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   Table of Contents      
ORIGINAL ARTICLE
Year : 2004  |  Volume : 52  |  Issue : 1  |  Page : 29-34

Paediatric open globe injuries. Visual outcome and risk factors for endophthalmitis


Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Correspondence Address:
S Narang
Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


PMID: 15132376

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  Abstract 

Purpose: To study the incidence of open globe injuries and the outcome in children, and to study the risk factors for post-traumatic endophthalmitis.
Methods: Paediatric patient population. Retrospective analysis of 72 consecutive cases of open globe injury over 3 years (January 1998 to December 2000).
Results: The cause of trauma was sports related (n = 18), home-made bow and arrow (n = 16), household kitchen injuries (n = 10), cracker injuries (n = 7) and other miscellaneous outdoor activities (n = 16). In 5 children the cause could not be ascertained. Visual acuity of > 3/60 in the injured eye at the last follow-up examination was recorded in 37 of 70 patients (52.86%) whose visual acuity could be tested. The final visual acuity was significantly poorer in eyes where primary repair was delayed beyond 24 hours of injury (P<0.05). Post- traumatic endophthalmitis developed in 39 of 72 (54.16%) eyes. Bow and arrow and household injuries (P < 0.5) and eyes in which primary repair was delayed beyond 24 hours of injury (P<0.01) had a higher risk of endophthalmitis in univariate analysis. In multivariate analysis delayed repair was the only significant risk factor for the occurrence of endophthalmitis (P=0.014).
Conclusion: Delayed repair, bow and arrow injuries and household injuries were associated with significantly higher risk of endophthalmitis. The incidence of endophthalmitis can be reduced by early referral of trauma cases and parental supervision.

Keywords: Endophthalmitis, open globe injury, paediatric ocular trauma, secondary IOL


How to cite this article:
Narang 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

How to cite this URL:
Narang 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 [serial online] 2004 [cited 2019 Nov 12];52:29-34. Available from: http://www.ijo.in/text.asp?2004/52/1/29/14635



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Children suffer a higher percentage of open globe injuries than adults, comprising 19% -58.3% of all cases of ocular trauma. [1],[2],[3],[4]Ocular trauma is the leading cause of monocular blindness in children worldwide. [5],[6],[7]A major problem in the paediatric age group remains delayed diagnosis of trauma. Children may not recognise or even verbalise history of ocular trauma or symptoms of serious ensuing complications like endophthalmitis. Visual rehabilitation of these children is particularly difficult. Endophthalmitis following trauma in children has not been well studied. The present analysis was carried out to study paediatric open globe injuries and their visual outcome, and to determine the incidence and risk factors for post-traumatic endophthalmitis in children in north India.


  Material and Methods Top


We retrospectively analyzed 72 eyes of 72 children with paediatric open globe injury that presented to our tertiary eye-care facility over three years (January 1998 to December 2000). Only those patients who were less than 14 years of age were included in the study. We excluded eyes that had undergone any other surgical procedure in the preceding 3 months or if the open-globe injury had been repaired elsewhere. We also excluded eyes that were prephthisical at presentation and wherein primary repair was not possible. All the patients who were treated at our institute and had a minimum follow-up of 6 months were included in the analysis. The records were retrieved from the computerised database. The data included patients' demographic information; the cause, circumstance and time of the injury; time interval between trauma and repair; extent of open globe injury in terms of location and type according to the 'International Ocular Trauma Classification System' (IOTC). 8 The posterior most extent of the laceration was taken to define the injury according to IOTC. Patients' records were reviewed, and the presence of iris or vitreous prolapse; lens disruption; hyphaema or vitreous haemorrhage; retinal detachment or other posterior segment abnormalities; retained intraocular foreign body; signs of infection at the time of presentation; trauma- endophthalmitis interval; microbiology report and final visual acuity were noted. Details of initial and subsequent surgical interventions and visual rehabilitation methods were also noted.

The open globe injuries were repaired under general anaesthesia by one of the authors at the earliest after they reported to us. Corneal wounds were sutured using 10-0 monofilament sutures and 8-0 silk sutures were used for scleral wounds as far posteriorly as possible. Before repair, X-ray orbit antero-posterior and lateral view was done for all the cases to rule out radio opaque intraocular foreign body and ultrasound B scan was done with the probe placed gently over the eyelid if the child was cooperative. Anterior segment foreign bodies were removed through a separate limbal incision and posterior segment intraocular foreign bodies were removed by the pars plana route.

