a b s t r a c t

Introduction: Pediatric Ocular trauma is a common complaint in pediatric emergency departments (ED) and is a major cause of acquired Monocular blindness. However, data on its epidemiology and management in the ED are lacking. The objective of this study was to describe the characteristics and management of pediatric ocular trauma patients who visited a Japanese pediatric emergency department (ED).

Methods: The present, retrospective, observational study was conducted in a pediatric ED in Japan between March 2010 and March 2021. Children younger than 16 years who visited our pediatric ED and received the diagnosis of ocular trauma were included. ED visits for follow-up examinations for the same complaint were excluded. The patients’ sex, age, arrival time, mechanism of injury, signs and symptoms, examinations, diagnosis, history of urgent ophthalmological consultation, outcomes, and ophthalmological complications were extracted from electronic medical records.

Results: In total, 469 patients were included; of these, 318 (68%) were male, and the median age was 7.3 years. The incident leading to trauma occurred most frequently at home (26%) and most often involved being struck in the eye (34%). In 20% of the cases, the eye was struck by some body part. Tests performed in the ED included visual acuity testing (44%), fluorescein staining (27%), and computed tomography (19%). Thirty-seven (8%) patients underwent a procedure in the ED. Most patients had a closed globe injury (CGI), with only two (0.4%) having an Open globe injury (OGI). Eighty-five (18%) patients required an urgent ophthalmological referral, and 12 (3%) required emergency surgery. Ophthalmological complications occurred in only seven patients (2%). Conclusion: Most cases of pediatric ocular trauma seen in the pediatric ED were CGI, with only a few cases leading to emergency surgery or ophthalmological complications. Pediatric ocular trauma can be safely managed by pediatric emergency physicians.

(C) 2023

1. Introduction

Pediatric ocular trauma is a common injury encountered in the pedi- atric emergency department (ED). In the United States about 2.4 million cases comprising nearly 35% of all eye injuries are estimated to occur an- nually. [1,2] Ocular trauma in the pediatric population in developed countries has declined over the past few decades, largely thanks to bet- ter preventive measures. Nonetheless, this type of injury still accounts for a significant number of evaluations performed in EDs [3] and is a major cause of acquired monocular blindness. In the ED, emergency physicians examine children with eye injuries and determine if there

is any need for a referral to an ophthalmologist. However, although ap- propriate, initial assessment is crucial for optimizing patient manage- ment, a comprehensive Ocular examination is sometimes difficult to perform in young children because of their limited ability to cooperate [2]. The treatment decision varies depending on the treating physician even though there are criteria for an ophthalmological referral [4].

Previous studies have reported the characteristics and management of pediatric ocular trauma patients in various countries [2,5-20], but data from pediatric EDs in Japan are still scarce. The present study aimed to describe the characteristics and management of pediatric ocular trauma patients who visited a pediatric ED in Japan.

* Corresponding author.

E-mail address: [email protected] (M. Kinoshita).

https://doi.org/10.1016/j.ajem.2023.05.012

0735-6757/(C) 2023

1. Methods
   1. Study design

The present, retrospective, observational study was conducted in a pediatric ED in Japan between March 1, 2010 and March 31, 2021. Children younger than 16 years who visited our pediatric ED with eye-related complaints diagnosed as ocular trauma (International Classification of Diseases (ICD)-10: S05.0-9) were included. Patients presenting to our hospital for follow-up with a visit history for the same complaint, non-trauma patients, trauma patients whose eyes were not involved, and patients who were not seen in the ED were excluded. The present study was conducted in accordance with the Dec- laration of Helsinki (2013) and the Institutional Review Board of Tokyo Metropolitan Children’s Medical Center (TMCMC) (2021b-2).

• 1. Setting

Tokyo Metropolitan Children’s Medical Center is located in sub- urban Tokyo, Japan. Each year, about 35,000 children visit the ED, which admits any patient with illness and/or injury of any severity. All patients visiting the ED are children. Trauma patients are usually evaluated first by a pediatric or emergency medicine resident under the supervision of a board-certified emergency physician. The at- tending physician decides the indications for imaging tests, treat- ment procedures, need for consultation with a specialist, and disposition of the patients.

