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Journal of Trauma and Care

Cite this article: Megbelayin EO, Nkanga DG, Ibanga A, Okonkwo SN (2016) Pattern and Causes of Ocular Injuries in Calabar, Cross River State, Nigeria. J Trauma Care 2(1): 1012.

*Corresponding authorEmmanuel Olu Megbelayin, Department of Ophthalmology, University of Uyo Teaching Hospital, Uyo, Akwa-Ibom State, Nigeria; Telephone: 234-8036670920; Email: favouredolu@yahoo.com

Submitted: 13 September 2016

Accepted: 29 September 2016

Published: 03 October 2016

Copyright© 2016 Megbelayin et al.

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Keywords•Ocular Injuries•Calabar•Nigeria

Research Article

Pattern and Causes of Ocular Injuries in Calabar, Cross River State, NigeriaEmmanuel Olu Megbelayin1*, Dennis George Nkanga2, Affiong Ibanga2, and Sunday Nnamdi Okonkwo2

1Department of Ophthalmology, University of Uyo, Nigeria2Department of Ophthalmology, University of Calabar, Nigeria

Abstract

This study aim was to determine the pattern and causes of eye injuries in patients attending out-patient eye department of an urban eye center in southern Nigeria. It was a one-year retrospective study was conducted at University of Calabar Teaching Hospital, Department of Ophthalmology. Based on research objectives, an instrument was designed and all records of patients with ocular injuries were reviewed. A total of 104 patients who had ocular injuries were analyzed. The mean age was 26.8 years with a standard deviation of +/- 14.74. Male constituted 80.8% (84 patients) and female 19.2% (20 patients) with a male to female ratio of 1: 0.24. Trauma was unilateral in 100 (97.2%). Age, sex and occupation had no association with which eye was injured with p values of 0.28 (95% CI = 0.19-0.37), 0.27 (95% CI = 0.18-0.35) and 0.54 (95% CI = 0.44-0.63) respectively. Four tribes (Ibibio, Efik, Igbo and Ekoi) constituted over 60%. Sources of injury covered a wide range of objects with the highest frequency from fists during fights 17.3% (18 patients). Closed globe injury occurred in 94 (90.4%) patients. The conclusion was that blunt ocular injury was the commonest form of ocular trauma comprising mainly non-occupational related injuries.

INTRODUCTIONThe eyes as organs of vision are positioned at a vantage

part of the body to gain maximum advantage for their task. This demands that they are exposed even though partly housed in the bony orbits. The exposure makes them susceptible to injuries unlike other sense organs that are well protected. Indeed Nordber [1] reported that the eyes came third to hand and feet in body injuries despite constituting only 0.27% of the total body surface area and 4% of the facial area.

Ocular injuries occur world-wide contributing 2.3 million and 19 million to bilateral and unilateral visual disability respectively [2]. Sadly, most of the causes of ocular injuries are either preventable or avoidable with developing countries bearing the burden and consequences [3,4]. Compounded by paucity of economic wherewithal [5], injudicious use of non-orthodox eye medications [6], undue delay to present at eye care facilities [7] and pervasive quackery [8], the outcome of eye injuries are often bleak. The causes of eye traumas are variable and have been linked with occupation [9], sex [10], Age [4], culture [1] and civil unrest [12].

Besides loss of vision, earnings and productivity, there is attendant increase in the cost to society because of exorbitant healthcare spending [13]. Negel et al. [2], in their findings showed

that in the United State alone an estimated 2.5 million ocular injuries occur annually, with hospital charges amounting to $200 million. This sum exceeds $ 5 billion yearly with direct and indirect costs combined. The global economic effect of this health challenge is therefore enormous. In an earlier comprehensive review of global eye injury, Negel [14] reported that an estimated 55 million people could not perform their daily paid jobs, while over 750 thousand people were hospitalized. Unfortunately developing countries carry the largest burden of ocular trauma and yet the least able to afford the costs [3].

Public health approach has been identified as a viable means of reducing ocular injuries [15]. And one public health intervention strategy is provision of epidemiological data through well-designed retrospective or prospective studies especially in areas where such are scarce. This study became necessary because of the need to determine the pattern and causes of ocular trauma among the patients who patronized our eye health facility in a previous year. It is hoped that the information obtained will guide the populace and policy makers on how best to prevent unsafe ocular practices thereby maintaining needed ocular health.

