Introduction. Pediatric ocular trauma is a significant worldwide problem of public health importance being a leading cause of non-congenital unilateral blindness. This study evaluated the proportion, type and causes of ocular injuries among children in a rural hospital of Nigeria. Methods. Children (<16 years) presenting with ocular trauma at the Eye clinic of the Presbyterian Joint Hospital, Ohaozara, Ebonyi state, Nigeria, between November 2011 and May 2012 were studied. Participant’s socio-demographics, type of trauma, cause of trauma, and occupation of parents were collected and analysed. Results. The Proportion of ocular injuries was 26.4%. Injuries were more common among males (P=.041) and children from lower social class (P=.026). Injuries occurred more frequently during farm work (59.4%) and play (21.9%). The most common causes of injury were stick (34.4%) and stones (21.8%). Conclusion. The proportion of ocular injuries among children at the rural hospital is high. Most causes are preventable.
Pediatric, rural, ocular trauma, Nigeria
Ocular trauma is an important and preventable global problem of public health importance. It is a major cause of visual loss and ocular morbidity. Globally, 1.6 million people are blind, 2.3 million have low vision and 19 million have unilateral visual loss from ocular trauma.1 In children, ocular trauma is a leading cause of noncongenital unilateral blindness.2 The developmental, psychological, and socioeconomic impact of the resulting blindness on them can be profound. In the United States, in year 2000, there were more than 7,500 hospitalizations for the treatment of pediatric eye injuries, resulting in more than 88 million USD in treatment costs.3 A hospitalbased study in Iran reported that 278 children were hospitalized for ocular injuries over a three-year period.4 Of these, approximately 12% resulted in uni-ocular blindness. In the north-eastern region of Columbia, Serrano et al. recorded 415 incidents of childhood eye injuries over a five-year period with 55.3% of the open globe injuries resulting in severe visual impairment and blindness.5 Changing environmental factors [End Page 63] such as increased automobile use in urban areas and sporting activities are important determinant of causes, severities and outcomes of ocular trauma.6 Other reported factors associated with childhood ocular trauma are family socio-cultural habits and socioeconomic status.5 Childhood ocular trauma poses a peculiar medical management challenge as accurate evaluation of eye injuries is difficult, especially in pre-verbal children. Additionally, there are problems of late presentation and unavailability of trained personnel and appropriate equipment for treatment, especially in poor-resource settings of the sort found in developing countries.
Most hospital-based Nigerian studies on ocular trauma in children were conducted in urban tertiary centers.7–10 Data remain scanty on causes and pattern of ocular injuries in the pediatric population in rural Nigerian hospital settings.11 This study aimed to evaluate the proportion, types, and causes of ocular trauma among children seen in a rural secondary eye care center in south-eastern Nigeria. The generated data will form the basis for an evidence-based advocacy for revision of eye health policies by government and assist health educators and eye care providers in addressing the peculiar trauma-related eye care needs of the poor rural children in Nigeria, and under similar settings elsewhere through a preventive approach.
Ebonyi state (created on October 1st, 1996) is one of the five component states of Nigeria’s south-east geo-political zone. The state is made up of 13 administrative sub-units or Local Government Areas (LGA). Farming is the predominant occupation of the state’s inhabitants. Bicycles and motorbikes are the major means of transportation. There are numerous public and privately-owned eye care centers in Ebonyi state. Of these, Presbyterian Joint Hospital (established in 1912 and located in Uburu, Ohaozara LGA) provides eye care and general medical care to the rural inhabitants of the local government area and the neighboring eight rural local government areas of Ebonyi state. The hospital’s eye care unit is a 20-bed facility manned by one visiting consultant ophthalmologist, one diplomate ophthalmologist, one optometrist, one trained ophthalmic nurse, and six auxiliary nurses. It provides promotive, preventive and curative eye care through its medical, refractive, and limited surgical services.
The study was a descriptive cross-sectional survey. All the children (younger than 16 years) attending the eye clinic of Presbyterian Joint Hospital Uburu, Ohaozara, Ebonyi state, between November 1st 2011 and May 1st 2012 were enrolled in the study. Children who presented for routine medical check-up and had no eye complaints were excluded from the study.
