Sudanese Journal of Ophthalmology

ORIGINAL ARTICLE
Year
: 2013  |  Volume : 5  |  Issue : 2  |  Page : 62--66

Wooden sticks as objects of ocular injury: Are they really bad?


Mehul Shah, Shreya Shah, Sandip Vora, Dilip Batra, Ritu Pandya 
 Department of Ocular Trauma, Ocular Trauma Center, Drashti Netralaya, Dahod, Gujarat, India

Correspondence Address:
Mehul Shah
Drashti Netralaya, Nr. GIDC, Chakalia Road, Dahod - 389 151, Gujarat
India

Abstract

Background: To compare the incidence of infection and damage caused by wooden stick with that caused by other objects and evaluate other objects causing ocular injury. Setting: Tertiary care hospital in rural part of central western India. Materials and Methods: This was a prospective observational cohort study designed in 2002. Patients with all open-globe injuries in either eye, diagnosed and managed between January 2003 and December 2009, were enrolled in our study. The injuries were grouped as those caused by wooden stick and injuries by other objects. Data were collected in International Society of Ocular Trauma initial and follow-up report form and were analyzed. Results: In our study, there were 687 cases of which 496 were open-globe cases. Wooden stick is one of the most common objects of injury in a rural setting. Wooden stick associated with any infection, the final visual outcome was significantly better than that of the injury caused by other objects. (P = 0.002). The outcome measures were final visual acuity and complications. Conclusion: Despite the wooden stick being a common object of injury, it is an important predictive factor for better visual recovery and is not associated with any infection.



How to cite this article:
Shah M, Shah S, Vora S, Batra D, Pandya R. Wooden sticks as objects of ocular injury: Are they really bad?.Sudanese J Ophthalmol 2013;5:62-66


How to cite this URL:
Shah M, Shah S, Vora S, Batra D, Pandya R. Wooden sticks as objects of ocular injury: Are they really bad?. Sudanese J Ophthalmol [serial online] 2013 [cited 2019 Oct 18 ];5:62-66
Available from: http://www.sjopthal.net/text.asp?2013/5/2/62/124827


Full Text

 Introduction



Trauma is a cause of monocular blindness in the developed world, although few studies have addressed trauma in rural areas. [1] The etiology of ocular injury in rural areas is likely to differ from that in urban areas, and is worthy of investigation. [2],[3],[4] Any strategy for prevention requires knowledge of the cause of injury, which may enable more appropriate targeting of resources toward preventing such injuries. Both eye trauma victims and society bear a large, potentially preventable burden. [3]

Open-globe injury is associated with a breach in the wall of the eyeball, which may be associated with entry of organisms into the globe. Vegetative injury is known to cause infection, particularly fungal, hampering final visual outcome. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20]

Objectives

The study objectives were:

to study the types of objects causing injuryto study infection caused by objects causing injury andto compare the incidence of infection and damage caused by wooden sticks with that caused by other objects

 Materials and Methods



We obtained approval from the hospital administrators and research committee to conduct this study and received the participants' written consent.

This was a prospective observational cohort study designed in 2002. Patients with all kinds of traumatic cataracts in either eye, diagnosed and managed between January 2003 and December 2009, were enrolled in our study, and those consenting to participate and not having other serious body injuries were included.

For each patient enrolled in our study, we obtained a detailed history, including details of the injury, and information on eye treatment and surgery performed to manage past ocular trauma. Data of both the initial and follow-up reports were collected using the online Birmingham Eye Trauma Terminology System (BETTS) format of the International Society of Ocular Trauma. Details of the surgery were also collected using a specified pretested online form.

The cases of traumatic cataract were grouped as open- and closed-globe injuries. All open-globe injury cases were included in the study. Open-globe injuries were further categorized into those with lacerations and those that had ruptured. Lacerations of the eyeball were subcategorized into eyes with perforating injuries, penetrating injuries, or injuries involving an intraocular foreign body. Wooden sticks included branches of trees, firewood, and thorns, but did not include human-fashioned or -treated material. Wooden sticks included tree branches and thorns having different levels of sharpness according to which they caused various types of injury.