MATERIAL AND METHODThis study was hospital-based and retrospective in design. It

was conducted in the department of ophthalmology, University

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of Calabar Teaching Hospital, Nigeria from January 2011 to December 2011. Instrument was developed in line with the study objectives and included a section on demography and another on various parts of ocular injuries according to Birmingham Eye Trauma Terminology System Classification [16]. Visual acuity was evaluated using the Snellen’s chart for the literates and illiterate E chart for the illiterates. Anterior segment was examined with the help of pen torch and slit lamp bio-microscope. The study followed the guidelines of the Helsinki Declaration for retrospective research. Patients received treatments based on ocular assessment and diagnosis with 15 of them having surgical intervention.

Categories were created for the following variables: age, occupation, duration of injury, cause of injury, place of injury, visual acuity, and type of injury. Mean age was calculated. Frequencies were calculated as percentage for gender, type of injuries, objects of injuries. Association of globe injuries with gender were examined individually on 2X2 tables with associated χ2 statistics. Association of presenting visual acuities with duration of presentation was also examined individually on 2X2 tables with associated χ2 statistics. SPSS software version 20.0 package (SPSS Inc., Chicago, IL, USA) was used. All p values were two sided and p values less than 0.05 were considered statistical significant at 95% confidence interval (CI).

RESULTSThere were a total of 104 patients who had ocular injuries

in the year under review. The mean age was 26.8 years with a standard deviation of +/- 14.74. With an age range of 1 to 63 years, there was a bi-modal distribution of 20 years (10 patients) and a clustering between 40 to 45 years (14 patients).

Male constituted 80.8% (84 patients) and female 19.2% (20 patients) with a male to female ratio of 1: 0.24. Details of age and sex distribution are presented in table 1. Right Eyes were affected in 35 (33.7%), left eye 65 (62.5%) and both eyes in 4 (3.8%). Age, sex and occupation had no association with which eye was injured with p values of 0.28 (95% CI = 0.19-0.37), 0.27 (95% CI = 0.18-0.35) and 0.54 (95% CI = 0.44-0.63) respectively. Age, sex and occupation were not also significantly associated with types of the eye injury patients sustained with p values of 0.39 (95% CI = 0.30-0.48), 1.00 (95% CI = 0.97-1.00) and 0.16 (95% CI = 0.054-0.177) respectively.

The analysis of the occupation of the patients as shown in table 2 revealed that students, civil servants and traders constituted 56.7% (59 patients) with students contributing the highest (29%).

Ethinicity, as presented in table 3, had 4 tribes (Ibibio, Efik, Igbo and Ekoi) constituting over 60%. Sources of injury, as seen in table 4, covered a wide range of objects with the highest frequency from fists during fights 17.3% (18 patients). Closed globe injury occurred in 94 (90.4%) patients.

Table 5 shows that the association between type of trauma and gender did not reach statistical significance with a p value of 0.95 (95% CI = 0.89-1.02). Sixty one (58.7%) presented at the hospital between 2 to 7 days of sustaining eye injury (Figure 1).

The best and the worst presenting VAs were between 2 to

Table 1: Age and Sex Distribution.SN Patients’ Characteristics Number Percent

AGE1 1-10 16 15.42 11-20 22 21.23 21-30 28 26.94 31-40 17 16.35 41-50 14 13.56 >50 07 6.70

TOTAL 104 100.0SEX

1 Male 84 80.82 Female 20 19.2

TOTAL 104 100.0

Table 2: Occupational Distribution of Patients. Occupation Frequency Percent1 Civil Servants 15 14.42 Trading 15 14.43 Students 29 27.94 Cyclists 6 5.85 Contractors 1 1.06 Lecturers 1 1.07 Applicants 3 2.98 Palm Wine Tappers 1 1.09 Apprentices 2 1.910 Drivers 6 5.811 Welders 4 3.812 Farming 3 3.913 Cattle Rearing 1 1.014 Fishing 1 1.015 Child (Minor) 16 15.4 Total 104 100.0