All the patients received at least 5 days of prophylactic intravenous ciprofloxacin (dosage of 10mg/kg body weight/12 hourly). Topical ciprofloxacin 0.3%, betamethasone 0.1% and atropine 1% were instilled after surgery. Oral prednisolone (1mg/kg/day) was administered in cases with significant cellular inflammatory reaction. Prophylactic intravitreal vancomycin 1mg and ceftazidime 2.25 mg were injected after withdrawing 0.2 cc of vitreous in all the eyes presenting for repair beyond 48 hours of sustaining trauma. Any case presenting with features suggestive of endophthalmitis during follow-up was immediately subjected to a standard 3-port pars plana vitrectomy (PPV) if the corneal condition permitted posterior segment view.

For this study, "endophthalmitis" was defined as the presence of hypopyon, vitritis, vitreous exudates, and retinal periphlebitis.9 Culture positivity was not taken as a stringent criterion for the diagnosis of endophthalmitis. Undiluted vitreous samples were taken at the beginning of the PPV by attaching a 2cc syringe to the suction tubing of the vitreous cutter and sent for microbiological (bacterial and fungal) evaluation. At the conclusion of PPV, intravitreal injection of vancomycin 1mg and ceftazidime 2.25mg was given. In eyes with poor visibility of posterior segment due to a poor corneal condition, intravitreal vancomycin 1mg and ceftazidime 2.25mg was injected after withdrawing 0.2cc of vitreous; alternatively, pars plana vitrectomy was done using keratoprosthesis followed by penetrating keratoplasty under general anaesthesia .

Postoperatively, systemic / oral antibiotics were continued for 14 days. Oral prednisone (1mg/kg/day) were administered in all cases of endophthalmitis after giving intravitreal injection if there was no wound infiltrate. Topical betamethasone 0.1%, ciprofloxacin 0.3% and atropine 1% eye drops in children older than 6 years and eye ointment in children < 6 years of age were also started postoperatively. If the clinical condition deteriorated 48 hours after surgery, intravitreal antibiotics were repeated depending on the culture and sensitivity report with or without repeat pars plana vitrectomy. After the acute phase, if the eye had visual potential, a subsequent surgical intervention was done when required. For unilateral aphakes, contact lens was recommended after removal of corneal sutures 3-6 months after primary repair. In the interim period, especially in children less than 8 years of age, amblyopia treatment was started at the earliest. This consisted of full refractive correction with glasses and occlusion therapy, depending on the child's age. A contact lens trial was done for all the aphakic eyes after removing the corneal sutures. In aphakes who were intolerant to contact lens, secondary IOLs were considered at least 6 weeks after trauma in non-infected eyes and 3 months after trauma in cases of endophthalmitis. IOL power was calculated using the SRK II formula.10,11 Posterior chamber in-the-bag or sulcus supported IOLs were implanted if the posterior capsule support was adequate. Scleral fixated IOLs, using 10-0 polypropylene, were implanted if the capsular support was not adequate.

Patients were kept under regular follow-up and any signs of endophthalmitis or any other complications of trauma were looked for. A functionally successful outcome was defined as Snellen's visual acuity of more than or equal to 3/60 (as would be required for unaided ambulation) with attached retina and no signs of infection at the time of last follow-up examination. Patients with visual acuity of ž 3/60 who had uncontrolled glaucoma or progressive corneal oedema also met the success criteria. The chi square test for independence tested the relationship of various baseline variables to final visual outcome as well as endophthalmitis in phase 1 analysis. In phase 2 analysis, the compound effect of variables significant in phase 1 was analysed using the forward stepwise multivariate logistic regression (SPSS software).


  Results Top


The study included 72 eyes of ocular trauma in 53 male children and 19 female children with age ranging from 2 to 13 years (mean 7.1 years). 57 children (79.17%) sustained injury in the rural set up and 15 children (20.83%) in an urban setting. The ocular injuries were sustained during outdoor sports in 34 eyes (home-made bow and arrow in 16 and other outdoor sports in 18), household activities in 10, cracker injuries 7, miscellaneous outdoor activities in 21 (wood 4, stone 1, pencil 3, hammer and chisel 3, door handle 1, fall from height 2, calendar wire 1 and barbed wire 1, unknown cause 5 eyes) [Table - 1]. Of the 72 eyes, 33 (45.83%) presented within 24 hours of sustaining trauma, 13 (18.06%) between 24-72 hours, 22 (30.56%) beyond 72 hours of trauma. The time of injury was not known in 4 children where neither the children nor their parents were aware of the injury. These four children were brought in with complaints of mild eye congestion or suspected decrease in vision.

