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Original Article
Ocular trauma in Indian pediatric population
Vishal Katiyar, Sonal Bangwal, Sanjiv Kumar Gupta, Vinita Singh, Kumari Mugdha, Poonam Kishore
Background: Trauma to the eye and ensuing visual disability is an important cause of preventable monoocular
blindness in the pediatric age group in India. Policy decisions are helpful in preventing this kind of trauma and
improving the required trauma management services warrant an accurate estimate of various aspects of ocular trauma
and its outcome in Indian population. Aims: To understand the patterns of ocular trauma in Indian pediatric population
and its shortterm visual outcome. Settings and Design: Atertiary center based, retrospective, observational study.
Materials and Methods: Data collection from January 2010 to June 2013 including demographic profile, place of
injury, distance from tertiary center, type of health care facility first sought, time delay in first treatment, medicolegal
status, pattern of ocular injury on Birmingham Eye Trauma Terminology System(classification), trauma elsewhere in
the body, treatment given by us, and best corrected visual acuity(BCVA) at the time of presentation and 3months.
Statistical Analysis: Multinomial logistic regression analysis to identify factors independently affecting BCVA
posttreatment which included age, time of the first contact, and time delay in treatment, pretreatment BCVA.
Results and Conclusions: Mean age of injury was 7.63.3years with 151(79.1%) males and 40(20.9%) females.
Seventyeight percent of patients were from rural areas and 43% first sought treatment at some other government health
facility. Majority of children 83/191(43.5%) sustained injuries at agricultural fields. Best visual acuity was observed
in cases of closed globe injuries which was better than 6/18 in 81.8%(18/22) cases.

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DOI:
10.4103/2320-3897.174400
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Key words: Best corrected visual outcome, Birmingham Eye Trauma Terminology System (classification), closed
globe injuries, globe rupture

Trauma to the eye and ensuing visual disability is an important

cause of preventable monoocular blindness in the pediatric
age group in India. The ensuing visual disability has significant
emotional, psychological, and Socio-economical impact on
the individual person, family, and to the society as a whole.[1]
Policy decisions helpful in preventing this kind of trauma and
improving the required trauma management services warrant
an accurate estimate of the pattern of the ocular trauma in
Indian population.[2] Most of our understanding of this issue
is based on the studies from developed countries[3,4] with very
limited studies from India.[5] We planned this epidemiological
study to understand the patterns of ocular trauma in Indian
pediatric population and its shortterm visual outcome.

Materials and Methods

The study was conducted after ethical clearance and was
performed in accordance to the tenets of the Helsinki
Declaration. Retrospective tertiary centerbased analysis of
medical records of all pediatric patients presenting at the
Department of Ophthalmology, from January 2010 to June
2013 was done.
Data collection included demographic profile of the
patients, place where injury occurred, its distance from the
tertiary center, type of health care facility first sought, time
delay in first treatment, medicolegal status of ocular injury
Department of Ophthalmology, KGMU, Lucknow, Uttar Pradesh, India
Address for correspondence: Dr.Vishal Katiyar, Department
of Ophthalmology, KGMU, Lucknow, Uttar Pradesh, India.
Email:vishalkatiyar@rediffmail.com
Manuscript received: 13.03.2015; Revision accepted: 21.10.2015

on Birmingham Eye Trauma Terminology System(BETTS

classification), trauma elsewhere in the body, treatment given
by us, and BCVA at the time of presentation and 3months.
Modes of injuries were classified under following heads:
Domestic environment trauma: This included cases of injury
due to stationary items, household items
Trauma sustained during outdoor activities: This included
cases of injuries while playing with ball, stone pellets, bow
and arrow, wooden top, sticks, Gulli Danda(a local sport
involving sharp wooden sticks)
Fire cracker injuries during Diwali and other festive
occasions
Road traffic accidents
Animal attacks
Agriculture field and work place related injuries: Injuries
sustained in agricultural fields and other places not meant
for recreation
Miscellaneous.
The visual acuity was charted in Snellens score and
converted to LogMAR equivalent for further analysis.
This is an open access article distributed under the terms of the Creative
Commons AttributionNonCommercialShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work noncommercially, as long as the
author is credited and the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com

Cite this article as: Katiyar V, Bangwal S, Gupta SK, Singh V, Mugdha K,
Kishore P. Ocular trauma in Indian pediatric population. J Clin Ophthalmol
Res 2016;4:19-23.