Table 3: Distribution Based on Tribes. Tribes Frequency Percent1 Ibibio 28 26.92 Efik 16 15.43 Oron 5 4.84 Annang 5 4.85 Igbo 16 15.46 Ekoi 13 12.57 Bekwara 4 3.88 Qua 2 1.99 Hausa 1 1.010 Obubra 1 1.011 Ijaw 1 1.012 Idoma 2 1.913 Eket 1 1.014 Abi 2 1.915 Boki 3 2.916 Mbitu 1 1.017 Ejagam 1 1.018 Cameron 1 1.019 Ugep 1 1.0

TOTAL 104 100.0

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7 days of the eye injury. Those presenting after one month had significant ocular morbidity with 11(41.4%) having VAs <3/60 to No perception of Light (table 6). Only 1 (0.9%) patient used protective glasses at work, 98 (94.2%) did not use and in 5 (4.9%) it was not stated in the record.

DISCUSSIONThis study was conducted in a tertiary health center that

attends to referrals from lower cadres of eye care in the entire state and its environs. It is a federal health institution with affordable charges than private eye clinics explaining its broad clientele base. This background may account for some of the information to be discussed subsequently.

Ocular injuries appear common in certain age groups as demonstrated across multiple studies in different geographical areas [12,17,18]. In this study the mean age was around 27 years with bimodal peaks. This outlook links ocular injuries to younger ages when individuals are agile and involved in economic activities. This was the trend in Kashmir, India [12], Enugu, Nigeria [17], and Kuching, Malaysia [18]. In a similar hospital-based study in United State, Klopfer et al. [19], reported a bimodal peak but the peaks were at about 20 years and over 70 years as against the peaks of the current study of 20 years and around 40 years. The marginal difference could be accounted for by the larger population size of the earlier study which was a 10 year review. Young age means lengthy blind years which carry an added significance when the effects of permanent disability on their quality of life are considered. Loss of productivity and cost

on health care system is also immense.

The risk of men sustaining ocular injury has been found to be between 2 and 5 times higher than that of female across several studies [20-23]. This study shows similar findings - male: female ratio of 1: 0.24. Males had 4 times higher risk of injury related blindness. This, among others, has been attributed to higher tendency to risk-taking behavior. It is likely however those females have more unreported cases of ocular injuries especially arising from domestic chores and the possibility of being hampered by economic constraints. These under-reported reasons may also account for the disproportionate male-female difference in eye injuries across many studies.

The source and mechanism of injury are plausible indicators of which eye will be involved. The preponderance of left eye involvement in the current study is averse to several studies [17,18,24,25]. Reason adduced for right eyes being commonly involved is that most people are right-handed [24]. This presupposition appears insufficient because eyes are not used like the hands and quality of vision is not innately lateralized to an eye. What perhaps determines which eye is involved in an injurious scenario is the quality of vision. The eye with a better vision is more likely to “face” the injurious agent as the individual wants to take advantage of the better eye at all times. Indeed if the right-handed hypothesis is to apply, the left eye should be more prone to injury especially arising from assaults and fights. Because the right hand is more likely to be used to hit the left face and eye in combats. The current study has combats, fights and unintended fist injury as chief contributors to eye injuries and could have accounted for the predominant left eye involvement.

A study has reported changing patterns of eye injuries in Nigeria in which preponderance of war-related injuries in the early 70s was replaced by home and school related injuries as well as industrial trauma. Furthermore with the rising incidence of armed robbery and civilian-armed combats in Nigeria, gunshot injuries are becoming more common [26]. This trend still continues a decade after the observation was made as noted in this study. The wave of global violence with uprising of various militia groups has not spared Nigeria with it various geographical parts reporting sectarian crisis or student restiveness. Security agencies are called to dispel violent student protests with attendant injurious consequences.

