|Year : 1988 | Volume
| Issue : 2 | Page : 82-85
Ocular injuries in union territory of Pondicherry-Clinical presentation
Mathew Krishnan, Renuka Sreenivasan
Professor of Ophthalmology, JIPMER, Pondicherry, India
Professor of Ophthalmology, JIPMER, Pondicherry
Source of Support: None, Conflict of Interest: None
1704 cases of ocular injuries were seen in 7 years. Of these, 1039 cases had extraocular injuries. Foreign bodies were the commonest - 1298 (90.2%), followed by lid lacerations (7.7%). 250 cases had intraocular injuries and these have been analysed with reference to the clinical presentation. Perforating injuries were seen in 173 eves (69.2%). The most common manifestation was corneal tear (89.3%) 135 (78.03%) cases had uveal prolapse.
Among the 77 cases of blunt injuries there was subluxation of the lens in 30 eves (35.96%), hvpheama in 21 eves (27.2%) and secondary glaucoma in 17 eves (22.07%).
|How to cite this article:|
Krishnan M, Sreenivasan R. Ocular injuries in union territory of Pondicherry-Clinical presentation. Indian J Ophthalmol 1988;36:82-5
| Introduction|| |
Intraocular trauma is an important cause of blindness in modern society. The extent of injuries depends on the nature of trauma, extent of damage to the intraocular structures, presence of intraocular foreign body and the site of injury. We analysed the cases of trauma to the eyes particularly those of intraocular injuries with special reference to the parameters mentioned above.
| Material and Methods|| |
A retrospective analysis of the cases with ocular injuries, who attended the JIPMER Hospital, Eye Department over a 7 year period (January, 1980 to December, 1986) has been made. These patients were divided into 2 categories - those with extraocular injuries and those with intraocular trauma These were further analysed as to the structures involved, site and nature of injuries and the damage to the intraocular structures.
| Observations|| |
A total of 1704 cases had some form or other of ocular trauma, 1439 cases had extraocular injuries, the main causes being foreign bodies in 1278 (90.2%), lid injuries in 111 (7.71%), corneal abrasion in 12 (0.83%) and subconjunctival haemorrhage in 18 (1.25%). Of the 250 cases with intraocular injuries 173 (69.2%) had penetrating trauma and 77 (30.8%) blunt trauma
| Penetrating injuries|| |
1. The left eye was more commonly involved.
2. Only 106 out of 173 patients (61.27%) sought consultation within 48 hours. 45 patients (26.01%) sought consultation between 2 and 7 days of injury. A few 22 (12.71%) reported after 7 days of injury.
3. Nature of injury Most patients sustained injuries with non-metallic objects (129 cases 74.56%), stick being the most common-52 cases (40.31%) followed by stone-25 cases (19.37%). Of the metallic objects, iron was the most common afflicting agent 33 out of 44 cases (75%) [Figure - 1].
4. Site of perforation - corneal perforation was the commonest 154/173 (89.01%) followed by scleral 39/173 (22.54%). 20 patients had comeo-scleral tears.
5. Other findings
Uveal prolapse was seen in a large proportion of cases 135 out of 173 (78.03%), cataract in 68 out of 173 eyes (39.30%), rupture of the lens in 20 eyes (11.56%), hypheama in 39 eyes (22.54%), retained intraocular foreign body in 12 eyes (6.9%) [Figure - 2][Figure - 3]. Delayed complications L e. panophthalmitis, iridocyclitis and secondary glaucoma were found in 47 eyes (27.16%).
| Blunt injuries|| |
i) The left eye was more commonly involved 41 out of 77 eyes (53.2%).
ii) Time of consultation - A large number of patients came for consultation after 1 week of injury-27 out of 77 cases (35.8%), 24 patients (27%) reported within 48 hrs
iii) Mode of injury- Stick was the commonest means of injury 18 out of 67 (23.37%) followed by bullgore injuries 14 (18.18%). Blast injuries occurred in 10 eyes (12.98%).
Subluxation of the lens was seen in 30 eyes (38.96%) [Figure - 5], secondary glaucoma was seen in 17 eyes (22.06%), hypheama in 21 eyes (27.27%), rupture of globe in 14 cases (20.8%), macular changes in 13 cases (19.4%) and cataract in 10 eyes (14.92%). Other findings like vitreous haemorrhage, central retinal -artery occlusion, carotico-cavemous fistula [Figure - 6] ophthalmoplegia [Figure - 7] were seen in 16 eyes (20.72%). This is because children formed a major part of the study.
| Discussion|| |
i) Mode of Injury: Stick was found to be the most common object. of insult in penetrating trauma This is probably to be expected in an agricultural society. This also probably adversely affects visual prognosis as the chances of post traumatic uveitis and infection are high Panda et al (1) have different observations. They report articles like gillidanda, bow and arrow as the most common offending agent This is because children formed a major part of the study. Eva (Sweden) (2) reported tools (work materials) to be the most common offending agent (41.76%) and twigs to be next in frequency (12.18%) followed by missiles 116 (26.18%), explosives 13 (2.9%). Oyin (Nigeria) (3) also reported injuries with stick to be the commonest (44.9%).
