Hindawi Publishing Corporation
Journal of Ophthalmology
Volume 2016, Article ID 7173515, 5 pages
http://dx.doi.org/10.1155/2016/7173515
Research Article
An Important Cause of Blindness in Children:
Open Globe Injuries
Meral Yildiz,1 Sertaç Argun KJvanç,1 Berna Akova-Budak,1
Ahmet Tuncer Ozmen,1 and SadJk Gorkem Çevik2
1Department of Ophthalmology, Uludag University, School of Medicine, 16059 Bursa, Turkey
2Department of Ophthalmology, Şevket Yılmaz Training and Research Hospital, 16310 Bursa, Turkey
Correspondence should be addressed to Sertaç Argun Kıvanç; sakivanc@gmail.com
Received 21 January 2016; Revised 10 April 2016; Accepted 19 April 2016
Academic Editor: Marcel N. Menke
Copyright © 2016 Meral Yildiz et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Objective. Our aimwas to present and evaluate the predictive factors of visual impairment and blindness according toWHO criteria
in pediatric open globe injuries.Methods. The medical records of 94 patients younger than 18 years who underwent primary repair
surgery were reviewed retrospectively. The initial and final visual acuity, anterior and posterior segment findings, and zone of
injury were noted.The patients were classified as blindness in one eye or visual impairment in one eye. Results. Of 412 patients who
presented with open globe injury, 94 (23%) were under 18 years old. Fifty-four (16 females, 38 males) children were included. The
mean age of the children was 7.1 ± 4.1 years. According to WHO criteria, 19 of 54 patients (35%) had unilateral blindness and 8
had unilateral visual impairment (15%). There was no significant relationship between final visual acuity and gender and injured
eye. In visually impaired and blind patients, presence of preoperative hyphema, retinal detachment, and zone 2 and zone 3 injuries
was significantly higher. Conclusion. Presence of hyphema and zone 2 and zone 3 injuries and retinal detachment may end up with
visual impairment and/or blindness in children.
1. Introduction 2. Methods
Globally, an estimated 70 million blind person-years are Of 412 patients who underwent primary repair surgery
caused by childhood blindness. Approximately 500.000 because of open globe injury at Department of Ophthalmol-
children become blind every year [1]. In least developing ogy, Uludag University, between January 2010 and December
countries congenital and developmental cataract, retinal 2014, the medical records of 94 patients who were younger
pathology, and congenital anomalies are the main causes of than 18 years were reviewed retrospectively. The Uludag
nontraumatic blindness [2]. Ocular trauma is an important University Hospital administration approved the study. The
cause of eye morbidity and leading cause of noncongenital patients younger than 18 years old with at least 6 months of
monoocular blindness among children [3–5]. Worldwide, follow-up were included. The exclusion criteria were closed
eighteen million people have uniocular blindness from globe injury and major head trauma which might have
traumatic injury and every year a quarter of a million of injured chiasmal and retrochiasmal optic pathways. The ini-
children present with serious ocular trauma [6]. Two percent tial and final examinations of the patients were evaluated.The
to 14% of the pediatric ocular trauma patients ended in initial visual acuity, final visual acuity, anterior and posterior
visual impairment or blindness [7–9]. In this study, our aim segment findings, zone of injury, computed tomography, and
was to present and evaluate the predictive factors of visual ultrasound findings were noted.
impairment and blindness according to WHO criteria in Zone of injury was classified according to Ocular Trauma
pediatric open globe injuries. Classification Group: zone 1 as wound involvement limited
2 Journal of Ophthalmology
Table 1: Presenting and final visual acuity of children with open globe injuries.
Final VA
>6/18 <3/60 6/18–3/60 Total
𝑁 Row% Column% 𝑁 Row% Column% 𝑁 Row% Column% 𝑁 Row% Column%
N/A 13 56 48 5 22 26 5 22 62.5 23 100 43
Initial VA >6/18 4 80 15 0 0 0 1 20 12.5 5 100 9
<3/60 8 35 30 14 61 74 1 4 12.5 23 100 43
6/18–3/60 2 67 7 0 0 0 1 33 12.5 3 100 5
Total 27 50 100 19 35 100 8 15 100 54 100 100
VA: visual acuity,𝑁: number,%: percent, N/A: not available, Row%: the distribution of percent of patients in each initial visual acuity group according to final
visual acuity groups, and Column%: the distribution of percent of patients in each final visual acuity group according to initial visual acuity groups.
to cornea, zone 2 full thickness wound involving the sclera Table 2: Subjects that cause open globe injuries.