2016 Journal of Clinical Ophthalmology and Research | Published by Wolters Kluwer -Medknow

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Katiyar, et al.: Ocular trauma in Indian pediatric population

Results

to the tertiary center. Almost similar number (42%) sought

medical or surgical help at the tertiary center on the first
place. Only 14.7% patients sought treatment from a private
practitioner on the first place.

We retrospectively reviewed the records of 191 pediatric

patients from January 2010 to June 3013. Multinomial
logistic regression analysis was done to identify the factors
independently affecting BCVA posttreatment namely age, time
of first contact, time delay in treatment, and pretreatment BCVA.
Mean age of injury was 7.63.3years(range 114years) with
151(79.1%) males. Seventyeight percent of patients were from
rural areas. Male children between the age of 6 and 10years
constituted the largest group accounting for 41.1%(80/191)
of total patients. Fifty percent (20/40) female patients were
below 5years of age.

Mean time interval from the onset of event/symptoms

to the first contact with any health facility was 8.2514.6
h(range 1 h5days). Similarly, mean time interval from the
onset of event/symptoms to definitive treatment at the tertiary
center was 27.637.9 h(range 1 h8days). The mean first
contact time interval and mean definitive treatment time
interval(11.820.3 h, 39.445.4 h) was significantly
higher when patients sought other government health facility,
rather than coming directly to the tertiary center(5.25.7
h, 11.225.1 h)(P<0.001), respectively.

There was a mean inflow of 4.541.97cases per month,

ranging from a single case in month of September to 17
cases in the month of October. Almost onefourth(26.7%) of
pediatric patients were from the same district, 46.2% cases
from adjoining six districts and 27.1% patients from far off
12 districts[Figure1].

Table1 shows the distribution of various modes of

injuries in patients presenting as ocular emergencies.
Majority of children 83/191(43.5%) sustained injuries at
agriculture fields and work places adjoining their residence,
out of which 83.5% were males and 49% were in age group
of 610years. This was followed by injuries sustained in
domestic environments and accounted for 21.5%(41/191)
cases. Ocular injuries associated with road traffic accidents
accounted for 8.4%(16/191) of patients presenting in
emergency with majority(75%) related to two wheelers.
Fire cracker injuries accounted for about 7.3% (14/191)
of injuries, mostly during Diwali season(October or
November). Eye injuries due to fire arm accounted for just
one case. Five out of 191(2.4%) had come with emergencies
not associated with trauma such as retinoblastoma or
orbital cellulitis.

Less than half of the cases(43%), first sought treatment

at some other government health facility(Peripheral Health
Centre or Community Health Centre) before being referred

Laceration in the corneoscleral region of eye 92/191(48.2%),

closed globe injuries 59/191(30.9%), and globe rupture
24/191(12.6%) were the common injuries seen in the patients
presenting as emergencies[Table2].
Eighteen percentage of patients had facial trauma along
with ocular injury and 8.8% cases had associated head
trauma. 2.8% patients had injuries elsewhere at the time
of presentation. Of all the ocular emergencies, only one
case(0.5%) was registered as medicolegal elsewhere.