• 1. Data collection

Data on the following characteristics of the patients were collected: sex, age, time of injury, time between injury and visit, means of trans- port to the ED, place of occurrence of the injury, mechanism of the in- jury, object(s) involved, involvement of sports activity, signs and symptoms reported by the patient, tests and procedures performed in the ED, diagnosis, urgent referral to an ophthalmologist, requirement for an emergency operation, patient disposition, and the presence of ophthalmological complications.

Visual acuity was assessed using the visual acuity test chart. Abnor- mal visual acuity was defined as poorer visual acuity in the affected eye than in the unaffected eye or in the affected eye before the injury. Visual acuity in children who were unable to use the chart, such as preverbal children, was evaluated by measuring fixation and preferential looking, and abnormal visual acuity was defined by the absence of appropriate behavior when one eye was covered [10].

Ocular traumas were classified according to the Birmingham Eye Trauma Terminology (BETT). Closed globe injuries (CGI) were classified as a contusion or a lamellar laceration while open globe injuries (OGI) were classified as a rupture, penetration, intraocular foreign body -related or perforation [21]. An ophthalmological complication was defined as any new, acute complaint or deterioration/persistence of the ocular trauma initially diagnosed in the ED [12]. The presence of complications was determined from medical charts at the time of data extraction in August 2021.

• 1. Chart review method

A chart review was conducted using a structured method [22]. The designated abstractor (M.K.) was trained in the abstraction method before data abstraction, constructing the abstraction form, and defining the variables through discussion with the investigators (T.I. and T.M.). The abstractors were not blinded to the data abstrac- tion. To verify the data, after data abstraction was begun, meetings were periodically held (by M.K., T.I., and T.M.) to confirm the defini- tions of the terms and the accuracy of the abstracted patient data randomly.

• 1. Statistical analysis

Statistical analyses were performed using SPSS statistical software, version 18.0 (SPSS Inc. Chicago, IL, U.S.A.). Summary statistics were pre- sented as a proportion with a 95% confidence interval (CI) or as the me- dian with an interquartile range (IQR). Tests for association were conducted using Fisher’s exact test. P < 0.05 was considered to indicate statistical significance.

1. Results

Fig. 1 shows the patient flow. During the survey period, 419,088 pa- tients visited our ED, 96,559 had trauma, and 559 met the inclusion criteria of the ICD-10. Of the latter, 90 patients were excluded for the rea- sons shown in Fig. 1, and 469 were finally included for analysis. Table 1 shows the patient demographics. Of the 469 patients included, 318 (68%) were male. The median age was 7.3 years (IQR: 3.1-11.5 years). Children aged 0 to 2 years accounted the largest percentage of the popu- lation (24%). The injuries occurred most frequently at home (n = 122; 26%), followed by school (n = 75; 16%). As for the mechanisms of in- jury, resulting from a direct blow to the eye were the most common (n = 161; 34%), followed by being struck by a thrown or fired projec- tile (n = 99; 21%).

Table 2 shows the type of object and sport involved in the injury. Most of the injuries were caused by body parts (20%; e.g., finger, hand, knee). Sports-related implements (baseball, etc.) were involved in 18% of the cases. More than half the objects were blunt. One hundred seven (23%) eye injuries occurred during a sports-related activity. Base- ball and softball were the most common sports associated with eye trauma (65%), followed by soccer (16%).

Table 3 lists the signs and symptoms reported by the patients. The most common complaint was eye pain (30%), followed by periorbital swelling (27%) and red eye (25%).

Table 4 lists the tests and procedures performed in the ED. The tests included visual acuity tests (44%), fluorescein staining (27%), and com- puted tomography (CT) (19%), which demonstrated abnormal findings in 13%, 31%, and 75% of the cases, respectively. The Abnormal CT findings included orbital fractures (57/66), retrobulbar hemorrhages (1/66), eyelid subcutis foreign bodies (2/66), intracranial hemorrhages (4/66), Skull fractures (6/66), Facial fractures (5/66), and lung contusion (1/ 66). Thirty-seven patients required evaluation or treatment for their in- jury in the ED. All the procedures were performed by an ED physician, except in one case which required suturing of the ocular conjunctiva by an ophthalmologist. Six patients were sedated for wound inspection and treatment; one of these was intubated.