and within 5mm from the corneoscleral limbus, and zone 3
as wound involvement posterior to the anterior 5mm of the Cause of injury 𝑁 %
sclera [10]. Metal (knife, scissors, fork, wire, and foreign body) 28 51.8
The patients were classified according to WHO criteria Wood (branch of tree, plank, and pencil) 8 14.8
as blindness in one eye or visual impairment in one eye. Glass 7 13.0
Blindness was defined as presenting distance visual acuity Others (cable, toy, needle, and edge of a locker) 4 7.4
<3/60, VI as 3/60 to 6/18 with available correction according N/A 7 13.0
to WHO Vision 2020 Action Plan. Total 54 100.0
For statistical analysis, SPSS 22 statistical program was
𝑁: number,%: percent, and N/A: not available.
used. Pearson Chi-square and Fisher’s exact test were per-
formed to compare qualitative data. Pearson correlation anal-
ysis was used to assess the relation between the parameters.
The statistical significance was set at 𝑃 < 0.01 or 𝑃 < 0.05. 6 (11.1%), and zone 3 in 13 (24.1%) children, respectively. At
presentation, hyphema was noted in 12 (22.2%), iris injury in
15 (27.8%), and retinal detachment (3.7%) in 2 children. Lens
3. Results injury was noted in 28 (51.9%) children. At surgery, it was
noted that of 28 patients 13 had capsular rupture. Following
Of 412 patients who presented to Department of Ophthal- lens aspiration, retinal detachment was observed in 6 patients
mology with open globe injury between January 2010 and with capsular rupture during surgery.
December 2014, 94 (23%) were under 18 years old. Fifty-four All the patients underwent primary repair and during
(16 females, 38 males) children with at least 6 months of their follow-up underwent further surgeries as required.
follow-up were included in the study. The mean age of the The primary repair consisted of primary suturing of scleral
children was 7.1 ± 4.1 years (range: 2–16 years) and the mean laceration with 8-0 vicryl stitches or corneal perforation with
follow-up was 16.6 ± 10.4months (range: 6–46 months). We 10-0 nylon stitches. In 13 cases with capsular rupture, lens
divided the children into 3 groups according to age as 0–4 (19 aspiration was performed at the time of primary repair with-
children), 5–8 (20 children), and ≥9 years (15 children). out intraocular lens (IOL) implantation. Ultrasonography
Thirty-seven children (68.5%) referred to the department was performed in all patients postoperatively. Except the 8
within 24 hours, 15 (27.8%) within 24–48 hours, and 2 (3.7%) patients diagnosed with retinal detachment before and at the
of them after 48 hours following the trauma. There was no time of surgery, there was no retinal detachment. Ten of 13
relation between timing of surgery and visual outcome (𝑃 = patients with zone 3 injury and 3 of 6 patients with zone 2
0.559). injury had vitreous hemorrhage.
The visual acuity (VA) of 23 children (42.6%), all under The mean number of surgeries including primary repair
8 years old, could not be measured at presentation. Two was 1.6 ± 0.8. Eight patients who had undergone primary
children (3.7%) had VA of no light perception and 12 (22.2%) repair and lens aspiration had undergone anterior vitrectomy
had VA of light perception. The mean VA of 17 children and secondary IOL implantation. Three patients developed
(31.5%) whose Snellen VA could be measured was 0.2 ± 0.3 endophthalmitis after primary repair. Two of them had
(Table 1). intraocular foreign body. All 3 patients had undergone pars
Four children (7.4%) had intraocular foreign body at plana vitrectomy.
presentation. All the injuries were of penetrating type; the The final visual acuities of 8 patients (14.8%) were light
cause of the injury was unknown in 7 children. Fifty-seven perception and 4 patients were no light perception (7.4%).
percent of them were ≥9 years old. The cause of injuries is The mean final visual acuity of the others was 0.5 ± 0.4
given in Table 2. The injuries related with knife occurred (Table 1). According to WHO criteria, 19 of 54 patients
under 9 years old. The injuries related with pencil occurred (35%) had unilateral blindness and 8 had unilateral visual
above 4 years old. Zone 1 injury was in 35 (64.8%), zone 2 in impairment (15%). There was no significant relationship
Journal of Ophthalmology 3
Table 3: The relationship between decreased vision and initial examination findings.