Figure 1: Pattern of inflow of cases to trauma centre from adjoining

districts

Table 1: Mode of injury

Circumstances in which injuries were
sustained

Sex

Age in years

Female

Male

Accidents in domestic environment

12 (6.3%)

290 (15.2%)

Agriculture field and work place related injuries

14 (7.3%)

69 (36.1%)

Outdoor playing or recreational activities

4 (2.1%)

22 (11.5%)

Road traffic accidents

9 (4.7%)

Fire cracker

6.00 - 10.00

11.00+

14 (7.3%)

16 (8.4%)

11 (5.8%)

41 (21.5%)

25 (13.1%)

41 (21.5%)

17 (8.9%)

83 (43.5%)

4 (2.1%)

17 (8.9%)

5 (2.6%)

26 (13.6%)

7 (3.7%)

5 (2.6%)

8 (4.2%)

3 (1.6%)

16 (8.4%)

0 (0%)

14 (7.3%)

3 (1.6%)

6 (3.1%)

5 (2.6%)

14 (7.3%)

Fire arm, assault and other physical violence

0 (0%)

1 (.5%)

1 (.5%)

0 (0%)

0 (0%)

1 (.5%)

Animal attacks

0 (0%)

5 (2.6%)

1 (.5%)

4 (2.1%)

0 (.0%)

5 (2.6%)

Miscellaneous

20

< = 5.00

Total

1 (.5%)

4 (2.1%)

3 (1.6%)

2 (1.0%)

0 (0%)

5 (2.6%)

40 (20.9%)

151(79.1%)

56 (29.31%)

94 (49.2%)

41 (21.5%)

191 (100.0%)

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Katiyar, et al.: Ocular trauma in Indian pediatric population

Table2: Pattern of injuries as per Birmingham Eye Trauma Terminology System (BETTS classification)
Various situations in which injury was sustained
Pattern of
injuries as
per (BETTS
classification)
Closed globe
injury
Contusion
Lamellar
laceration
Rupture
Laceration
Intraocular
foreign body
Total

Accidents
Agriculture
Outdoor Road traffic
Fire
in domestic field and work
playing or
accidents cracker
envoirnment
place related recreational
injuries
activities

Fire arm,
assault
and other
physical
voilence

Animal Miscellaneous
attacks

12

14

12

59

6.3%

7.3%

4.7%

6.3%

4.7%

.5%

.5%

.5%

30.9%

1.0%

1.6%

2.1%

.0%

.0%

.0%

.0%

.0%

4.7%

1.6%

.0%

.0%

.0%

.0%

.0%

.0%

.0%

1.6%

15

24

.0%

7.9%

1.6%

1.0%

1.0%

.0%

.0%

1.0%

12.6%

24

50

92

12.6%

26.2%

3.7%

1.0%

1.6%

.0%

2.1%

1.0%

48.2%

.0%

.5%

1.6%

0%

0%

0%

0%

0%

2.1%

41

83

26

16

14

191

21.5%

43.5%

13.6%

8.4%

7.3%

.5%

2.6%

2.6%

100.0%

Of all the cases, 62.3%(119/191) patients required surgical

intervention at the time of presentation, and the rest were
conservatively managed.
BCVA at presentation and 3months after management
is shown in Table 3. At 3months posttreatment, only
34/122(26.7%) could achieve a visual acuity better than 6/18.
Percent(22/34) of these patients had closed globe injuries.
Onethird of these patients had lacerations(12/34) and were
able to achieve a BCVA better that 6/18. Fortyfour percentage
(54/122) had a BCVA<3/60 at 3months posttreatment. Globe
rupture(23/54) and laceration(27/54) together accounted for
92.5%(50/54) of all cases with final BCVA<3/60 at 3months
post treatment. BCVA at 3months was below 3/60 in cent
percent(23/23) cases of globe rupture and in 42.1% (27/64)
cases of laceration. The best visual outcome was observed in
cases of closed globe injuries which was better than 6/18 in
81.8%(18/22) cases.
Linear regression analysis of the factors affecting the
BCVA at 3months revealed that the BCVA at the time of
presentation was the only factor independently affecting
the final visual outcome[Table4]. The age of the child and
delay in presentation did not affect the final outcome. In
the multinomial logistic regression of factors affecting the
final BCVA, we observed that only patients with closed globe
injury or contusion had final BCVA better than 3/60 after
3months.

