Usa

Retrospective; single-institution-based; open-globe trauma studied; epidemiological; 3-year survey

Men are typically injured from projectiles (penetrating trauma), women from falls (rupture)

[36]

Table 1.7.1 (continued) Analysis of recent epidemiological studies

Country

Study design and duration, subjects

Most important findings

Reference

India

Prospective; single-institution-based; single etiology studied; epidemiological + clinical; 1-year survey

The bottle rocket is the most devastating firework; poor initial visual acuity, open globe trauma, APD, and endo-phthalmitis are poor prognostic factors

[70]

India

Prospective; rural-population-based; epidemiological; history-based

4.5% of persons with monocular and 0.4% of bilateral trauma prevalence in lifetime; higher than for glaucoma, AMD, or diabetic retinopathy

[59]

Cote d'Ivoire

Prospective; single-institution-based; pediatric population studied; epidemiological + clinical; 16-month survey

Most injuries occur during unsuper-vised play; 55% final monocular blindness rate

[54]

single-institution-

based; all injury types included;

epidemiologi-

cal + clinical; 9-year survey

The injury incidence rate did not decline during the study period; 40% of eyes lose useful vision

[46]

Table 1.7.1 (continued) Analysis of recent epidemiological studies

Country

Study design and duration, subjects

Most important findings

Reference

Germany

Retrospective; data from two institutions compared; open globe trauma studied; epide-miological; 18-year survey

The risk of open globe trauma (i.e., rupture) in older people has been increasing; the overall rate has remained steady

[66]

Croatia

Retrospective; single-institution-based; adult population studied; epidemiologi-cal + clinical; 5-year survey

The home is the place of injury in 41%; 18% final monocular blindness rate

[30]

Nepal

Prospective; single-institution-based; all injury types included; epidemi-ological + clinical; 6-year survey

Delay of care is a major cause of poor outcome

[34]

single-institution-

based; pediatric population studied;

epidemiologi-

cal + clinical; 5-year survey

Only 8% of closed but 55% of open globe injuries caused severe visual impairment

[67]

France

Retrospective; single institution-based; all injury types included; epidemiological; 11-year survey

Ophthalmological emergencies should not be treated at general ERs but at ophthalmic emergency centers

[23]

Selected publications that provide an international perspective from the last decade

Selected publications that provide an international perspective from the last decade

Table 1.7.1 (continued) Analysis of recent epidemiological studies

Country

Study design and duration, subjects

Most important findings

Reference

Singapore

Prospective; single institution-based; all injury types included; epide-miological; 3-month survey

Low rate of protective goggle use at the workplace

[75]

Singapore

Retrospective; nationwide; only severe trauma studied; epidemiological; 6-year survey

The rate of trauma occurrence did not decline during the study period but the rate of hospitalization did; the incidence peaks in young adults and in those over 70 years

[78]

Hungary, USA

Prospective; nationwide; only severe trauma studied; epi-demiological + clinical; 15-year survey (ongoing data collection)

The spectrum of trauma varies considerably in the two countries; comparison helps highlight certain unique characteristics

[38]

Selected publications which provide an international perspective from the last decade

Selected publications which provide an international perspective from the last decade it is different: the person is often young; therefore vocational issues play an increased role.

1.7.2 Clinical Epidemiology

Several studies have been published on the incidence and prevalence of ocular trauma. The data vary greatly, based on study design as well as geo graphical and societal factors. Table 1.7.2 shows the findings from selected reports.

Table 1.7.2 Incidence and prevalence rates of eye injuries; a literature review

Finding

Country and study design

Reference

Incidence rate for eye injury: 65 for males, 38 for females

Nepal, districtwide

[34]

Incidence rate for persons hospitalized with eye injury: 8.1

Scotland; nationwide

[17]

Incidence rate for persons hospitalized with eye injury: 12.6

Singapore; nationwide

[78]

Incidence rate for persons hospitalized with eye injury: 13.2

USA; nationwide

[35]

Incidence rate for persons hospitalized with eye injury: 15.2

Sweden; countywide

[6]

Incidence rate for persons hospitalized with eye injury: 23.9

Croatia, countywide

[30]

Cumulative lifetime prevalence: 860

Nepal; nationwide

[7]

Cumulative lifetime prevalence: 14,400

USA; citywide

[32]