Vision
value∗𝑃 >6/18 <6/18
𝑁 Row% Column% 𝑁 Row% Column%
Zone 1 22 62.9 81.5 13 37.1 48.1
Injury zones Zone 2 0.034 3 23.1 11.1 10 76.9 37.0
Zone 3 2 33.3 7.4 4 66.7 14.8
Traumatic cataract No 0.102 16 61.5 59.3 10 38.5 37.0
Yes 11 39.3 40.7 17 60.7 63.0
Hyphema No 0.050 24 57.1 88.9 18 42.9 66.7
Yes 3 25.0 11.1 9 75.0 33.3
Iris injury No 0.362 21 53.8 77.8 18 46.2 66.7
Yes 6 40.0 22.2 9 60.0 33.3
Retinal detachment No 0.022 26 56.5 96.3 20 43.5 74.1
Yes 1 12.5 3.7 7 87.5 25.9
∗Pearson Chi-square test.
%: percent, N/A: not available, Row%: the distribution of percent of patients in each initial visual acuity group according to final visual acuity groups, and
Column%: the distribution of percent of patients in each final visual acuity group according to initial visual acuity groups.
between final visual acuity and gender and injured eye. In 4. Discussion
visually impaired and blind patients, presence of hyphema
and retinal detachment was significantly higher. The rela- Open globe injures end in visual impairment and blindness at
tionship between decreased vision and initial examination a significant rate in injured children andmay restrict children
findings was shown in Table 3. There was no statistically lifelong and cause serious morbidity. The factors influencing
significant difference between 3 age groups in terms of visual visual outcome after ocular trauma are variable both in adults
impairment/blindness rates ( ). Seven of 19 patients and in children. Mechanism of injury, location of injury,𝑃 = 0.884
with blindness had retinal detachment at presentation. At initial visual acuity, presence of relative afferent pupillary
final examination, 6 had corneal scar with 2 of these also defect, hyphema, endophthalmitis, vitreous hemorrhage, and
having aphakia, and 2 patients had macular scar. Two retinal detachment are among the factors that have been
patients had phthisis bulbi. In one patient, retinal detachment mostly investigated [11–16]. In some studies lens injury is
developed due to PVR formation. One patient had traumatic proposed as a poor prognostic factor while others suggest
cataract but his parents did not give consent for the secondary that it does not affect the outcome [15]. The pattern and
surgery. burden of visual impairment in children with open globe
Five patients with visual impairment had corneal trauma injury may vary from region to region and may be associated
and aphakia and were planned for secondary IOL implanta- with the socioeconomic development level of the region. A
tion and corneal transplantation. Two had retinal scar due to study from Jamaica mentioned that 36% of the all pediatric
foreign body. One had retinal detachment at presentation. ocular traumas were open globe injury [17]. The studies
No significant difference was noted between children from Nigeria report that approximately 64.1–100% of open
with regard to visual impairment or blindness when they are globe injuries present with an initial visual acuity of <6/60
grouped as preschool and school-aged children (𝑃 = 0.783). [18, 19]. According to final visual acuity, they report that
There was also no significant relationship between the object 79.4% of children become visually impaired. Of these 39.7
that caused the injury and visual outcome. were blind. In a report from Iran, 48.9% had initial visual
Eight of 14 patients with initial VA of light perception or acuity <6/60 and 28.3% had final visual acuity <6/60 for
below had the same VA at final visit. Three of 23 patients all patterns of ocular injury [20]. However, these studies
whose initial VA could not have been assessed had final VA do not mention the factors resulting in visual impairment.
of light perception or below (Table 1). In a recent study from Thailand, 40.8% of the children
All the patients had occlusion in their fellow eye imme- obtained a final visual acuity of >6/60. They reported that
diately after the primary repair. At 3rd week postopera- retinal detachment was significantly correlated with poor
tively, their refractive errors were corrected with specta- final visual outcome, consistent with the findings of Lee et
cles. During follow-up, the aphakic patients had occlusion al. [11]. In our study, 15% had visual impairment, and 35%
therapy and transient rehabilitation with glasses or contact were blind. We also found a significant relationship between
lenses. After secondary IOL implantation, they were fol- visual impairment and injury zone, retinal detachment, and
lowed up regularly for detection of uncorrected refractive hyphema. A study from Canada involving 131 pediatric open
errors. globe injuries identified risk factors for final visual acuity
4 Journal of Ophthalmology
<20/40 as age younger than 5 years, wound length, injury site, References
rupture, vitreous hemorrhage, and retinal detachment [12].