Fig. 2 shows the BETT classification of the injuries. Two patients had OGI, both of which were Penetrating injuries; one case occurred

Fig. 1. Flow chart of patient selection.

ED, emergency department; ICD-10, International Classification of Diseases, 10th Edition.

Table 1

Patient characteristics (N = 469).

n (%)

Table 2

Type of object causing injury and sports involvement.

n (%)

Male sex 318 (68)

Age (years)

Median (IQR)	7.3 (3.1-11.5)
0-2	111 (24)
3-5	88 (19)
6-8	84 (18)
9-11	83 (18)
12-15	103 (22)
Time at injury occurrence 12:00 AM - 8:59 AM	21 (5)
9:00 AM - 4:59 PM	200 (43)
5:00 PM - 11:59 PM	178 (38)
Unknown	70 (15)
Time between injury and visit (min)
Median (IQR)	88 (52-182)
means of transportation to hospital
Walk-in	377 (80)
Ambulance	92 (20)

Place of injury occurrence

Home 122 (26)

School 75 (16)

Park 17 (4)

Public area (outdoors) 37 (8)

Public area (indoors) 13 (3)

Outdoors (details unknown) 69 (15)

Indoors (details unknown) 21 (5)

Unknown 115 (25)

Mechanism of injury

Blow to the eye	161 (34)
Thrown/fired projectile	99 (21)
Fall	80 (17)
Exposure to liquid irritant	34 (7)
Collision with an object	25 (5)
Particle flew into eye	21 (5)
Eye poke/self-inflicted eye poke	18 (4)
Scratch	8 (4)
Animal	7 (2)
Burn	2 (0.4)
Unknown	14 (3)

IQR, interquartile range.

in a 7-year-old, male patient who had a corneal perforation requiring emergency surgery when his eye was pierced by an iron rod when he fell. The other case was that of a 5-year-old, male patient whose cornea was perforated by a sharp, plastic object thrown by another child. Table 5 shows the diagnosis of each case of ocular trauma; 487 diagno- ses were made in 469 patients because some patients had multiple diag- noses. Contusion was the most frequently diagnosed injury (63%), followed by corneal wound (12%) and subconjunctival hemorrhage (10%).

Table 6 shows the patient outcomes (requirement for urgent referral to an ophthalmologist, emergency operation, disposition, and ophthal- mological complication). Eighty-five patients were urgently referred to an ophthalmologist. Two, emergency operations for ocular trauma were performed for a 7-year-old, male patient with a corneal perfora- tion caused by falling on an iron rod (above) and a 7-year-old, female patient with a conjunctival laceration caused by a cat scratch. For non- ocular trauma, an emergency operation was done for orbital fractures (7/10), eyelid subcutis foreign body (1/10), eyelid laceration (1/10), and intracranial hemorrhage (1/10). Six patients were hospitalized for ocular trauma, such as corneal perforation (2/6), conjunctival laceration (1/6), iridodialysis and hyphemia (1/6), corneal laceration (1/6), and retrobulbar hemorrhage. Other cases requiring hospitalization involved orbital fractures (25/48), Traumatic brain injuries (4/48), Skull fractures (4/48), eyelid lacerations (3/48), concussions (4/48), and child abuse (8/48). Ophthalmological complications occurred in seven patients, in- cluding oculomotor disturbance (1/7), diplopia (2/7), retinal detach- ment (2/7), cataract (2/7), ptosis (2/7), wound reopening (2/7), Visual impairment (1/7), and Vision loss (1/7).

Objects (N = 469)

Body part 93 (20)

Ball 86 (18)

Ground /floor 41 (9)

Liquid 34 (7)

Furniture 31 (7)

Toy 12 (3)

Sand 11 (2)

Paper 8 (2)

Animal 7 (2)

Baseball bat /racket 6 (1)

Hook 6 (1)

Pen /pencil 5 (1)

Chopstick 5 (1)

Twig 5 (1)

Flame 1 (0.2)

Miscellaneous blunt object 85 (18)

Miscellaneous sharp object 17 (4)

Unknown 16 (3)

Sports involvement (N = 107)?