Incidence of "penetrating" eye injuries: 3.6

Australia; hospital-based

[21]

Incidence rate of eye injuries requiring hospitalization: 15.2

Australia; hospital-based

[21]

Incidence rate of open globe injuries: 3

Germany; hospital-based

[66]

Incidence rate of "perforating" eye injuries: 3.3

Sweden; hospital-based

[10]

Incidence rate of monocular blindness caused by injuries: 4.1

Croatia, countywide

[30]

Incidence rates are per 100,000 population and per year unless otherwise indicated

Incidence rates are per 100,000 population and per year unless otherwise indicated

Table 1.7.2 (continued) Incidence and prevalence rates of eye injuries; a literature review

Finding

Country and study design

Reference

Of all monocular blindness cases, 40% caused by trauma

US; population-based

[15]

Incidence rate of hospitalized cases of eye injuries: 13.2

U.S.; hospital-based

[73]

Prevalence of trauma-related bilateral blindness: 200

Nepal; interview-based

[7]

Incidence rate of eye injuries requiring medical treatment: 975

U.S; interview-based

[24]

Incidence rate of acute, hospital-treated eye injuries: 423

US; ER and hospital records

[31]

One-year cumulative incidence of blinding outcome from serious ocular trauma: 0.41

Scotland; hospital-based

[17]

Incidence rate of eye injuries among professional boxers: 17.1 per 100 matches

USA, statewide

[5]

Annual incidence rate of ER-treated eye injuries: 315

USA, nationwide

[52]

Annual incidence of ocular trauma per 100,000 employees: 537

USA, statewide

[26]

Incidence rates are per 100,000 population and per year unless otherwise indicated

Incidence rates are per 100,000 population and per year unless otherwise indicated

1.7.2.1 The USEIR

The USEIR is the world's largest database of serious eye injuries system (http://www.useironline.org/). Headquartered in Birmingham, Alabama, it collects initial and follow-up, epidemiological, and clinical information on all types of serious injury (defined as trauma resulting in permanent and significant structural or functional change to the eye or adnexa). The USEIR

encourages participation of individual ophthalmologists as well as institutions. Its customized software allows entering data over the Internet; the data are not incorporated into the database before undergoing multiple layers of quality checks. The data are secure: only those who entered them can access them, and no individual patient can be identified in the database. An identical database (http://www.weironline.org/) is available, free, for ophthalmologists working in any other country in the world.

While it is true that "eye injury can happen to anyone at any time," certain risk factors exist. Selected risk factors and injury occurrence characteristics are discussed below.

• The majority of those injured are young adults, with an average age around 30 years [38, 48, 65, 73].

• Those sustaining a serious eye injury over the age of 60 years (see Chap. 2.16) have different etiologies (rate of fall: 23% if over 60 years, 2% if under 60 years, _p<0.001), injury types (rate of rupture: 31% if over 60 years, 11% if under 60 years, _p<.001), and thus prognosis (poor final vision statistically significantly more common).2

1.7.2.3 Gender

• The typical male:female ratio is 4:1 [11, 18, 22, 23, 25, 30, 34, 36, 38, 43, 50, 53, 56, 60].

• In the USEIR, 79% of injured persons are males (male:female ratio: 3.8:1). Figure 1.7.1 shows a detailed breakdown of age and gender in the USEIR.

1.7.2.4 Socioeconomic Status

• The lower on the societal "ladder" a person is, the higher his risk of suffering an eye injury is [24, 43].

2 The report on this study from the USEIR and supported by a grant from the EyeSight Foundation in Birmingham, Alabama, is in press.

0-9 10- 19 20-29 30-39 40-49 50-59 60-69 70 + (years)

Fig. 1.7.1 Analysis of age and gender in the USEIR, based on 15,296 cases. In most age categories, a strong male preponderance is found. The lower figure in the first decade of life and the reversed figure among those over 70 years is probably due to behaviors that are less prominently different early and late in life; in the latter category it is also important to note that women live approximately 7 years longer than men.1 The most-at-risk period is between 10 and 40 years: 61% of all injuries occur in these three decades

0-9 10- 19 20-29 30-39 40-49 50-59 60-69 70 + (years)

Fig. 1.7.1 Analysis of age and gender in the USEIR, based on 15,296 cases. In most age categories, a strong male preponderance is found. The lower figure in the first decade of life and the reversed figure among those over 70 years is probably due to behaviors that are less prominently different early and late in life; in the latter category it is also important to note that women live approximately 7 years longer than men.1 The most-at-risk period is between 10 and 40 years: 61% of all injuries occur in these three decades

1 http://www.cdc.gov/nchs/data/series/sr_02/sr02_129.pdf

• The breaking of rules/laws (e.g., traffic violations, alcohol, or drug use) or unsettled social status (e.g., unemployment) also signifies an elevated risk [24, 58].