The instrument was an open–ended questionnaire developed de novo by the investigators, and pre-tested in a similar setting outside the study center. After obtaining oral consent from the parent/guardian, an optometrist research assistant used a pre-tested questionnaire to obtain data on age, sex, presenting complaint and duration of presenting complaint of the child. Data on educational qualification and occupation of parents/guardian were also obtained. Those presenting with ocular trauma were further assessed by the consultant ophthalmologist to document cause, nature, and place of trauma, activity during which trauma occurred, and anatomical [End Page 64] site of trauma. The definitive diagnosis of ocular sequelae of injury was made with the use of pen light (Unique optical Lagos, Nigeria), slit lamp biomicroscope (Haag Streit Ag, Bern, Swizerland) and direct ophthalmoscope (Keeler instrument, London, UK). The visual acuity was measured in bright illumination with the child standing six meters from a standard snellens E-chart (Unique optical Lagos, Nigeria). Each eye was measured separately with one occluded at a time.
The socioeconomic status of each child was determined using classification of social class proposed by Oyedeji.12 Each parent was scored separately by finding the average score of the two factors (occupation and level of education) in the social classification. The mean of the four scores (two each for mother and father) to the nearest whole number would be the social class assigned to the child. For example, if the mother was a junior school teacher (score 3) and the father a senior school teacher (score 2) and the educational attainment of the mother was primary six (score 4) and the father was a school certificate holder (score 2), the socioeconomic index score for this child was: (3 + 2 + 4 + 2) ÷ 4 = 2.75 (to the nearest whole number = 3). In the situation where any of the parents is dead, the social class of the child was determined by the occupation and educational attainment of the living parent or guardian. The scoring is from social classes I to V; social classes I and II were regarded as upper class, III as middle class, while IV and V constituted the lower social class.
Occupation was categorized as follows: Class I: public servants, professional, managers, large scale traders, businessmen and contractors. Class II: intermediate grade public servants and senior school teachers. Class III: junior school teachers, professional drivers, artisan. Class IV: Petty traders, laborers, messengers. Class V: Unemployed, full-time housewife, students and subsistence farmers.
Education was categorized as follows: Class I: University graduates or equivalents. Class II: School certificate ordinary level (GCE) who also had teaching or other professional training. Class III: School certificate or grade II teacher’s certificate holders or equivalent. Class IV: Modern three or primary six certificate holders. Class V: those who could just read and write or were illiterate.
The data were entered into and analyzed using the Statistical Package for Social Sciences (SPSS), version 18 (SPSS-Inc Chicago, Illinois, USA). Descriptive statistics were performed to yield percentages, frequencies, and proportions. Test for significance of observed inter-group differences were performed using chi-square for categorical variables and student-t test for continuous variables. In all comparisons, a p-value <.05 was considered statistically significant.
Prior to the commencement of study, ethical approval consistent with the tenets of the 1964 Helsinki Declaration was obtained from the Medical and Health Research Ethics Committee (Institutional Review Board) of the study center.
During the study period, 121 (100.0%) children comprising 64 (52.9%) males and 57 (47.1%) females aged 8.1±4.2 SD years (range 3 days–15 years) were seen at the eye clinic of presbyterian hospital. The socio-demographic characteristics of the study subjects are shown in Table 1. [End Page 65]
A total of 32 children consisting of 22 (68.8%) males and 10 (31.2%) females aged 8.4±4.2SD (range 0–15) presented with various ocular injuries giving a proportion of 26.4%. Male children were twice as likely to suffer an injury as females (male vs. female: 68.8% vs. 31.2%, OR 2.46, CI 1.06–2.01) and children of low socioeconomic class were twice as likely to suffer an injury as those from a higher social status (68.8% vs. 31.2%, OR 2.46, CI 1.06–2.01). Differences observed among the various age groups (0–5, 6–10, and 11–15 years) were not statistically significant (p=.632).