Baseball /Softball	70 (65)
Soccer	17 (16)
Tennis	4 (4)
Basketball	3 (3)
Handball	2 (2)
Gymnastics	2 (2)
Karate	2 (2)
Others	7 (7)

* Percentages are based on the total number of sports-related trauma (N = 107).

1. Discussion

The present study described the epidemiological profile and man- agement of pediatric ocular trauma cases seen in a pediatric ED in Japan. In this study, male patients (68%) outnumbered the female pa- tients, and the male-to-female ratio was 2.1:1. Other epidemiological studies of pediatric ocular trauma in the ED reported a male-to-female ratio varying from 1.5:1 to 2.7:1 [6,9,11,12,15,19]. This finding may be attributed to the stronger tendency in boys to engage in more aggres- sive, risky behaviors. The median age of the children presenting to the ED with ocular trauma was 7.3 years (mean: 7.4 years) as in other stud- ies [6,15,19,23]. The two, most common age groups were 0-2 years and 12-15 years in our study. Some studies have reported the 5-9-year-old age group [6,12,15], while other studies have reported the 0-4-year-old group, as being the most susceptible to ocular injury [9,11]. Young chil- dren are vulnerable to ocular injury because their underdeveloped motor skills do not enable efficient avoidance behavior, they have a lim- ited ability to assess risk, and their natural curiosity prompts risky be- havior [20]. In the present study, 60% of patients aged 12-15 years were injured while playing sports, suggesting that the high incidence of ocular trauma in the older age groups is related to this type of activity.

Table 3

Signs and symptoms reported by patients (N = 469).

Signs and symptoms n (%)

Eye pain 143 (31)

Periorbital swelling 127 (27)

Red eye 117 (25)

Visual disturbance 68 (15)

Periocular wound 35 (8)

Nausea/Vomiting 33 (7)

Bloody tears 26 (6)

Eyeball wound 6 (1)

Headache 5 (1)

Not specified 22 (5)

Total 582 (469 patients)

Table 4

Tests and procedures performed in ED.

n (%) Findings

Table 5

Distribution of ocular injuries (N = 469).

Diagnosis n (%)

Tests? Normal (%)+ Abnormal (%)+

Visual acuity testing	204 (44%)	178 (87)	26 (13)
Fluorescein staining	128 (27%)	89 (70)	39 (31)
Slit lamp	41 (9%)	37 (90)	4 (10)
Fundoscopy	1 (0.2%)	1 (100)	0 (0)
Ultrasonography	21 (5%)	21 (100)	0 (0)
Eye	10 (10/21)	10 (100)	0 (0)
Trunk (FAST)	11 (11/21)	11 (100)	0 (0)
CT	88 (19%)	22 (25)	66 (75)
Head	88 (88/88)	22 (25)	66 (75)
Trunk	2 (2/88)	1 (50)	1 (50)

Procedure?

Irrigation 24 (5)

Removal of foreign body 5 (1)

Superficial foreign body 4 (1)

Eyelid subcutis foreign body 1 (0.2)

Wound suturing 7 (2)

Ocular conjunctival wound? 1 (0.2)

Eyelid laceration 6 (1)

Procedural sedation 6 (1)

Intubation 1 (0.2)

FAST, focused assessment with sonography for trauma.

* Percentages are based on the total number of patients (N = 469).

⁺ Percentages are based on the number of patients undergoing each test.

^? Percentages are based on the total number of patients (N = 469).

^? Sutured by an ophthalmologist in the ED.

Many studies have shown that the most common place of pediatric eye injury occurrence is the home [6,7,9,10,12,14,15,19,23], a finding sup- ported by the present study. Children spend long periods of time at home, accounting for why young children (aged 0-4 years) in particular have the highest risk of eye injury while at home [9].

The most common mechanism of injury was a direct blow to the eye (34%), followed by an injury inflicted by a thrown or fired projectile (21%). Matsa et al. [11] reported that a blow to the eye was the most common cause of injury (22.5%), followed by sports-related accidents (14.2%) and falling (10.5%). Kadappu et al. [14] reported that self- or

Fig. 2. Classification of patients according to the Birmingham Eye Trauma Terminology (BETT) [21].