• Among those aged 25-65 years in the U.S., blacks and Hispanics have a 40-60% higher risk than whites [73].

• Race is an especially important risk factor in becoming a victim of assault: in the U.S., blacks have a risk twice as high as whites [73] and a more than twice as high risk of having visual impairment from injury [32].

• Even an activity such as driving has its racial component: per mile traveled, 13- to 19-year-old black and Hispanic male teenagers have a nearly twice as high risk of dying in an MVC than white teenagers of the same age [2].

• Race and socioeconomics have a combined effect.

• The significant shift from the workplace to the home, identified first by USEIR researchers [38] in the context of a large, multicenter study, has been confirmed in several subsequent studies [30, 34, 52, 66]. In some rural areas in developing countries the workplace remains the most important site [37]. Figure 1.7.2 shows a detailed breakdown of the place of injury in the USEIR.

• The proportion of workplace injuries is relatively low (19% in the USEIR database),3 and it shows a continuing downward trend: it was 28% prior to 1989 [77] and 12% in 2005. This reduction is due to the fewer number of workers in industry [12], the availability of proper eye-protective devices [74], and the employee-enforced laws requiring to actually wear them (see below).4

• The increase in the rate of injuries occurring at home is dramatic. Two societal facts appear to contribute to this development: the rising number of elderly people (in the U.S. in 2003, the average 75-year-old person

3 Nevertheless, among all nonfatal occupational injuries, ocular trauma results in the highest percentage of days missed from works on the first and second days after the injury (45 and 23%, respectively; U.S. Department of Labor, 27 March 2003, Washington).

4 In addition, the importance of public education should not be neglected. This author operated on a car mechanic who presented with an IOFB he sustained as he was working on a car in his garage. When asked whether he wore eye protection, the mechanic explained that he does wear it at the his workplace - where it is mandatory - but not when he is doing the very same work at home.

Work

Home

Street/Highway

Sport/Recreation

Other

School

Public Place

Farm

Fig. 1.7.2 The place of injury in the USEIR, based on 13,645 cases (See the text for further details.)

could still expect to live another 11.8 years5) and the rising popularity of the do-it-yourself movement: the use of power tools, for instance, is a well-known risk factor for eye injury.

• Street and highway as the site of injury increased from 15% in 1995 to 19% in 2005 in the USEIR. The reason is not an increase in MVCs but, sadly, violence.

1.7.2.7 Source

• What the most common object causing a serious eye injury is largely depends on the location of the study; for instance, in one report from India hypodermic needles were found to the most significant culprit [27]. The significance of the study site is also shown by the very different national scenes (U.S., Hungary, Mexico) when comparing injuries caused by pressurized bottles [39] or by the proportion of injuries inflicted by champagne bottle corks (Fig. 1.7.3).

5 http://www.cdc.gov/nchs/data/hus/hus05.pdf#027

Fig. 1.7.3 Typical champagne bottles in the U.S. and Hungary. In the USEIR, 0.06% of all serious eye injuries are caused by champagne bottle corks; in the HEIR, 2.2% (p<0.00001). Since Hungarians do not consume significantly more champagne than Americans, the explanation is most likely found in the presence of warning labels on the bottles in the U.S. (a,b) and their omission on the bottles sold in Hungary (c). These findings highlight the efficacy of a well-designed preventive measure

Fig. 1.7.3 Typical champagne bottles in the U.S. and Hungary. In the USEIR, 0.06% of all serious eye injuries are caused by champagne bottle corks; in the HEIR, 2.2% (p<0.00001). Since Hungarians do not consume significantly more champagne than Americans, the explanation is most likely found in the presence of warning labels on the bottles in the U.S. (a,b) and their omission on the bottles sold in Hungary (c). These findings highlight the efficacy of a well-designed preventive measure

• Figure 1.7.4 shows a detailed breakdown of the source of injury in the USEIR, which includes data from rural as well as urban areas.