The injuries were equally open globe 16 (50%) and closed globe 16 (50%) in nature. The majority [19 (59.4%)] of the injuries occurred during farming activities. The most common causes of injury were sticks [11 (34.4%)] and stones [7 (21.9%)]; see Figure 1. The most frequent ocular sequelae of injury were cataracts [16 (50%)] in closed globe injuries and corneal wounds [10 (31.3%)] in open globe injuries; see Figure 2. Of the 26 (81.3%) subjects whose presenting distance visual acuity could be measured, the visual acuity in the injured eye was less than 6/60 in 20 (62.5%) and 6/24–6/60 in 6 (18.8%). The visual acuity of the rest could not be ascertained due to age and lack of cooperation. Only 5 (15.6%) patients presented within 48 hours of injury.
More male than female children had ocular trauma in this study. The observed pro-male gender distribution of ocular trauma in this present study is similar to the previously reported male gender preponderance in childhood ocular trauma.7–10,13–15 This could be attributed to the greater tendency for males to be involved in injury-prone contact sports and recreational activities. Additionally [End Page 66]
[End Page 67]
environmental and socio-cultural factors tend to permit male involvement in more high-risk outdoor hard jobs than females.
There was slight preponderance of ocular injuries in the age group 5–10 and 11–15 though this age difference was not statistically significant. This is in keeping with findings by other investigators.2,15,16 Children in this age group tend to be active, with some degree of freedom for play without supervision. More important in this rural setting is that they are more likely to be used for farm work than those younger than five years of age. This will tend to put them at risk of farming-related ocular trauma. This only partially agrees with an urban study by Dalia et al.13 which found that about 50.7% of pediatric ocular trauma occurred in children aged 2–younger than 7 years, followed by those aged 7–<12years (36%). The most common cause of injury in that study was a fall to the ground from some height,13 which is expected in an urban setting where infrastructural and domestic facilities predispose children to falling. Education of children, parents, and guardians on protection of the eyes during work and supervision of children (particularly boys) at play are suggested to reduce the amount of ocular trauma in these scenarios. In addition, an effective legal framework to protect vulnerable children from child labor would be very worthwhile.
Proportion of ocular trauma
The proportion of ocular injuries among children in this study was 26.4%. This is high compared with the 3.7% reported in Egypt.10 The study in Egypt was conducted at an urban tertiary hospital setting while this study was conducted in a poor rural primary care setting with a predominantly agrarian population that had associated involvement in injury-prone farming activity. This implies higher trauma-related visual impairment in the rural area in the face of poor availability of eye care resources for effective management. In this study children of low socioeconomic class were twice as likely to suffer an injury as those from a higher social status. Ariturk et al.17 found that low socioeconomic status, socio-cultural status, and family negligence are important predisposing factors for eye injury. The majority of the feeder populations of the study center are poor subsistent farmers who cannot afford to hire paid farm workers. Consequently they resort to using their children to work on the farm, thereby putting them at risk of farming-related ocular injuries. In this study farming was the most frequent activity pre-staging eye injury. In a study by Onyekonwu et al.7 playing was the most frequent activity prior to eye injury. The study was conducted in an urban tertiary hospital while the present study was conducted in a rural secondary care mission hospital. As reported by Anugwom,18 poverty is the main cause of child labor in Nigeria. In a low and medium-income country similar to Nigeria, prevalence rate of child labor has been reported to be as high as 42.8% in rural areas and 24.9% in urban areas.19 In rural agrarian areas, child labor takes the form of involvement in agricultural activities. This farming vocation of rural children invariably predisposes them to farming-related eye injuries. Government intervention—especially in the area of social provisioning and economic empowerment, particularly of the rural populace—is needed to reverse this trend.