Contusion 307 (63)

Subconjunctival hemorrhage	48 (10)
Corneal wound	56 (12)
Conjunctival wound	4 (1)
Iritis	5 (1)
Iridodialysis	2 (0.4)
Hyphemia	16 (3)
Retinal edema	6 (1)
Lens opacity	2 (0.4)
vitreous hemorrhage	1 (0.2)
Traumatic optic neuropathy	1 (0.2)
Retrobulbar hemorrhage	1 (0.2)
Superficial foreign body	4 (1)
Not specified	35 (7)
Total	488 (469 patients)

other-inflicted eye poking was the most common mechanism (26%), followed by thrown projectiles (21%).

In the present study, blunt objects tended to be more commonly in- volved in causing ocular injuries than sharp objects. The type and fre- quency of objects causing pediatric eye trauma vary in previous reports and may reflect cultural and economic differences between countries. In an Australian study [14], the most common object report- edly causing eye injury was a stick (15%). In a French study [7], it was a body part (14%), and in a Brazilian study by Rohr et al. [23] it was a wooden object (11.7%). In the present study, most of the injuries were caused by a body part (20%), followed by a sports-related implement, such as a ball (18%). Injuries caused by chopsticks (n = 5) point to the uniquely cultural aspect of the object involved. Another study [5] re- ported cases of ocular trauma involving a knife (3%) or spoon (1%); an Australian study by Kadappu et al. [14] reported the involvement of kitchen utensils (8%). Indeed, children may be more susceptible to ocu- lar injury from handling cutlery. The ocular trauma caused by chopsticks in our study occurred when the patient fell while holding the chopsticks themselves (2/5) or when they collided with another person holding chopsticks (1/5) or were hit in the eye by a chopstick thrown by another person (1/5). One patient whose eye was injured through improper use of chopsticks underwent emergency surgery to remove an eyelid subcu- tis foreign body. A report of pediatric eye trauma by Archambault et al.

[6] also included two cases requiring surgery for a knife-related injury incurred in a fall. The use of eating utensils by young children should therefore be monitored and supervised.

In the present study, seven cases (2%) of ocular trauma were inflicted by a dog (3/7) or a cat (4/7), most of which occurred in the

Table 6

Patient outcomes (N = 469).

Outcomes n (%)

Urgent referral to an ophthalmologist 85 (18)

Emergency operation 12 (3)

Emergency operation for ocular trauma 2 (0.4) Emergency operation for non-ocular trauma 10 (2)

Disposition

Discharged	412 (88)
Hospitalized for ocular trauma	6 (1)
Hospitalized for non-ocular trauma	48 (10)
Unknown	3 (0.6)
Ophthalmological complication	7 (1)
Diplopia	2 (2/7)
retinal detachment	2 (2/7)
Cataract	2 (2/7)
Ptosis	2 (2/7)
Wound reopening	2 (2/7)
Oculomotor disturbance	1 (1/7)
Visual impairment	1 (1/7)
Vision loss	1 (1/7)

home (6/7). Previous studies also reported that 1-2.5% of ocular injuries were related to household pets [7,11,14,20,23]. Young children do not have the cognitive capacity to interact appropriately with animals with- out supervision [11]. Reminding pet owners that young children are more susceptible to injuries incurred while interacting with animals and should therefore be kept away from them is important to prevent- ing ocular trauma.

Previous studies have reported that sports-related accidents accounted for 9-14.9% [6,9-12,14,15] of pediatric ocular trauma cases, and in the present study, 107 (23%) cases of ocular trauma occurred while the patients were engaged in sports-related activities. Sports- related ocular trauma is also an important risk factor of hospitalization [24]. However, most, serious eye traumas incurred while playing sports are preventable [25]. Many strategies for preventing eye injury currently focus on sports and recreational activities [9]. For example, the American Academy of Pediatrics and the American Academy of Ophthalmology have recommended protective eyewear for all those engaging in sports involving the risk of eye injury [26]. No such recommendations have been issued in Japan, and protective eyewear is not used often enough. Our results underscore the importance of preventive measures to reduce sports-related eye trauma in Japan.

There are at present no large studies describing the signs and symp- toms of ocular trauma in children presenting to ED. In our study, 31% of the patients presented with eye pain, and 27% presented with periocular swelling. Further studies may be useful for identifying the signs and symptoms that are risk factors of ophthalmological complications.