• Various blunt objects remain the most frequent cause (33%). Their significance would be even higher if not for the "fall" category (5%): this injury typically happens to elderly people getting injured at home, and the culprit is usually a blunt object such as a door knob or the edge of a piece of furniture.

• Among sharp objects, nails represented 21%. This is explained by the widespread use of wood as construction material in the U.S. (forestry, carpentry).

• Among those who are injured as a result of a fall, the likelihood of a prescription glass contributing to the injury was significantly higher in the those over 65 years of age [69].

Blunt object Sharp object MVC

BB/pellet/paintball Fall

Firearms Fireworks Other

Fig. 1.7.4 The source of injury in the USEIR, based on 15,031 cases (See the text for details.)

• Although the individual's own risk is impossible to estimate,6 it is interesting to review which types of sports cause the most number of injuries (Fig. 1.7.5). Paintball is an emerging menace in the non-powder-gun category [61, 72].

1.7.2.8 Intent

• Assault was the cause in 19% of injuries in the USEIR (Fig. 1.7.6); 1% was self-inflicted.

6 No data are available about the number of players or the duration of participation.

Fig. 1.7.5 Sport-related ocular trauma in the USEIR, based on 1,075 cases. The bars and the numbers on the left within the bars show the proportion of each sport among all sports injuries. The numbers to the right of the bars show the percentage of eyes with a final visual acuity of worse than 20/40 in each sport

Fig. 1.7.5 Sport-related ocular trauma in the USEIR, based on 1,075 cases. The bars and the numbers on the left within the bars show the proportion of each sport among all sports injuries. The numbers to the right of the bars show the percentage of eyes with a final visual acuity of worse than 20/40 in each sport

Fig. 1.7.6 The intent of injury in the USEIR, based on 12,559 cases

• Firearms were responsible for 71% of all self-inflicted ocular trauma. Surprisingly, the enucleation rate was more than three times higher (25 vs 7%) in this group than among those who were assaulted.

1.7.3 Prevention O Pearl

It is human nature to presume that although "eye injuries happen, they happen to somebody else." To be effective, it is this mindset that prevention must change.

All ophthalmologists have a responsibility to contribute to the fight for preventing eye injuries by identifying risk factors in general and risky behaviors in particular. The contribution can range from warning a single individual of the dangers in a given situation (Fig. 1.7.7) to initiating legislation against a more general threat. Using common sense in daily life is also crucial; everyone should realize, for instance, how dangerous a bungee cord is (Fig. 1.7.8).

Several published reports have identified areas amenable for the introduction of preventive measures and showed the benefits of such measures.

1.7.3.1 MVC-related Deaths and Injuries

• Although the number of drivers increased sixfold between 1925 and 1997 in the U.S., the annual death rate has declined from 18 to 1.7 per 100 million vehicle miles traveled (a 90% decrease) in the same period.7 Several factors (e.g., better road design, improved driver education, energy-absorbing vehicle systems, the use of laminated, not heat-toughened, windshields [45]) contributed to the improvement, but it was primarily the introduction of seat belts and air bags that must be credited.

7 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4818a1.htm

Fig. 1.7.7 Risky activity: a scene from everyday life. The author took this picture in Berlin, Germany, during a large ophthalmology conference in 2005. The worker was repairing a metallic fence: hammering, chiseling, welding, and using power tools to cut and strip. He did not wear eye protection. The sad irony of the scene is that it occurred at the memorial of Albrecht von Graefe

Fig. 1.7.7 Risky activity: a scene from everyday life. The author took this picture in Berlin, Germany, during a large ophthalmology conference in 2005. The worker was repairing a metallic fence: hammering, chiseling, welding, and using power tools to cut and strip. He did not wear eye protection. The sad irony of the scene is that it occurred at the memorial of Albrecht von Graefe

Fig. 1.7.8 A worn bungee cord. Bungee cords are very useful around the house to fasten/clamp/anchor/secure/tie/fix various objects. They can cause very severe injury, including loss of the eye, if they become loose on the opposite end from the user. The risk is compounded by the fact that the cords can also disintegrate with time; this specimen is from the author's own collection

Table 1.7.3 Rate of facial fracture among 3,731 patients injured during a motor vehicle crash. (From [68])

No restraint

Seat belt only

Air bag only

Seat belt and air

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