They did not find an association between hyphema and poor [1] World Health Organization, VISION 2020 Action Plan 2006–
final visual outcome, inconsistent with our findings. Also 2011, World Health Organization, Geneva, Switzerland, 2007.
contrary to their results, we showed no association between [2] P. Gogate, K. Kalua, and P. Courtright, “Blindness in child-
age and visual impairment, probably due to a smaller sample hood in developing countries: time for a reassessment?” PLoS
size in this study. In our study, visual impairment/blindness Medicine, vol. 6, no. 12, Article ID e1000177, 2009.
rates were similar in age groups. On the other hand, the [3] E. Strahlman, M. Elman, E. Daub, and S. Baker, “Causes of
objects that caused the injuries were different among the pediatric eye injuries. A population-based study,” Archives ofOphthalmology, vol. 108, no. 4, pp. 603–606, 1990.
groups. Another study also identified mechanism of injury
and length of time prior to surgery as risk factors [21]. [4] M. Soylu, N. Demircan, M. Yalaz, and I. Işigüzel, “Etiology ofpediatric perforating eye injuries in Southern Turkey,” Oph-
A recent study from Australia analysing outcome of open thalmic Epidemiology, vol. 5, no. 1, pp. 7–12, 1998.
and closed globe eye injuries in children reported wound [5] P. A. DeRespinis, A. R. Caputo, P.M. Fiore, and R. S.Wagner, “A
length, wound site, and lens injury as parameters of poor survey of severe eye injuries in children,”The American Journal
visual outcome. They reported that 27 percent of open of Diseases of Children, vol. 143, no. 6, pp. 711–716, 1989.
globe injuries had a final visual acuity <6/60 [22]. Our [6] J. Abbott and P. Shah, “The epidemiology and etiology of
study was inconsistent with this study in terms of lens pediatric ocular trauma,” Survey of Ophthalmology, vol. 58, no.
injury. 5, pp. 476–485, 2013.
Presenting visual acuity is also reported to be predictive [7] C. J. MacEwen, P. S. Baines, and P. Desai, “Eye injuries in
for visual outcome [23, 24]. However, it is not always possible children: the current picture,” British Journal of Ophthalmology,
to obtain a reliable initial visual acuity in children especially vol. 83, no. 8, pp. 933–936, 1999.
following a remarkable trauma experience. Another study [8] C. A. Moreira Jr., M. Debert-Ribeiro, and R. Belfort Jr.,
found that initial vision was a less reliable predictor of final “Epidemiological study of eye injuries in Brazilian children,”
visual outcome [25]. In our study, initial visual acuity of Archives of Ophthalmology, vol. 106, no. 6, pp. 781–784, 1988.
42.6% of children could not be obtained. All of them were [9] A. S. Poon, J. S. Ng, D. S. Lam, D. S. Fan, and A. T. Leung,
under 8 years old, which could have made the assessment “Epidemiology of severe childhood eye injuries that required
of visual acuity difficult. In others, the rate of initial visual hospitalisation,”Hong KongMedical Journal, vol. 4, pp. 371–374,
acuity that could not be assessed changed from 24% to 1998.
32% [10, 13, 20–22]. Since the initial visual acuity is not [10] D. J. Pieramici, P. Sternberg Jr., T. M. Aaberg et al., “A system
available at all times in children, it may have a limited role for classifying mechanical injuries of the eye (globe). TheOcular Trauma Classification Group,” American Journal of
for predicting the final visual outcome following open globe Ophthalmology, vol. 123, no. 6, pp. 820–831, 1997.
injury. [11] C.-H. Lee, L. Lee, L.-Y. Kao, K.-K. Lin, and M.-L. Yang,
Relative pupillary afferent defect is used to calculate the “Prognostic indicators of open globe injuries in children,”
ocular trauma score and has been also shown among the American Journal of EmergencyMedicine, vol. 27, no. 5, pp. 530–
factors suggesting unfavourable visual outcome in children 535, 2009.
as well as in adult population in open globe injuries [26– [12] H. Bunting, D. Stephens, and K. Mireskandari, “Prediction of
28]. However, it is difficult to show the presence of relative visual outcomes after open globe injury in children: a 17-year
pupillary defect in young children as it is difficult to cooperate Canadian experience,” Journal of AAPOS, vol. 17, no. 1, pp. 43–
during examination. 48, 2013.