Another important feature of this study is its description of the man- agement, outcomes, and prognosis of pediatric patients presenting to the ED with ocular trauma. The most common test performed in the ED was visual acuity (VA) testing; 13% of our patients receiving VA test- ing had abnormal findings. A similar figure of 13.4% was reported by Cohen et al. [10]. Other tests included fluorescein staining (27%), CT (19%), and slit-lamp examination (9%), which found an abnormality in 31%, 75%, and 10% of cases, respectively. It is important to perform these tests in the ED to determine whether urgent referral to a specialist is necessary by assessing for corneal perforation, orbital fracture, etc.

Thirty-seven patients (8%) underwent some form of procedure in the ED for their ocular trauma. All the procedures, including irrigation, suturing, and sedation, were performed by the emergency physician, except in one case where an ophthalmologist sutured a conjunctival wound. Most patients in the present study had CGI, and only two had OGI (0.4%). The rate of OGI was lower than reported in previous, epide- miological studies of pediatric ocular trauma in the ED (2.1-6.7%) [12,15,18], and the figure may vary depending on the hospital setting, such as whether it is a tertiary emergency facility and whether there is access to an ophthalmologist. Most of the injuries diagnosed were contusions or other conditions not requiring surgery. Ophthalmological tests, such as the visual acuity test, fluorescein staining, and slit-lamp, were performed in the ED by an emergency physician as needed. Most of the procedures in the ED were also performed by an emergency phy- sician. >80% of children presenting to the ED for ocular trauma did not require an urgent referral to an ophthalmologist, and none of these had an ophthalmological complication as far as could be determined through follow-up. Cohen et al. reported similar findings, stating that most children presenting to the pediatric ED with an eye injury can be safely managed by an ED physician [10]. In the present study, only two patients (0.4%) required emergency surgery for ocular trauma. When periocular injuries, such as orbital fractures and eyelid lacera- tions, were included, the number rose to 11 (2%). Previous studies of children with ocular trauma presenting to the ED reported a surgery rate ranging from 1.7 to 15.5% [6,10,12,15,18]. Simple comparisons are difficult because the findings are influenced by the particular hospital setting as mentioned above or by inclusion criteria, such as whether or not orbital fractures or ocular adnexal injuries were included. On the other hand, some patients experienced ophthalmological complica- tions of ocular trauma despite having no abnormal test findings. Cohen

et al. reported that in pediatric ocular trauma in the ED, an injury involv- ing a high-velocity mechanism should prompt an urgent consultation with an ophthalmologist even if a visual acuity test and an eye examina- tion by an emergency physician produce normal results [10]. Pediatric ocular trauma can be managed safely by pediatric emergency physicians as long as they work with an ophthalmologist to Optimize patient care. Further studies aimed at identifying the factors associated with ophthal- mological complications in pediatric ocular trauma in the ED setting are warranted.

The present study has several limitations. First, it was retrospective and conducted in a single pediatric ED, which may affect the generaliz- ability of the results. Second, because the participants were extracted using the diagnostic code (ICD-10: S05.0-9), some cases may have been omitted. Third, some of the data (e.g., place, time of injury) were unavailable because the study was retrospective. Finally, the presence of ophthalmological complications was assessed using information in medical records and/or a referral letter to an ophthalmologist, which may have omitted information about complications. Further, prospec- tive studies are needed to address these limitations.

1. Conclusion

The present study demonstrated the characteristics and manage- ment of pediatric ocular trauma cases in a pediatric ED in Japan. Most of the cases were of CGI, with only a few cases requiring emergency sur- gery or associated with ophthalmological complications. Many cases of pediatric ocular trauma can be safely managed by pediatric emergency physicians.

Funding

This research did not receive any specific grant from funding agen- cies in the public, commercial, or not-for-profit sectors.

Presentation

None.

CRediT authorship contribution statement Masakazu Kinoshita: Writing - original draft, Investigation, Formal

analysis, Data curation. Takateru Ihara: Writing - review & editing, Supervision, Methodology, Conceptualization. Takaaki Mori: Writing - review & editing, Supervision, Project administration, Methodology, Conceptualization.

Declaration of Competing Interest

None.

Acknowledgments

The authors thank Mr. James Robert Valera for his assistance with editing this article.

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