Majority of the patients reported after 24 hours and within one week with fairly good vision indicating vision alone might

Table 4: Sources of Eye Injuries.SN Sources Number Percent1 BLUNT OBJECTS

a Flying objects 10 10.6b Insects 4 3.7c Stones 4 3.7d Football 3 2.9e Cloth hanger 3 2.9f Bag of rice 1 0.9g Side mirror 1 0.9h Unintended (fist) 4 3.8

2 SHARP OBJECTSa Sticks 11 10.6b Pen 5 4.8c Iron filling 4 3.7d Cow horn 3 2.8e Mopping stick 2 1.9f Nail 1 0.9g Spanner 1 0.9h Metal protector 1 0.9i Bottles 3 2.9

3 COMBATSa Fighting 18 17.3b Assaults 13 12.5c Robbery 2 1.9

4 UNKNOWN 1 0.95 ROAD TRAFFIC ACCIDENTS 9 8.6

TOTAL 104 100

Figure 1 Time of presentation to health facility.

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not be the primary indication for patient to present to hospital. Ocular pains, redness, tearing and foreign body sensation among other reasons may make patient with eye injury come to hospital despite a good vision. Omolase et al. [24], reported that most of the subjects reported within 24 hours which eventually accounted for good visual outcome. The reason giving for early presentation was proximity to health center. This study was conducted in a center that has wider patient coverage which could have explained the extra few days delay. Babar et al. [26], Mackiewicz et al. [27], and Yaya et al. [28], reported late presentation of patients which was thought to be due to the long distance of health facilities from the patients. In this study, majority that came after one month had very poor vision. McGwin et al. [29], and Schmidseder et al. [30], reported late presentation is associated with poor vision.

Closed globe injury was by far the commonest type of injury similar to what Omolase et al. [24], reported in a hospital-based study. But in another southern Nigerian study, Okoye et al. [17], reported preponderance of open globe injury. This difference could have been because of study design which focused on eye injured patients that were hospitalized. The possibility of open globe cases being admitted in the hospital is higher to enable globe exploration, repair and post-operative recovery.

The use of protective goggles was abysmally low in this study considering that there were workers who should have used them during the course of their duties. In another Nigerian study [24], no subject wore protective glasses. This reflects poor eye safety consciousness among the research population and underscores the need for educating people regarding the use of protective eyewear to decrease visual loss due to trauma.

The obvious limitations of this study are that it was retrospective and consequently the dependent and independent variables were not controlled by the researchers. It was hospital-based such that patients’ selection was skewed only to those who could not tolerate their complaints. Finally, studies on trauma are

seasonal and may not reflect the pattern in subsequent years or the same year in another location.

In summary, sources of ocular injuries are ubiquitous and could occur on any occasion during human activities. Unfortunately, many of such injuries are accidental arising from not necessarily hazardous practices. It seems likely that the trend and prevalence of ocular injuries are determined by prevailing socio-economic situation. But public health strategies are time tested avenues for cost-effective prevention of visual loss from avoidable causes.

It is therefore recommended that primary eye care service be available at all health institutions in Cross River state and other states of Nigeria. Secondly, appropriate and efficient referral system that prioritizes ocular injuries should be put in place. In addition, occupational health and safety rules and regulations protecting people at risk need to be designed and implemented. Finally, workers should be informed about the risk of eye injuries within their occupation. Hence appropriate and comfortable protective device with regular use must be advocated.

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Table 5: Association of types of globe injuries and gender.M F TOTAL χ2

(P-value)Number Percent Number Percent Number PercentCLOSED GLOBE 76 73.1 18 17.3 94 90.4

OPEN GLOBE 8 7.7 2 1.9 10 9.6

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M =male, F = female, χ2 = Chi-square

Table 6: Presenting Visual Acuity in Relation to Duration of Presentation.

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Total χ2(p-value)6/6-6/18 <6/18-6/60 <6/60-3/60 <3/60-NPL

<24 hours 3 (6.5%) 2 (16.6%) 6 (54.5%) 8 (22.9%) 19 (18.3%)

2-7 days 33 (71.7%) 5 (41.7%) 3 (27.3%) 13 (37.1%) 54 (51.9%)

8-30 days 6 (13.1%) 3 (25%) 1 (9.1%) 3 (8.6%) 13 (12.5%)

>30 days 4 (8.7%) 2 (16.7%) 1 (9.1%) 11 (41.4%) 18 (17.3%)

Total 46(100%) 12 (100%) 11(100%) 35(100%) 104 (100%) 130.429 (0.375)

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Cite this article

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