Following open globe injuries, presence of hyphema, zone [13] M.M. Schörkhuber,W.Wackernagel, R. Riedl, M. R. Schneider,
2 and zone 3 injury, and retinal detachment may end up with andA.Wedrich, “Ocular trauma scores in paediatric open globe
visual impairment and/or blindness in children. Therefore injuries,” British Journal of Ophthalmology, vol. 98, no. 5, pp.664–668, 2014.
great care should be taken when the children are referred [14] H. S. Al-Mezaine, E. A. Osman, D. Kangave, and A. M. Abu El-
with hyphema, skleral injury, and retinal detachment and Asrar, “Prognostic factors after repair of open globe injuries,”
appropriate management should be initiated in an effort to Journal of Trauma-Injury Infection & Critical Care, vol. 69, no.
minimize visual impairment. 4, pp. 943–947, 2010.
[15] O. Yalcin Tök, L. Tok, E. Eraslan, D. Ozkaya, F. Ornek, and Y.
Bardak, “Prognostic factors influencing final visual acuity in
Additional Points open globe injuries,” The Journal of Trauma, vol. 71, no. 6, pp.1794–1800, 2011.
This study is about the main causes of childhood blindness [16] S. M. Teixeira, R. R. Bastos, M. S. Falcão, F. M. Falcão-Reis,
from a developing country.The authorsmentioned the effects and A. A. Rocha-Sousa, “Open-globe injuries at an emergency
of open globe injuries on visual impairment and blindness. department in Porto, Portugal: clinical features and prognosticfactors,” European Journal of Ophthalmology, vol. 24, no. 6, pp.
932–939, 2014.
[17] L. Mowatt, A. McDonald, and D. Ferron-Boothe, “Paediatric
Competing Interests ocular trauma admissions to theUniversityHospital of theWest
Indies 2000–2005,”TheWest IndianMedical Journal, vol. 61, no.
None of the authors have any proprietary interests. 6, pp. 598–604, 2012.
Journal of Ophthalmology 5
[18] O. Okoye, A. Ubesie, and C. Ogbonnaya, “Pediatric ocular
injuries in a resource-deficient rural mission eye hospital in
Southeastern Nigeria,” Journal of Health Care for the Poor and
Underserved, vol. 25, no. 1, pp. 63–71, 2014.
[19] C. O. Ojabo, K. N. Malu, and O. S. Adeniyi, “Open globe
injuries in Nigerian children: epidemiological characteristics,
etiological factors, and visual outcome,” Middle East African
Journal of Ophthalmology, vol. 22, no. 1, pp. 69–73, 2015.
[20] D. Aghadoost, M. R. Fazel, and H. R. Aghadoost, “Pattern
of pediatric ocular trauma in Kashan,” Archives of Trauma
Research, vol. 1, no. 1, pp. 35–37, 2012.
[21] R. J. Baxter, P. R. Hodgkins, I. Calder, A. J. Morrell, S. Vardy,
and A. R. Elkington, “Visual outcome of childhood anterior
perforating eye injuries: prognostic indicators,” Eye, vol. 8, no.
3, pp. 349–352, 1994.
[22] S. Kadappu, S. Silveira, and F. Martin, “Aetiology and outcome
of open and closed globe eye injuries in children,” Clinical and
Experimental Ophthalmology, vol. 41, no. 5, pp. 427–434, 2013.
[23] O. Tok, L. Tok, D. Ozkaya, E. Eraslan, F. Ornek, and Y. Bardak,
“Epidemiological characteristics and visual outcome after open
globe injuries in children,” Journal of AAPOS, vol. 15, no. 6, pp.
556–561, 2011.
[24] H. S. Al-Mahdi, A. Bener, and S. P. Hashim, “Clinical pattern
of pediatric ocular trauma in fast developing country,” Interna-
tional Emergency Nursing, vol. 19, no. 4, pp. 186–191, 2011.
[25] J. C. Rudd, E. A. Jaeger, S. K. Freitag, and J. B. Jeffers,
“Traumatically ruptured globes in children,” Journal of Pediatric
Ophthalmology and Strabismus, vol. 31, no. 5, pp. 307–311, 1994.
[26] F. Kuhn, R. Maisiak, L. Mann, V. Mester, R. Morris, and C. D.
Witherspoon, “The ocular trauma score (OTS),”Ophthalmology
Clinics of North America, vol. 15, no. 2, pp. 163–165, 2002.
[27] A. Gupta, I. Rahman, and B. Leatherbarrow, “Open globe
injuries in children: factors predictive of a poor final visual
acuity,” Eye, vol. 23, no. 3, pp. 621–625, 2009.
[28] Y. Meng and H. Yan, “Prognostic factors for open globe injuries
and correlation of ocular trauma score in Tianjin, China,”
Journal of Ophthalmology, vol. 2015, Article ID 345764, 6 pages,
2015.