Discussion
In the present study, we observed a distinct dip in the average
Journal of Clinical Ophthalmology and Research - Jan-Apr 2016 - Volume 4 - Issue 1

inflow of pediatric ocular trauma patients, in months of July

and September and a surge in the month of October. This
pattern of rise and fall in patients inflow is parallel to a similar
fall and rise in overall Outpatient Department patients,
observed in clinical practice, in this region. The sowing season
of Kharif crops(paddy and sugarcane) lasts from the mid of
June to end of July which demands significant investment in
low levels of public financing, lack of a comprehensive risk
pooling mechanism, and high outofpocket expenditures in
the context of rising health costs are key factors impacting
the utilization of health services by poor people especially
from rural areas.[6] Only around 10% of the Indian population
is covered under some form of social or voluntary health
insurance, [7] rest are forced to make an outofpocket
expenditures to seek medical treatment. The poor, more so
in rural areas,[8] are affected more by immediate availability
of money to avail health care;[9] hence are less likely to seek
health services. The inefficient allocation of resources to
different levels of services and different geographical regions
could be responsible for patients seeking treatment outside
their districts.[10] It could also be due to high absenteeism
among health workers(reported to be higher than 40% in
some studies), limited opening hours, limited availability of
drugs and other supplies, poor physical environments, and
poor provider training and knowledge in such areas.[11,12]
Health expenditures per capita in state is estimated to be
mere 974 rupees in 20042005.[13]
The number of government hospital beds in urban areas
is more than twice that in rural areas. As physical distance
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Katiyar, et al.: Ocular trauma in Indian pediatric population

Table3: BCVA at presentation and at 3 months after presentation

BETTS

Closed globe
injury
Contusion
Rupture
Laceration
Intraocular
foreign body
Total

BCVA at presentaion

BCVA at 3 months after management

Total

>6/18

6/18-6/60

6/60-3/60

<3/60

>6/18

6/18-6/60

6/603/60

<3/60

18

11

18

34

13.6%

3.8%

.0%

8.3%

14.8%

3.3%

2.5%

1.6%

25.8%

4.5%

.0%

.0%

.8%

3.3%

.8%

.8%

.8%

5.3%

23

23

23

.0%

.0%

.0%

17.4%

.0%

.0%

.0%

18.9%

17.4%

11

44

12

18

27

64

8.3%

5.3%

1.5%

33.3%

9.8%

3.3%

14.8%

22.1%

48.5%

0%

0%

0%

3.0%

0%

8%

1.6%

8%

3.0%

35

12

83

34

10

24

54

122

26.5%

9.1%

1.5%

62.9%

27.9%

8.2%

19.7%

44.3%

100.0%

Table4: Regression analysis of factors affecting visual outcome

BCVA after treatment (log MAR )
Age ( years)
Delay in first contact with any health facility (hours)
Delay in treatment (hours)
BCVA at presentation (log MAR )

Mean

Std. Deviation

Pearson Correlation

Beta co-efficient

P-value

1.43
8.71
6.73
23.18
1.91

1.13
2.80
11.30
36.26
1.27

.026
-.032
.038
.821

.021
-.043
-.075
.838

.731
.787
.639
0

to facilities is a key determinant for access, overcoming

this through outreach or better transport, roads and
communication networks is important. This may partly explain
that 43% of patients seeking treatment were from adjoining
districts, which are well connected to Lucknow by highways.
Predominance of males(79%) seeking treatment could be due
to preference to invest in male child rather than a female, a
phenomenon common in India and in other Asian countries
or because of higher involvement of the same in agriculture
activities, as compared to females who are engaged in domestic
chores.
Only 15.7% patients in our study sought treatment from
a private practitioner before coming to a trauma center. This
may be because private practitioners tend to be centered in
wealthier urban areas and have bias against poor patients with
medical condition having a poor prognosis and medicolegal
implications such as pediatric ophthalmic emergencies. The
private sector dominates service provision of highend curative
services.[6]
Male child in the age group of 610years was found to
be most commonly affected group in the study. Besides the
obvious preference of the parents to seek treatment for the
injured male child, higher incidence of injuries in males.
This can be explained by the fact that in most of
the Indian households, children are routinely engaged
22