The assessment of best corrected visual acuity was not very reliable at presentation as most of the children were uncooperative immediately after sustaining trauma. However, an attempt was made to assess visual acuity. Visual acuity at presentation was >6/12 in one eye (1.39%), 3/60 to 6/12 in 5 (6.94%) and light perception to less than 3/60 in 52 (72.22%) eyes. 14 children were uncooperative for visual status assessment at presentation. 46 eyes (63.89%) had sustained zone 1 injury, 20 (27.78%) zone 2 injury and 6 (8.33%) zone 3 injury. Type A (globe rupture) was seen in 3 eyes (4.17%), type B (penetrating eye injury without intraocular foreign body) in 59 (81.94%), type C (penetrating injury with intraocular foreign body) in 9 (12.5%) and type D (globe perforation) with intraorbital foreign body in one (1.39%). A foreign body was seen in 10 (13.89%) cases, of which one was in anterior segment, 8 in posterior segment, and one in the orbit. Foreign bodies included eyelash (n=3), wooden splint (n=4), stone (n=1) and iron (n=2). The primary repair was done by one of the authors. Subsequent surgery was scheduled by the authors in consultation with each other. Anterior segment foreign body was removed at the time of primary repair through a separate limbal incision with forceps after injecting viscoelastic into the anterior chamber. Of the 8 posterior segment foreign bodies, 3 were removed at the time of primary repair, 3 were removed in subsequent surgery within one week of trauma and 2 foreign bodies (cilia) were undetected at the time of primary repair and were first detected and removed during PPV for endophthalmitis. The eyes with posterior segment IOFB received PPV and foreign body removal through pars plana with the help of foreign body forceps. The orbital foreign body was radio opaque metallic foreign body and was left as such because it was unlikely to cause any inflammation. Hyphaema was seen in 29 eyes (40.28%) and was drained at time of primary repair in all.

Lens injury was seen in 39 eyes (54.17%). The lens matter aspiration at the time of primary repair was done in 3 eyes. Pars plana lensectomy and vitrectomy at the time of primary repair was done in 23 eyes; these eyes had signs of endophthalmitis. Of the rest, 4 eyes were subsequently operated for lens matter aspiration and IOL implantation; 2 eyes showed spontaneous absorption of lens matter and secondary IOL was implanted in the sulcus; 3 eyes received parsplana lensectomy later and 4 remaining eyes were prephthisical before any secondary intervention.

Iris prolapse and vitreous prolapse through the wound was seen in 29 eyes (40.28%) and 13 eyes (18.06%) respectively. Iris abscission was done for 9 eyes and the prolapsed tissue was reposited in the rest (20 eyes). Manual vitrectomy was done with cellulose sponge in the eyes with vitreous prolapse and the wound was cleared of vitreous. Posterior segment disruption was present in 28 eyes; this method choroidal detachment (n=2), retinal detachment (n=4), and vitreous haemorrhage (n=20), posterior perforation (n=1), retinal granuloma around the undetected eyelash (n=1) which was detected at the time of PPV. No prophylactic scleral buckle or cryotherapy was applied. These problems were dealt with in subsequent surgeries.

Of the 6 eyes with zone 3 open globe injury, two became prephthisical before any further intervention. One eye had signs of endophthalmitis at the time of initial presentation and intravitreal antibiotics alone were given after primary repair in view of the bad corneal condition. The hypopyon disappeared after intravitreal antibiotic administration. The eye was subsequently subjected to pars plana vitrectomy, penetrating keratoplasty and silicone oil temponade 7 days after injury. Keratoprosthesis was used in this eye to perform complete PPV. Another eye with zone 3 injury presented with signs of endophthalmitis 20 days after repair and was then subjected to PPV. Intraoperatively, previously undetected cilia were found in the vitreous cavity and vitreous exudates were found localised around cilia. In two eyes with zone 3 injury mild vitreous haemorrhage cleared within 2 weeks and no retinal breaks or vitreous incarcination were identified. These eyes were not subjected to pars plana vitrectomy.