Other demographic details collected included entry of the patient, residence, activity at the time of injury, object of injury, and previous examinations and treatments. After enrollment, all patients were examined using a standard method. Visual acuity was checked using Snellen's chart, and the anterior segment was examined using a slit lamp.

Based on lenticular opacity, the cataracts were classified into total [Figure 1], membranous [Figure 2], white soft [Figure 3], and rosette [Figure 4] types. When an ophthalmologist did not observe clear lens matter between the capsule and the nucleus, the cataract was defined as a total cataract. When the capsule and organized matter were fused and formed a membrane of varying density, it was defined as a membranous cataract. When loose cortical material was found in the anterior chamber together with a ruptured lens capsule, the cataract was defined as a white soft cataract. A lens with a rosette pattern of opacity was classified as a rosette type cataract.{Figure 1}{Figure 2}{Figure 3}{Figure 4}

For a lens that was partially opaque, the posterior segment examination was performed with an indirect ophthalmoscope and a +20 D lens. When the optical medium was not clear, a B-scan was performed to evaluate the posterior segment.

The surgical technique was selected according to the morphology and condition of tissues other than the lens. Phacoemulsification was used to operate on cataracts with hard, large nuclei. With a lens that had either a white soft or rosette-type cataract, uni- or bimanual aspiration was used. Membranectomy and anterior vitrectomy, either by an anterior or a pars plana route, were performed when the cataract was membranous.

In all patients undergoing corneal wound repair, the traumatic cataract was managed in a second procedure.

In children younger than 2 years, both lensectomy and vitrectomy via a pars plana route were performed, and the same surgical procedures were used to manage the traumatic cataract. Lens implantation as part of the primary procedure was avoided in all children younger than 2 years.

All patients with injuries and without infection were treated with topical and systemic corticosteroids and cycloplegics. The duration of medical treatment depended on the degree of inflammation in the anterior and posterior segments of the operated eye. The operated patients were re-examined after 24 h, 3 days, and 1, 2, and 6 weeks to enable refractive correction. Follow-up was scheduled for the third day, weekly for 6 weeks, monthly for 3 months, and every 3 months for 1 year.

At every follow-up examination, visual acuity was tested with Snellen's chart. The anterior segment was examined with a slit lamp; the posterior segment was examined with an indirect ophthalmoscope. Eyes with vision better than 20/60 at the glasses appointment (6 weeks) were defined as having a satisfactory grade of vision.

During the examination, data were entered online using a specified pretested format designed by the International Society of Ocular Trauma (initial and follow-up forms) that was exported to a Microsoft Excel spreadsheet. The data were periodically audited to ensure completion. We used the Statistical Package for Social Studies (SPSS 17) to analyze the data. The univariate parametric method was used to calculate frequency, percentage, proportion, and 95% confidence interval (CI). We used binominal regression analysis to determine the predictors of postoperative satisfactory vision (>20/60). The dependent variable was vision >20/60 noted at the 6-week follow-up after cataract surgery. The independent variables were age, gender, residence, time interval between injury and cataract surgery, primary posterior capsulectomy and vitrectomy procedure, and type of ocular injury.

 Results



Our cohort consisted of 687 (72.2%) patients with traumatic cataracts [Figure 5], including 496 eyes with open-globe ocular injuries and 191 (27.8%) eyes with closed-globe injuries [Figure 5]. The patients consisted of 492 (71.6%) males and 195 (28.4%) females. The mean patient age was 27.1 ± 18.54 years (range 1-80 years).{Figure 5}

