It is estimated that up to 6 million children worldwide experience some form of ocular trauma each year, of who up to 5% require hospital admission.1 Furthermore, the long-term morbidity of ocular trauma is significant, and it is the leading cause of acquired unilateral blindness in the paediatric age group.2

The sequelae of eye injuries in children are more severe compared to adults, since ocular maturity is not achieved until age 9–10 years, thereby increasing the risk of amblyopia and the years of impaired vision.3 Between 8% and 14% of these children develop severe visual impairment or blindness, which has an impact on their personal, social and occupational development.4

Fortunately, it is estimated that paediatric ocular trauma can be prevented in up to 90% of cases.5 In order to implement preventive measures, we first need to know the circumstances surrounding these injuries.

Although the epidemiological characteristics of ocular trauma have been described in the literature in both developed and developing countries,2 to date only one retrospective, single-centre study published by Burgueño et al. in 1998 has been conducted in Spain describing the epidemiology, injury mechanisms and preventive aspects of eye injuries in children aged less than 14 years managed in the emergency department.6

Since that study had a local scope, its results may not be representative of all of Spain, which motivated the study presented here, the objectives of which were to describe the prevalence and epidemiological characteristics of traumatic eye injuries managed in paediatric emergency departments (PEDs) in Spain, and to analyse potential risk factors for immediate sequelae.

In the period under study, participating PEDs received a total of 242 134 visits, of which 1007 corresponded to episodes of ocular trauma (0.42%; 95% CI, 0.40−0.45%), and 858 were included in the study (Fig. 1).

Fig. 1.

Flow chart of the sample selection process.

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Epidemiological characteristics

Patients with ocular trauma were predominantly male (60.1%) and had a median age of 6.5 years (IQR, 3.5–10.5). We found an increasing proportion of male patients with increasing age (age < 1 year: 52.9%; 1−4 years: 59.2%; 5−9 years: 58.8%; 10−14 years: 64.0%; 15–16 years: 68.0%), although the trend was not statistically significant (P = .134) (Fig. 2).

Fig. 2.

Distribution of ocular trauma cases by age and sex.

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Table 1 presents the characteristics of patients with ocular trauma.

Table 1.

Epidemiological characteristics of traumatic eye injuries.

N	n	%	95% CI
Sex
Male	511	60.1%	(56.7−63.4%)
Female	339	39.9%	(36.6−43.3%)
Unknown	8	0.9%
Age group
< 1 year	34	4.0%	(2.8−5.5%)
1−4 years	274	32.0%	(28.9−35.3%)
5−9 years	309	36.1%	(32.9−39.4%)
10−14 years	213	24.9%	(22.0−27.9%)
≥ 15 years	26	3.0%	(2.0−4.4%)
Unknown	2	0.2%
Day of the week
Monday-Friday	653	76.3%	(73.3−79.1%)
Saturday	84	9.8%	(7.9−12.0%)
Sunday or holiday	119	13.9%	(11.7−16.4%)
Unknown	2	0.2%	(0−0.8%)
Time of day
Morning	356	41.6%	(38.3−45.0%)
Afternoon	393	46.0%	(42.5−49.3%)
Night	106	12.4%	(10.3−14.8%)
Unknown	3	0.3%	(0.1−1.0%)
Time to seeking care
< 1 h	159	18.7%	(16.1−21.4%)
1−24 hours	578	67.8%	(64.6−71.0%)
>24 h	115	13.5%	(11.3−16.0%)
Unknown	6	0.7%	(0.3−1.5%)
Setting
Home	291	34.9%	(31.6−38.2%)
School/sports grounds	286	34.3%	(31.0−37.6%)
Streets	99	11.9%	(9.7−14.2%)
Park/countryside	104	12.5%	(10.3−14.9%)
Other outdoor	21	2.5%	(1.6−3.8%)
Other indoor	34	4.1%	(2.8−5.6%)
Unknown	23	2.7%	(1.7−4.0%)
Witnessed by an adult
No	273	31.8%	(28.7−34.9%)
Yes	556	64.8%	(61.6−68.0%)
Unknown	29	3.4%	(2.2−4.6%)
Location
Right	424	49.4%	(46.0−52.8%)
Left	412	48.5%	(45.1−51.9%)
Bilateral	22	2.6%	(1.6−3.9%)
Cause
Sports	82	9.6%	(7.7−11.8%)
Physical fight	17	2.0%	(1.2−3.2%)
Play	469	54.8%	(51.4−58.2%)
Household accident	49	5.7%	(4.3−7.5%)
Outdoors	69	8.1%	(6.3−10.1%)
Person	25	2.9%	(1.9−4.3%)
Other unintentional	96	11.2%	(9.2−13.5%)
Unknown	51	6.0%	(4.5−7.8%)
Causative agent
Blunt	417	48.7%	(45.3−52.1%)
Sharp	258	30.1%	(27.1−33.3%)
Burn	50	5.8%	(4.4−7.6%)
Other	133	15.5%	(13.2−18.1%)
Previous care
None	539	62.8%	(59.5−66.1%)
Health professional	300	35.0%	(31.8−38.3%)
School staff	19	2.2%	(1.3−3.4%)
Pre-existing refractive error
No	822	96.0%	(94.5−97.2%)
Yes	36	4.2%	(3.0−5.8%)