Endophthalmitis was observed in 33 eyes at initial presentation to our institute and 6 eyes developed endophthalmitis during the course of their follow up, within 20 days of trauma. All these eyes were given intravitreal antibiotics at the conclusion of primary repair. Of the endophthalmitis eyes, parsplana vitrectomy was done for 23 eyes at the time of primary repair, 3 eyes responded to intravitreal antibiotics only, 9 eyes subsequently needed pars plana vitrectomy with intravitreal antibiotic injection and 4 became prephthisical before any further intervention. Repeat intravitreal antibiotics were injected in 9 eyes. The culture was positive in 9 of the 39 eyes with endophthalmitis and vitreous grew Staphylococcus epidermidis in 3 eyes, Staphylococcus aureus in 3, Pseudomonas aeruginosa in 2, and Streptococcus pneumoniae in one eye. Vitreous biopsy was done in 51 eyes at the time of primary repair. The eyes that had no signs suggestive of endophthalmitis did not show positive cultures.

Fifty-one children required subsequent surgery including scleral buckling (2 eyes), PPV with scleral buckling with silicone oil/perfluoropropane gas tamponade (10 eyes), cataract surgery and intraocular lens (IOL) implant (4 eyes), secondary sulcus supported IOL (2 eyes), secondary scleral fixated IOL (13 eyes), pars plana vitrectomy (10 eyes), pars plana vitrectomy with scleral buckle and penetrating keratoplasty (1 eyes), pars plana lensectomy (3 eyes), repeat pars plana vitrectomy (2 eyes), and silicone oil removal (4 eyes). Silicone oil was left in the eye for a minimum period of 6 months after surgery.

Cataract surgery and IOL implantation was planned after a minimum of 6 weeks of injury and 3 months in cases of endophthalmitis. Of the 19 eyes that underwent IOL implantation, the final visual was > 6/12 in 15 eyes, 6/24 in one, 6/36 in two and 6/60 in one eye. Post-surgical complications after IOL implantation included: increase in intraocular pressure (1 eye), disc oedema (2 eyes), cystoid macular oedema (one eye), fibrinous anterior segment reaction (7 eyes), IOL tilt (2 eyes), hyphaema (2 eyes) and amblyopia (one eye) in scleral fixated IOL; and complications like IOL decentration (1eye), posterior synechiae (one eye), fibrinous reaction in anterior chamber (one eye) after 'in the sulcus'/ 'capsular bag' IOL. Oral prednisolone (1mg/kg body weight) and topical betamethasone 0.1% were used for the control of inflammation and ketorolac 0.5% was instilled along with betamethasone 0.1% for cystoid macular oedema. Monocular aphakes were rehabilitated by contact lens (n=2), sulcus supported IOL (n=2), scleral fixated IOL (n=13) and spectacles (n=6).

Seventy of 72 patients cooperated for the final visual acuity assessment; the two patients who were uncooperative for visual acuity assessment were excluded from the statistical analysis. Functionally successful outcome (visual acuity of > 3/60) was achieved in 37 of 70 eyes (52.86%) and of these, visual acuity was > 6/12 in 15 eyes (21.43%). The results were comparable endophthalmitis and non-endophthalmitis patients. Functionally successful outcome could be achieved in 17 of 37 (45.95%) eyes with post-traumatic endophthalmitis and 20 of 33 (60.61%) eyes without any sign of endophthalmitis. Delayed repair was the single most important predictor of poorer functional outcome. Four eyes in which the time of trauma was not known were excluded from the statistical analysis. 18 of 33 eyes (54.55%) that presented to us within 24 hours attained successful functional outcome compared to 7 of 20 eyes (35%) that presented after 72 hours of sustaining trauma ( P<0.05) [Table - 2]. Age, gender, extent and type of injury, iris/vitreous prolapse, posterior segment complications, endophthalmitis, and subsequent surgery did not show any correlation with visual results in paediatric trauma cases. The causes of poorer visual acuity included epiretinal membrane, posterior perforation in macular area and, retinal folds in one eye each, glaucoma in 2 eyes, amblyopia in 2 eyes, post-treatment retinal detachment (CME, high astigmatism and amblyopia) in 6 eyes, post-treatment endophthalmitis (macular ischaemia, CME, optic atrophy, epiretinal membrane) in 9 eyes, and phthisis in 11 eyes.

