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Ocular injury in pediatric patients admitted with major trauma

Published:January 22, 2021DOI:https://doi.org/10.1016/j.jcjo.2020.12.024
      An estimated 2.4 million eye injuries occur in the United States annually, 35% of which occur in children under the age of 17years.

      Prevent Blindness America. The scope of the eye injury problem. www.preventblindness.org/sites/default/files/national/documents/fact_sheets/FS93_ScopeEyeInjury_0.pdf [Accessed March 1, 2018] 2021.

      Ocular trauma is a leading cause of childhood visual impairment and blindness and concurrence with other trauma can result in complicated rehabilitation and can negatively affect development. However, few reports detail the effects of polytrauma in pediatric patients admitted with ocular injuries.
      • Brophy M
      • Sinclair SA
      • Hostetler SG
      • Xiang H.
      Pediatric eye injury-related hospitalizations in the United States.
      • Garcia TA
      • McGetrick BA
      • Janik JS.
      Ocular trauma in children after major trauma.
      • Garcia TA
      • McGetrick BS
      • Janik JS.
      Spectrum of ocular injuries in children with major trauma.
      We sought to evaluate the epidemiology of these patients using the National Trauma Data Bank (2008–2014).

      National Trauma Data Bank. www.facs.org/quality-programs/trauma/ntdb [Accessed March 1, 2018] 2021.