in farming or domestic chores(such as cooking and

fetching fire wood)[14] as many households lack sufficient
infrastr ucture. [15] Agriculture continues to employ
nearly 50% of Indian work force in 2009, which is again
laborintensive and dominated by small holders.[16] Children
are employed in farming as it requires more labor input. In
20092010, state recorded a gross dropout rate of 26.3%
in elementary grades(class18) out of which onefourth
children were employed in agriculture.[17]
Diwali season witnesses a surge in fire cracker injuries.
We observed that fire cracker injuries alone account for about
7.3%(14/191) of injuries. This is like most of the earlier studies
in which the most common group affected was formed by
children below 16years of age. The Firework Act 2003 and
The Firework Regulation Act, 2004, banned the purchase and
possession of firecrackers around bonfire night by children
below 18years of age. Edwin etal. noticed that there was a
positive impact of this ban and, in 2004, the injuries reduced
to 83% of previous years.[18] Prophylactic actions in the form
of change of legislation, implementation of legislation and
dissemination of information were effective in reducing the
incidence significantly in Denmark.[19] Public education in
schools, strict standardization of firecrackers, supervision
by adults, restriction in personal use of firecrackers, and
promotion of public display of firecrackers are the other means
suggested.
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Katiyar, et al.: Ocular trauma in Indian pediatric population

Laceration in the corneoscleral region was the most common

injury 92/191(48.2%) and globe rupture 24/191(12.6%)
together constituted half of all injuries higher incidence
of open globe injuries in common in the studies from poor
developing countries mostly sustained while working in
agriculture fields,[20] but the studies from developed world
shows a predominance of closed globe injuries mostly
sustained while playing in school.[21] Laceration and more so
the globe rupture was associated with extremely poor visual
prognosis. All the patients who had globe rupture and 22.6%
of patients with laceration in the corneoscleral region had
the final visual acuity<3/60. More than half of the patients
with closed globe injuries(18/34) had final visual outcome
better that 6/18 on Snellens. As seen in regression analysis
shown in Table4, we also observed that final BCVA of the
patient after the treatment was independently affected only
by the BCVA charted at the time of presentation. The age of the
patient, delay in presentation and treatment, were the factors
not found to be independently affecting the final BCVA of the
patients as shown. Among accurate predictors of final visual
acuity, studies on pediatric trauma have reported poor visual
acuity at presentation and open globe injuries to be associated
with poorer visual outcome,[22] We did not find the age of child
a predictor of the final visual outcome like other studies.[21]
There was a significantly larger delay, not only in receiving
the definitive treatment(27.637.9 h[range 1 h8days])
but also in presentation of child to any health facility after the
trauma(8.2514.6 h[range 1 h5days]). The high incidence
of open globe injuries and their association with poorer visual
outcome even with adequate early treatment were possible
reasons for this observation. Although our study duration was
fairly long(January 2010June 2013), followup could not be
extended beyond 3months because of dropouts.

Conclusion
Most of the injuries were sustained in work places which
can be avoided by discouraging child labor. Activities such
as fireworks should be done under proper supervision. The
inefficient allocation of resources to different levels of services
and different geographical regions and absenteeism among
health workers should be corrected. Better health care facilities
should be provided in rural areas so that the delay in seek of
treatment is avoided.
Financial support and sponsorship

Nil.
Conflicts of interest

There are no conflicts of interest.

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