We analyzed several demographic factors, including gender (P = 0.340), patient entry (P = 0.4), and socioeconomic status (79% were from lower socioeconomic class and residence, and 95% were from rural areas). None of these showed a significant relationship with final visual acuity, according to cross-tabulation and statistical tests. The object causing the injury (P = 0.3) and the activity at the time of the injury (P = 0.3) were also not significantly associated with satisfactory final visual acuity. We came across a distribution of 687 injuries according to BETTS [Figure 5], of which wooden sticks were found to be the most common object (55.9%) causing injury in our study [Table 1] and [Table 2]. Activity during injury is described in [Table 2]. Most case histories were suggestive of breaking of sticks while acquiring wood for cooking, fence making, traveling over top of vehicles, playing with sharp objects (in the case of children), and labor jobs without use of protection. We did not find any injury caused by assault.{Table 1}{Table 2}

Work at home was a common activity during injury [Table 3]. {Table 3}

The final visual outcome in cases of injury with a wooden stick was significantly different from that in cases of injuries by other objects [Table 4].{Table 4}

The overall incidence of infection was 0.4%, and injury with wooden sticks had an incidence of zero compared with other objects, though this difference was not statistically significant [Table 5]. Final visual outcome was significantly affected by infection [Table 6].{Table 5}{Table 6}

 Discussion



We studied the objects of injury and classified injury with BETT. This study focused on a rural tribal population and not an urban or industrialized population, which reflects the fact that wooden sticks and thorns were the common objects of injury.

One of the strengths of this study is its prospective design and a large number of cases.

Wooden sticks were the most common object of injury in our study (55.9%) [Table 1] and [Table 2]. They were also common in a study of rural Tanzania by Deepa Abraham, [2] but are not common objects according to the US ocular trauma registry. [21]

We came across 687 injury cases, of which 496 were open globe, as defined by the BETTS classification. [22]

We found that the total incidence of infection was 0.4%, which is much less than endophthalmitis incidence of 2-17% reported by Viestenz et al. In addition, incidence of 4-8% was reported by Cebulla. [11],[13]

Final visual outcome following open-globe injury with a wooden stick was significantly better than that of the injury caused by other objects (P = 0.002).

Many studies reported that an object of injury is known to cause infection in the presence of an open-globe injury. [1],[2],[3],[4],[23],[24] We suggested the authorities to provide readymade fence, alternative cooking fuel, regulate travel rules, and also counseled parents to take care of their children.

 Conclusion



A 0.4% incidence of infection was found in injury with all other objects, but the incidence of infection following open-globe injury by wooden stick was minimal. As this was an observation made in a particular geographic area, it may not be generalized.

 Acknowledgments



The language part of this document has been checked by at least two professional editors, both native speakers of English. For the certificate, please see:textcheck.com/certificate/ZlRw08

Article Summary:

Article Focus:

Wooden stick as object of ocular injury.

Strengths and weakness of the study

Strengths: Larger database and usage of standard classification method, i.e. BETTS

Limitation: Included many neglected injury cases

Weakness: Uncontrolled study; one-third enrollment from outreach limits generalization of findings; loss of follow-up of 12 patients at various stages of the study