      This retrospective study was approved by our Institutional Review Board. De-identified patients (<21 years of age) admitted with ocular trauma were identified using ICD-9CM (International Classification of Disease Ninth Revision - Clinical Modification) stands for International Classification of Disease Ninth Revision - Clinical Modification. stands for International Classification of Disease Ninth Revision - Clinical Modification. codes (800.00 to 959.9). Sex, race/ethnicity, age, type of ocular injury, mechanism, intention, hospital length of stay, injury severity score (ISS), and Glasgow Coma Score (GCS) were tabulated. ISS is an assigned numerical value indicating extent of injury in patients with polytrauma. GCS indicates the degree of traumatic brain injury (TBI). Mean, median, standard deviation (SD), and interquartile range were calculated for all continuous variables that were subsequently categorized for logistic regression analysis, 2-tailed Student's t test, and χ2 calculations, using SPSS version 24 (IBM Corp, Armonk, NY). Significance was set at p < 0.05. Patients with incomplete or unspecified data were excluded.
      Of the 316,485 patients admitted with ocular trauma, 58,765(18.6%) were <21 years of age. Mean (SD) age was 11.9 years (6.9) and most were 12 to 21 years of age (59.3%). Males (68.7%) outnumbered females (31.3%). Whites accounted for 59.1%, Blacks, 17.6%, and Hispanic ethnicity, 16.3% (Table 1). Most injuries were unintentional (76.3%). Common mechanisms were motor vehicle traffic accident - occupant (MVTO), 28.1% and struck by/against, 16.1%. Common injuries were eye/adnexa contusion (30.6%), orbital injuries (29.9%), and open adnexa wounds (29%). Open globe injury occurred in 11.6%. More than half (54.7%) had TBI. Mean (SD) hospital length of stay was 5 days (9) and mortality rate was 2.9% (Table 1).
      Table 1Descriptive findings and demographic data of pediatric ocular trauma, National Trauma Data Bank (2008–2014)
      CharacteristicNumberPercentCharacteristicNumberPercentMean (SD)Median (interquartile range)
      YearAge (y)11.9 (6.9)14 (5–18)
      2008773313.20–310 81218.4
      2009836414.24–656269.6
      2010848414.47–11753212.8
      2011835714.212–1822 77238.8
      201288011519–2112 02320.5
      2013832514.2
      2014870114.8ISS
      ISS categories: 1–8 = minor, 9–15 = moderate, 16–24 = severe, and >24 = very severe injury severity.
      12.6 (4)15 (12–15)
      Total58 4751001–826 77745.6
      9–1513 28822.6
      Sex16–24867314.8
      Male40 39568.7>24762113
      Female18 37031.3Unknown24064.1
      GCS
      GCS categories: <8 = severe, 9–12 = moderate, and 13–15 = mild brain injury.
      13 (4)15 (14–15)
      Race<8804813.7
      Black10 36017.69–1221173.6
      White34 72159.113–1542 15571.7
      Other13 68423.3Unknown644511
      Hispanic960316.3TBI32 17354.7
      Injury typeMortality16872.9
      Penetrating35236
      Blunt41 89271.3Stay (d)5 (9)2 (1–5)
      Other984816.8121 05735.8
      Unknown350262–317 96230.6
      4–6876014.9
      Hospital level>610 91718.6
      I20 94635.6Unknown690.1
      II831914.2
      III10111.7Intention
      IV1500.3Assault957916.3
      Not applicable28 33948.2Self-inflicted4370.7
      Unintentional44 81276.3
      Locations29520Other180
      Home17 23929.3Undetermined4170.7
      Other29525.5Unknown35026
      Public building22323.8
      Recreation47208US regions
      Residential Institute3050.5Midwest1294222
      Street24 75442.1Northeast932315.9
      Unspecified44337.5South23 10539.3
      Unknown18523.2West12 28220.9
      Not applicable1610.3
      Unknown9521.6
      ISS, injury severity score; GCS, Glasgow coma score; TBI, traumatic brain injury.
      low asterisk ISS categories: 1–8 = minor, 9–15 = moderate, 16–24 = severe, and >24 = very severe injury severity.
      GCS categories: <8 = severe, 9–12 = moderate, and 13–15 = mild brain injury.
      The 19-21 year age group had the greatest odds of MVTO trauma (odds ratio [OR], 2.01; p < 0.001) and the 0- to 3-year age group, falls (OR, 3.24; p < 0.001). MVTO was the most common mechanisms in all race/ethnicities, however, Black children were most often injured by firearms (OR, 3.83; p < 0.001), White patients, by environmental causes (OR, 2.46; p < 0.001), and Hispanic patients, by hot objects (OR, 1.52; p < 0.001) than other race/ethnicities. Of the most common mechanisms, the Northeast had greatest odds of falls (OR, 1.44; p < 0.001), the South, MVTO (OR, 1.27; p < 0.001), the Midwest, struck by/against (OR,1.08; p = 0.007), and the West, motor vehicle traffic accident (MVT)-pedestrian (OR, 1.65; p < 0.001).
      The 0- to 3-year age group had greater odds of assault (OR, 2.38; p < 0.001) and the 19- to 21-year age group, and self-inflicted injury (OR, 1.45; p <0.001). Black and Hispanic patients were mostly victims of assault (OR, 2.68 and OR, 1.41; p < 0.001, respectively) and White patients, of unintentional and self-inflicted injury (OR, 2.28 and OR, 1.45; p<0.001, respectively) and White patients, of unintentional (OR, 2.28; p < 0.001)Firearm injury had greatest odds of very severe ISS (OR, 2.62; p < 0.001), and cut/pierce of low ISS (OR, 32.96; p < 0.001). Open globe injuries were most associated with low ISS (1–8; OR, 3.82; p < 0.001) and orbital injury, with higher ISS (9–15; OR, 1.75; p < 0.001). Optic nerve and visual pathway injuries had greatest odds of severe ISS (16–24; OR, 4.63; p < 0.001) as did injuries associated with TBI (OR, 12.52; p < 0.001; Table 2).
      Table 2Summary of regression analysis of association between mechanisms and ocular injury and injury severity score in pediatric ocular trauma National Trauma Data Bank (2008–2014)
