Ocular trauma is a major problem faced in Karachi which results from disobeyance to laws, weak security status, domestic violence, lack of education and awareness and a care-free attitude towards handling of hazardous objects. These could, occur at workplace, at home including fall, door injuries and accidental injuries.; be related to road traffic accidents, assault and to leisure activities, fireworks, blast injuries etc. Domestic accidents and assaults nearly make 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 big cause. [9]
Various studies have shown varied orders of incidence of trauma according to the socioeconomic and cultural circumstances in the site of event. Zakrzewski et al showed that workplace incidents were the commonest, followed by domestic causes. [10] 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%). [11]
Many a times the patient, the attendant or a quack manage the injury initially but when the trauma is severe or gets 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 which 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 till commencement of appropriate treatment. [12]
Our study was based on data collection of ocular trauma patients who presented at three large tertiary care hospitals of Karachi; the Isra Post-graduate Institute of Ophthalmology (IPIO), the Jinnah Post-graduate Medical Centre (JPMC) and the Dow International Medical College and Hospital (DIMC).
The number 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 population. Services offered are paid hence non-affording patients do not visit this center. The eye department is fairly new with limited faculty members as compared to the other two institutes and is still in its development stages.
Males outnumbered females in a10ll our three centers because they still work in bigger 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. [11]
In our study the commonest age of patients lied 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 lack of education, financial instability and social ill-development they 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 yet younger age.
Various studies showed the commonest 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 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 connecting 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. 44 cases presented with injury from assault and 29 of RTA. This mainly reflects the high frustration level of society, disobedience of traffic rules and the prevalent fearless attitude to indulge in assault and encounter, readily.
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, incidence of RTA and assault are also considered to be associated with alcoholism and substance use. [16]
14 cases at JPMC presented with chemical injury of which 4 occurred at workplace, 4 as a result of assault and 6 related to accidental exposure to agents like sanitizer, thinner, perfume, caustic soda and commonly available adhesives like Elfy. The over the counter availability of acids, alkalis and kerosene oil has consistently kept 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 Corona virus pandemic.
Koh et al showed that workplace presents the greatest risk of chemical injuries. [17] Alkali is a commoner cause than acid in workplace setting. 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 commonest cause of workplace chemical injuries overall and is found in plaster, mortar, cement, and whitewash. [18] 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% females getting affected. [19] The largest proportion of chemical eye injuries were seen in women in cleaning and kitchen jobs which results from splashing and spraying of liquids [20]. The cause has been attributed to, limited training. [21]
At 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 out skirts of Karachi surrounded by villages and farms. Whilst travelling through dusty lands and working in farms, they get 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 commonest causative agent. They often work without abiding by to any appropriate handling measures. In study of Ying Qi et al 21.4% cases resulted from metals, knives and scissors. Construction sector workers reported with 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.[11] Tan HH’s study revealed that 53% of the workers included cleaners, workersr and technicians. [22]. Bhupally et al showed chemical injuries to be the second commonest (13%) in their study. [12]
At DIMC cases of accidental injury resulting from various foreign bodies followed by that of 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 cause of ocular injury (43.42%). 29.4% cases were affected with metallic foreign body in the study of Khaqan et al.[19]
In the study of Bhupally et al the commonest mode of ocular trauma was blunt trauma (77.6%) [12]
Children overall suffered trauma with varied objects easily accessible at home and on streets. During the covid 19 pandemic, kids were mostly out of school and staying at home. This increased their chance to get exposed to various inciting agents like rooster’s and bird’s beaks, matchsticks, adhesives (elfy), pencils, knife, screw driver, scissors etc. Increased use of gadgets also impacted through 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 labour in Pakistan also exposes children to hazardous agents.[23] In the study of Malik I.Q. 70% casaes occured in the age group less than 10 years. The male: female ratio was 1.6:1 which incremented to 10:1 after age 10 years. [15] In the study by Khaqan H. A. 28.8% patients were less than 10 years old and the mean age of children was 8.09 years. [14] In the study of Ying Qi patients aged younger than 2y comprised 5.3%.[11] Commonest causes of ocular trauma have been found to be house-hold items, RTA and physical abuse in various studies. [24, 25]
Commonest sign at presentation at DIMC were impacted foreign body, at JPMC it was lid and corneal tears, followed by cases of chemical trauma. At IPIO Corneal foreign body, Keratitis, Corneal tear, Corneal opacity, Iris prolapse, Pupillary irregularity, Hyphema 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%. [13] In yet another study Intraocular foreign bodies (IOFB) were found in 15%, corneal tears in 75%, corneo-scleral tears in 24%, cataract formation in 61.6% and retinal detachment occurred in 9.81%.[15] In the study of Ying Qi the commonest signs were traumatic cataract (25.0%), endophthalmitis (16.8% ), intraocular foreign bodies (16.6% ), retinal detachment (15.0%) [11]
Worldwide, however, due to the ongoing pandemic, an overall decrease in the incidence of trauma was reported. Christey et al. reported a 43% reduction in injury related hospitalization. [26] Pellegrini et al reported 68.4% reduction in the number of eye trauma cases during the first month of the pandemic as compared to the same period of previous year. They found that a massive decrease occured in sport related ocular injuries (from 6.5–0.9%) [27, 32]. An increase in the household related ocular injuries was however, observed, however. [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 co-related with the high number of RTA cases. [14]
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. [31] Ocular trauma results in inability to continue jobs and chores at home and workplace. It increases financial and physical burden on the patient and attendants. [10, 30]. As seen by Quesada et al 6 patients suffered permanently partial disability. [19] 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. [19]
We recommend as in coherence with other studies that at workplace Personal Protective Equipment (PPE) must be provided by the authorities and religiously used by the 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 of domestic violence and child abuse would immensely reduce. Child labor and over the counter availability of chemicals be checked sternly. The care-free attitude towards handling of sharps at home be addressed via awareness sessions including pictorials and videos showing the possible consequences of ocular injuries via various common house-hold objects. [19, 33]