Causes and place of ocular trauma
Injury from sticks was the predominant cause of injury followed by injury from stones. Most of these injuries caused an open globe injury which is clinically more severe, with a little chance of visual recovery in the study area due to lack of appropriate modern eye care facilities for effective management of [End Page 68] severe eye injuries. No case of chemical eye injury was observed in this study. This differed from the findings by Dalia et al.13 who found that chemical injury accounted for 2% of all cases. Most injuries occurred on farms, followed by play at school. The dominant role of farm activities in causing ocular injuries in this study is expected as most people in this rural community are farmers. In contrast, other urban-based studies showed that the predominant place of injury is at home7–10 and on the street.13 Of interest is the case of violent assault resulting in severe ocular injury in one of the children (3.1%). This frequency is lower than that of a related but urban study by Adeoye,10 where assault accounted for 9.4% of all cases of eye injuries children. In a rural survey by Kulig et al.,20 participants admitted that violence was an issue in their communities. However, it is expected that violent activities should occur more in urban areas due to increase in alcohol and drug-related problems.20
Diagnosis and anatomical site of injury
Anatomical sites of injury determine the clinical diagnosis of the ocular injury. Some of the patients presented with multiple diagnoses with involvement of more than one part of the eye. The most frequent ocular sequelae of injury were cataracts and corneo-scleral laceration. Most cases of cataracts and hyphema resulted from blunt injury (closed globe injury). Penetrating injuries (open globe injuries) resulted in corneal and corneo-scleral lacerations. About 28% of the cases of the penetrating injuries ended up with evisceration. In a Kenyan survey,14 7% of children with open globe injuries had badly damaged eyes which was removed by evisceration/enucleation. This underscores the degree of severity of open globe injuries and the devastating impact on ocular morbidity particularly in poor resource areas. However, the study in Kenya was done in an urban tertiary center possibly with better facilities to manage severe ocular trauma which may account for the lower incidence of surgical eye removal observed.
Time to presentation
In this study, only 15.6% of the patients presented within the first 48 hours of injury. This is a smaller proportion than in the findings in rural Ethiopia where 32.4% of the patients presented within the first 48 hours.21 However, the latter study was conducted in a large tertiary referral center. Lack of funds and belief in traditional eye medications play a major role in delays. Dalia et al.13 reported that in patients with lower socioeconomic levels (primary education and low income level) the delay period of presentation was much longer than in higher socioeconomic levels, regardless of whether the injury was mild or severe.
Visual acuity profile
Most of the children presented with initial visual acuity of <6/60 of the involved eye. This included all the 16 cases of open globe injuries. This is in keeping with a study in India22 where 92.1% of the open globe injuries presented with an initial visual acuity of <6/60. The poor visual outlook in open globe injury is related to multiple involvement of ocular structures, degree of severity, and possible complication with intraocular infections. There is difficulty in effective ocular examination in the pediatric age group, particularly following injury. The eye clinic in Ohaozara is not equipped with adequate facilities for effective management of severe cases of ocular trauma. While simple procedures such as traumatic cataract surgery can be performed, more complex potentially visual-rehabilitative procedures involving vitrectomy cannot be done. While there is currently a health policy in Ebonyi state that provides for free child health care at all levels, there should be in place adequate [End Page 69] provision of appropriate infrastructure, equipment and human resources to allow for effective policy implementation.
The generalizability of the conclusions drawn from this study are limited by its hospital-based nature, the questionable accuracy of patient-reported data, selection bias due to study design, type of analysis, and limited sample size.
The proportion of ocular trauma among children in this rural mission hospital is high. Most of the causes are preventable. Eye health education campaign targeting parents, teachers, caregivers and children should be promoted to reduce the proportion of ocular trauma in children in the rural areas. Additionally, this will help promote early treatment-seeking behavior, which in turn reduces complications such as debilitating eye infections and blindness. Advocacy to government authorities for the provision of adequate eye care facilities and personnel to cater to the eye care needs of the poor rural populace in Nigeria and a strong legal system that apprehends and punishes assaults on children and the use of child labor should be enhanced.
Dr. Okoye is a consultant ophthalmic surgeon, Department of Ophthalmology University of Nigeria Teaching Hospital, Ituku Ozalla Enugu Nigeria. Dr. Ubesie is a consultant pediatrician, Department of Pediatrics University of Nigeria Teaching Hospital, Ituku Ozalla Enugu Nigeria. Dr. Ogbonnaya is a consultant ophthalmic surgeon, Department of Ophthalmology, Federal Teaching Hospital Abakiliki, Ebonyi State.
Many thanks to the medical director of Presbyterian Joint Hospital Ohaozara for his support. The clinic optometrist Dr Obasi is hereby thanked for assisting in data collection.
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