      MechanismISS
      ISS categories: 1–8 = minor, 9–15 = moderate, 16–24 = severe, and >24 = very severe injury severity.
      Frequencyp valueOR95% CI
      Fall1–82592<0.00011.151.09–1.22
      9–151451<0.0011.321.24–1.41
      16–247240.0030.880.81–0.96
      >24376<0.0010.470.42–0.52
      MVT-occupant1–85190<0.0010.420.41–0.44
      9–154154<0.0011.241.18–1.29
      16–243319<0.0011.741.65–1.83
      >243203<0.0012.041.94–2.14
      MVT-pedestrian1–8539<0.0010.330.30–0.36
      9–15688<0.0011.411.28–1.54
      16–24520<0.0011.621.47–1.80
      >24563<0.0012.101.90–2.32
      Pedal cyclist1–8219<0.0010.450.39–0.53
      9–15248<0.0011.621.38–1.89
      16–24162<0.0011.511.26–1.80
      >241230.0391.231.00–1.50
      Struck by/against1–86328<0.0013.092.94–3.24
      9–1520200.0020.920.87–0.97
      16–24541<0.0010.300.27–0.33
      >24198<0.0010.120.10–0.13
      Firearm1–8663<0.0010.600.55–0.67
      9–15341<0.0010.720.64–0.81
      16–243320.0061.181.05–1.34
      >24534<0.0012.622.36–2.91
      Cut/Pierce1–81449<0.00132.9624.98–44.37
      9–1536<0.0010.080.05–0.11
      16–2411<0.0010.040.02–0.07
      >245<0.0010.020.01–0.05
      Natural/Environment1–8295<0.0011.581.32–1.90
      9–151320.1471.160.94–1.42
      16–2449<0.0010.580.43–0.79
      >2428<0.0010.370.24–0.54
      Hot object1–8510<0.0018.176.36–10.63
      9–1553<0.0010.330.24–0.43
      16–2412<0.0010.110.06–0.20
      >246<0.0010.060.02–0.14
      Injury typeISSFrequencyp valueOR95% CI
      Open globe1–84951<0.0013.823.60–4.05
      9–15607<0.0010.300.27–0.32
      16–24475<0.0010.390.36–0.43
      >24578<0.0010.580.53–0.64
      Orbital fracture1–85407<0.0010.410.39–0.42
      9–155188<0.0011.751.70–1.82
      16–243338<0.0011.601.53–1.68
      >242802<0.0011.451.38–1.53
      Adnexal contusion1–86272<0.0010.530.51–0.55
      9–154788<0.0011.401.34–1.46
      16–243169<0.0011.391.32–1.46
      >242910<0.0011.501.42–1.58
      Open adnexal wound1–84951<0.0013.823.60–4.05
      9–15607<0.0010.300.27–0.32
      16–24475<0.0010.390.36–0.43
      >24578<0.0010.580.53–0.64
      Superficial wound1–83784<0.0011.251.19–1.32
      9–1517410.251.030.98–1.10
      16–24946<0.0010.810.75–0.87
      >24749<0.0010.710.66–0.77
      Visual pathway injury1–8176<0.0010.250.22–0.30
      9–151810.0040.790.67–0.92
      16–24189<0.0011.421.21–1.67
      >24380<0.0014.634.05–5.29
      Other cranial nerves1–8346<0.0010.250.22–0.28
      9–154830.0081.151.04–1.29
      16–24507<0.0012.151.93–2.39
      >24510<0.0012.552.29–2.83
      ISS, injury severity score; MVT, motor vehicle traffic accident.
      low asterisk ISS categories: 1–8 = minor, 9–15 = moderate, 16–24 = severe, and >24 = very severe injury severity.
      We affirmed previous findings for admitted patients with ocular trauma that included preponderance of male and older children, and association between open globe injuries and lower ISS and visual pathway injuries with higher ISS.
      • Brophy M
      • Sinclair SA
      • Hostetler SG
      • Xiang H.
      Pediatric eye injury-related hospitalizations in the United States.
      • Garcia TA
      • McGetrick BA
      • Janik JS.
      Ocular trauma in children after major trauma.
      • Garcia TA
      • McGetrick BS
      • Janik JS.
      Spectrum of ocular injuries in children with major trauma.
      ,
      • Georgouli T
      • Pountos I
      • Chang BY
      • Giannoudis PV.
      Prevalence of ocular and orbital injuries in polytrauma patients.
      ,
      • Abbot J
      • Shah P.
      The epidemiology and etiology of pediatric ocular trauma.
      These associations have management implications; patients with low ISS may be triaged to minor injury areas despite having potentially vision-threatening injuries. Additionally, we found that 54.7% had associated TBI and these patients had greater likelihood of severe ISS. Most patients survived with potential for long-term disability if not targeted for early multidisciplinary rehabilitation efforts. Demographic differences in mechanism and intention were identified. Black children, who represent 14% of children in the United States,

      America's Children. Key national indicators of well-being, 2017. www.childstats.gov/americaschildren/demo.asp [Accessed March 1, 2018].

      suffered 17.6% of ocular trauma. Also, they were mostly victims of assault and firearm injuries. White patients were more likely to be suicide victims than other race/ethnicities.
      Although extensive and detailed, data from the National Trauma Data Bank on pediatric patients admitted with ocular injuries was collected and submitted by emergency department and trauma team members. While serving to identify the most vision-threatening injuries and mechanisms, this study may have underestimated nationwide pediatric ophthalmic injuries and overstated severity. Despite these limitations, this study identified differences between groups that could assist in development of focused strategies aimed at preventing visual disability and morbidity in this vulnerable population.

      Acknowledgments

      The authors acknowledge John McNelis, MD, FACS, FCCM, MHCM, chair, and Melvin Stone Jr, MD, associate director, Trauma Services & Surgical Critical Care, Department of Surgery; and James Meltzer, MD, Department of Pediatrics, Jacobi Medical Center, Bronx, NY for their contributions and support.

      Footnotes and Disclosure

      The authors have no proprietary or commercial interest in any materials discussed in this article.

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