The development of endophthalmitis was not associated with age, gender, type, zone or grade of injury, iris or vitreous incarcination into the wound, lens disruption and rural environment. Bow and arrow injuries and household kitchen injuries showed a significantly higher incidence of endophthalmitis in phase 1 of the statistical analysis (P<0.05). 12 of 16 (75%) bow and arrow injuries and 8 of 10 (80%) household kitchen injuries developed endophthalmitis as compared to 19 of 46 (41.3%) other patients [Table - 3]. However, this did not emerge as a significant risk factor in phase 2 of the statistical analysis (P=0.102). Endophthalmitis was also associated with delayed repair of open globe injuries. In 4 eyes the time of injury was not known and these were excluded from the statistical analysis. 18 of the 22 eyes (81.82%) that presented beyond 72 hours of injury developed endophthalmitis compared to 17 of 33 eyes (51.52%) that presented within 24 hours of sustaining trauma. Delayed repair was the single significant factor for endophthalmitis in both phase 1 and 2 of the statistical analysis (Univariate analysis, P<0.01; multivariate analysis, P=0.014, [Table - 4].

Notably, the time interval between injury to presentation to hospital was significantly higher in children sustaining injury in a rural setting compared to an urban location. Of the 15 children that sustained injury in urban areas, 12 (80%) presented to our hospital within 24 hours of injury while only 21 of the 53 children (39.62%) sustaining injury in a rural area presented to us within 24 hours of trauma (P<0.05) [Table - 5]. But there was no significant difference in type of injury, functional outcome or incidence of endophthalmitis in urban or rural populations.


  Discussion Top


Paediatric ocular trauma, though one of the leading causes of monocular blindness in children, is not a well discussed entity. [5],[6],[7]The incidence of paediatric ocular trauma may be higher in developing countries due to less stringent laws relating to child care. Many of the injuries in children can be prevented by parental supervision, awareness of child's activities and use of proper protective measures. Better knowledge of the spectrum of ocular trauma in children in developing countries, and the risk factors for endophthalmitis following ocular trauma may help us prevent the same.

The demographic data (male preponderance and mean age) was similar to previous reports. [12],[13],[14],[15],[16]Significantly, about three-quarters of the injuries were sustained in rural areas. The incidence of post-traumatic endophthamitis is known to double in a rural setting. [17],[18]

A majority of the injuries were sports related, also similar to past reports,[5],[14],[19],[20] though certain unusual agents for paediatric injuries such as hypodermic needles have also been reported from India.[21] The incidence of endophthalmitis in our series at 54.17% (39 of 72 eyes) was much higher than the post-traumatic endophthalmitis in children in previously published series.[22],[23] In our series, homemade bow and arrow injuries accounted for a substantial number of cases and were associated with a higher incidence of endophthalmitis as has previously been reported from India.[14],[24],[25] This sport is unique to India and the incidence in the present study is comparable to that reported by Vasnaik et al.[14] The functional outcome in endophthalmitis eyes was comparable to non-endophthalmitis eyes. This was probably due to institution of prompt therapy in eyes with endophthalmitis.

Delayed repair, lens disruption, extent of wound, vitreous prolapse, posterior location of the wound, foreign body and rural setting are the known risk factors for poor visual outcome in ocular trauma.[24],[26],[27] In the present series delayed repair was significantly associated with poor visual outcome and was the only independent risk factor for the development of endophthalmitis. The extent and location of the wound, lens disruption, iris/vitreous prolapse, presence of intraocular foreign body were not significantly associated with endophthalmitis or poorer final visual outcome in our series, similar to the results of retrospective analysis by Farr et al.[15] Most of the eyes had endophthalmitis at the time of presentation to our institute and the rest developed endophthalmitis within 20 days of trauma. This is consistent with the earlier series.[28]

Ambulatory vision was achieved in 52.86% of the cases in the present series, similar to few other large recent series.[14],[15],[29] Many of our patients were unsuitable for contact lenses for a variety of reasons including low socio-economic status. Intraocular lens (IOL) was used as major rehabilitative measure. Studies have shown superior results of IOL including scleral fixated IOLs in unilateral aphakic children.[30],[31] In our patients there was no recurrence of endophthalmitis or other vision threatening side effects with scleral fixated IOL except in one eye that developed cystoid macular oedema.

We conclude that a higher incidence of post-traumatic endophthalmitis is seen in developing countries. Early referral of such cases is required to prevent several complications including endophthalmitis.



 
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    Tables

  [Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]


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