References

1Khatry SK, Lewis AE, Schein OD, Thapa MD, Pradhan EK, Katz J, et al. The epidemiology of ocular trauma in rural Nepal. Br J Ophthalmol 2004;88:456-60.
2Abraham DI, Vitale SI, West SI, Isseme I. Epidemiology of eye injuries in rural Tanzania. Ophthalmic Epidemiol 1999;6:85-94
3Alfaro DV 3rd, Jablon EP, Rodriguez Fontal M, Villalba SJ, Morris RE, Grossman M, et al. Fishing-related ocular trauma. Am J Ophthalmol 2005;139:488-92.
4Shah M, Shah S, Khandekar R. Ocular injuries and visual status before and after Their management in the tribal areas of Western India-A historical cohort study. Grafes Arch Clin Exp Ophthalmol 2008;246:191-7.
5Al-Mezaine HS, Osman EA, Kangave D, Abu El-Asrar AM. Risk factors for culture-positive endophthalmitis after repair of open globe injuries. Eur J Ophthalmol 2010;20:201-8.
6Wade PD, Khan SS, Khan MD. Endophthalmitis: Magnitude, treatment and visual outcome in northwest frontier province of Pakistan. Ann Afr Med 2009:8:19-24.
7Yang CS, Lu CK, Lee FL, Hsu WM, Lee YF, Lee SM. Treatment and outcome of traumatic endophthalmitis in open globe injury with retained intraocular foreign body. Ophthalmologica 2010;224:79-85.
8Zhang Y, Zhang MN, Jiang CH, Yao Y, Zhang K. Endophthalmitis following open globe injury. Br J Ophthalmol 2010;94:111-4.
9Cebulla CM, Flynn HW Jr. Endophthalmitis after open globe injuries. Am J Ophthalmol 2009;47:567-8.
10Andreoli CM, Andreoli MT, Kloek CE, Ahuero AE, Vavvas D, Durand ML. Low rate of endophthalmitis in a large series of open globe injuries. Am J Ophthalmol 2009;147:601-8.e2.
11Viestenz A, Schrader W, Behrens-Baumann W. Traumatic endophthalmitis prevention trial (TEPT)]. Klin Monbl Augenheilkd 2008;225:941-6.
12Wykoff CC, Flynn HW Jr, Miller D, Scott IU, Alfonso EC. Exogenous fungal endophthalmitis: Microbiology and clinical outcomes. Ophthalmology 2008;115:1501-7, 1507.e1-2.
13Gupta A, Srinivasan R, Gulnar D, Sankar K, Mahalakshmi T. Risk factors for post-traumatic endophthalmitis in patients with positive intraocular cultures. Eur J Ophthalmol 2007;17:642-7.
14Al-Omran AM, Abboud EB, Abu El-Asrar AM. Microbiologic spectrum and visual outcome of posttraumatic endophthalmitis. Retina 2007;27:236-42.
15Chhabra S, Kunimoto DY, Kazi L, Regillo CD, Ho AC, Belmont J, et al. Endophthalmitis after open globe injury: Microbiologic spectrum and susceptibilities of isolates. Am J Ophthalmol 2006;142:852-4.
16Gupta A, Srinivasan R, Kaliaperumal S, Saha I. Post-traumatic fungal endophthalmitis--a prospective study. Eye (Lond) 2008;22:13-7.
17Essex RW, Yi Q, Charles PG, Allen PJ. Post-traumatic endophthalmitis. Ophthalmology 2004;111:2015-22.
18Narang S, Gupta V, Simalandhi P, Gupta A, Raj S, Dogra MR. Paediatric open globe injuries. Visual outcome and risk factors for endophthalmitis. Indian J Ophthalmol 2004;52:29-34.
19Lieb DF, Scott IU, Flynn HW Jr, Miller D, Feuer WJ. Open globe injuries with positive intraocular cultures: Factors influencing final visual acuity outcomes. Ophthalmology 2003;110:1560-6.
20Sabaci G, Bayer A, Mutlu FM, Karagul S, Yildirim E. Endophthalmitis after deadly-weapon-related open-globe injuries: Risk factors, value of prophylactic antibiotics, and visual outcomes. Am J Ophthalmol 2002;133:62-9.
21Parver LM. The National eye trauma system registry. Public Health Rep 1993;28:625-30.
22Kuhn F, Morris R, Witherspoon CD, Mester V. The birmingham eye trauma terminology system BETT. J Fr Ophtalmol 2004;27:206-10.
23Junejo SA, Ahmed M, Alam M. Endophthalmitis in paediatric penetrating ocular injuries in Hyderabad. J Pak Med Assoc 2010;60:532-5.
24Duch-Samper AM, Chaques-Alepuz V, Menezo JL, Hurtado-Sarrio M. Endophthalmitis following open-globe injuries. Curr Opin Ophthalmol 1998;9:59-65.