The other common object of insult was stone Of the metallic objects iron was the most frequent object causing injury-33 out of 44 cases. Retained intraocular foreign bodies were seen in 6.9% cases.
ii) Site of Injury: Corneal perforation is most common (89.01%) obviously due to the fact that it is the most exposed part of the globe and therefore most liable to trauma Most other authors have also noted a similar preponderance of corneal perforation. Panda et al [l] report 80.4% comeal involvement Of the 39 cases with scleral perforation in our series 20 had comeal involvement as well
iii) Other features : Uveal prolapsed and lenticular damage were seen in 78.03% and 39.30% of cases respectively. Panda et al  reported uveal involvement to be less frequent (61.2%) than lens damage (74.8%). Oyin  report 58.6% incidence of uveal prolapsed and only 14.04% cataract Eva L (Sweden) sub found uveal prolapse in 20.4% cases and cataract in23.2% cases. Uveal prolapse is a well known sequelae of penetrating injury. Strikingly in this series most cases with retained foreign body had no iris prolapse. This is explained by the fact that the foreign body carries the uveal tissues inwards as it enters the globe. Hence, absence of uveal prolapse should make one suspect a retained foreign body. Retained foreign bodies were seen in only 12 out of 173 cases (6.9%). Panda et al (Delhi)  reported a higher incidence of retained intraocular foreign body (28%). In an agricultural set up, it is probably rarer to encounter foreign bodies travelling at a high speed, hence the lower risk of intraocular penetration.
Lenticular damage was also quite common, next only to uveal prolapse (50.6%). This is clinically significant as it contributes to post operative uveitis and glaucoma, thereby adversely affecting visual outcome. Panda et al (Delhi)  report hyphema in 21.7%, uveitis in 15.3%, secondary glaucoma in 7.7%.
i) Mode of injury - Injury with stick was seen in 23.37% cases and bullgore injuries in 18.18%. Blast injuries were seen in 12.98% i.e. 10 cases. Once again this is related to the profession of the patients in this series. Use of sticks and bullock to plough are still a common practice in the rural south. Hence, the farmers are constantly at risk of injury with these two agents
ii) Clinical findings - Subluxation of lens, secondary glaucoma and hypheama were seen in 38.96% and 22.27% cases respectively. Rupture of the globe was seen in 14 eyes (18.18%). Panda et al [l] reported a higher incidence of
corneal changes (38.4%) than lens changes (34.8%). Eva L' reported secondary glaucoma to be the most common finding followed by intraocular haemorrhage.
Presence of subluxation of the lens or secondary glaucoma is an important finding as they often require surgical intervention Oyin Oluria  report intraocular haemorrhage in 40.12% cases, cataract in 37.03% and subluxation in only 7.46%.
Time of consultation. This was strikingly different in the two groups - i.e those with perforating injury and those with blunt injury. Patients with penetrating injuries sought consultation earlier, (61.27 came within 48 hours) in comparison with those sustaining blunt trauma, (27.27% reported within 48 hours). This is possibly due to the fact that prolapse of intraocular contents associated with injection of the eyes terrifies the patient more than the silent intraocular damage done in blunt injuries, where the globe is intact It is also possible that blunt injuries are not referred by the local doctors immediately as immediate surgery is not often contemplated in these cases.
Oyin Olurin (Nigeria)  reports that only 20% patients were seen within a week of injury. This has been attributed to the difficulty in getting medical attention in time or failure of the patient to make use of available facilities. The socio-economic status of the patient does indeed have an important bearing on his enthusiasm to seek early medical relief. The fact that 26.01% of cases in this study reported after 48 hours of penetrating injury and 12.71% after 7 days of injury bears proof to this.
The delay in consultation is an important factor in the prognosis of injuries as it contributes to increased uveitis, infection and also renders suturing difficult.
There was no case of sympathetic ophthalmia in this study. In two studies elsewhere, Sorsby A  and Eva L2, sympathetic ophthalmitis was responsible for blindness in 2,8% and 6,7% of cases respectively. It is difficult to say whether the absence of sympathetic ophthalmia in this study is related to racial factors or the higher rate of infection protected the patients from developing sympathetic ophthalmia Whatever the reason, the absence of sympathetic ophthalmia in this study might be an indication to a more conservative approach to performing enucleation Enucleation may be restricted to a very few cases which do not quieten after surgical repair and in whom there is no useful vision.
Of the 1439 cases of extraocular injuries, foreign bodies were seen in 1278 (90.2%). Lid tears were seen in 111 cases (7.71%). 44 were treated as inpatients. Panda et all report only 16 cases of extraocular injuries which were severe enough to warrant admission. Of these 50% were lid tear, 4 cases had optic nerve injury and 6 had canalicular tear and two had osteomyelitis.
| References|| |
Panda A, IM Bhatia, Y Dayal. Afro Asian J Ophthal III 163-174, 1985.
Eva Lindstedt Acta OphthaL 144, 590-606, 1966
Oyin Olurin. A J O 72, 159-164, 1971
Sorsby A The causes of blindness in England and Wale Medical Research Council Memorandum No. 24, 1950.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7]
[Table - 1], [Table - 2]