocular injuries as hyphema22,27 and cataract19,28, our study documented iris prolapse and lens injury most frequently. On the other hand, our ratio for the presence of a intraocular foreign body (16.1%) was in agreement with the previously reported range in the literature: 4 to 22.1%8,22,23,29,30. We think that the concomitance of a intraocular foreign body in the pediatric open-globe injuries is especially important in the aspect that this subgroup requires a different treatment approach with possibly additional surgical interventions and different outcomes.
There wasn’t any clinical significant influence of hospital admission delay in terms of visual outcome in our study. Similarly, Wadeai et al. and Malek et al. did not found the delay in presentation time as a poor prognostic factor in their studies17,31. These findings may be due to the fact that the patients are usually admitted to hospital more urgently after more severe traumas.
Although the visual outcome demonstrated a statistically significant improvement after the treatment in our study, the mean VA of 0.83 ± 1.13 logMAR at the last visit displays a considerable loss compared to normal vision in terms of visual ability of the children. This finding is supported also by many other studies in the literature focusing on pediatric ocular trauma5,11,23. The undesirable visual outcome after pediatric ocular traumas despite of the advancements in microsurgery points out to the significance of further preventive measures reducing the probability and severity of ocular injuries in order to avoid substantial visual morbidity in children.
The limitations of the present study includes its retrospective nature, variable follow-up period and the relatively small size of patient group due to loss of some data because of the incomplete digitalization of medical files. A more detailed analysis of the factors effecting the final visual outcome can be achieved through studies with larger sample size.
In conclusion, our study demonstrated that the visual acuity at presentation and the presence of lens injury are prognostic factors for open-globe injuries in pediatric age group. These findings can be useful in terms of predicting the prognosis and managing the expectation of the children with open-globe injury and their parents. However, we believe that adoption of appropriate protective measures in order to avoid unnecessary injuries are far more effective in terms of preventing visual impairment than advancements in any kind of treatment or management strategies after the injury.