Values expressed as absolute frequency (n) and percentage (%) with the corresponding 95% confidence interval (CI).

This is the first multicentre study of national scope describing the prevalence and characteristics of traumatic eye injuries managed in the paediatric emergency setting in Spain. In addition, none of the studies to date had analysed potential risk factors associated with the development of immediate sequelae. Given that ocular trauma is a leading cause of noncongenital blindness, identifying these risk factors is essential for the purpose of developing specific preventive measures.

In the United States, the annual incidence of ocular trauma is of approximately 2.4 million cases.11 A large paediatric cohort study conducted in the United States reported an average of 70 310 injuries per year,12 although it did not determine the proportion of paediatric emergency visits that they accounted for. We found that in Spain, they account for 0.42% of emergency visits, a slightly higher percentage compared to other unintentional injuries such as poisonings, which account for 0.29% of emergency visits according to the working group of the Sociedad Española de Urgencias de Pediatría.13

Most of the studies in the literature have found a predominance of male patients,14,15 with a 1.5:1 male: female ratio, which is probably related to the tendency of boys to engage in riskier activities.15,16

The setting of the traumatic event varied between age groups, with the home being the most common in children aged less than 5 years, the school or sports/recreational facilities most common in children aged 5–14 years and the street in adolescents aged more than 15 years. These findings, which were consistent with the previous literature,17–21 reflect that preschool-aged children spend more time at home and therefore are more likely to get injured there. In addition, most eye injuries caused by household accidents occurred in children aged 1–4 years, the group in which injuries associated with exposure to chemicals, most commonly found in homes, were most frequent.18,22 Some regulations are already in place for the control of these products and to prevent potential exposure of children, for example child-resistant packaging that is meant to resist tampering by a 5-year-old child for at least 5 min, giving an adult the opportunity to intervene, but parents and caregivers must still be made aware of the important of using adequate containers and store these products carefully away from children.23

Play, as was the case in other countries, was the activity involved in most traumatic eye injuries2,21,22 and in every age group, except adolescents aged more than 15 years, in which the leading activity involved in ocular trauma was sports. Still, it is possible that the number of injuries associated with sports is underestimated, as our study was conducted in public hospitals and many such cases are managed in private health facilities on account of the health insurance policies that cover these activities. Several paediatrics associations and agencies have published recommendations on protective eyewear for athletic activities,14 since there is evidence that correct utilization of protective eyewear reduces the risk of severe eye injuries by up to 90%. The development of a national strategy for the prevention of sports injuries in the paediatric population, including ocular trauma, would be beneficial, in addition to the implementation of programmes for prevention of sports-related injuries in schools and adequate training of athletic coaches and outdoor activity counsellors.

Some studies have reported causes of injury such as animal bites, firearms and fireworks2,12,20 that were not involved in any cases in our study, possibly due to cultural differences between the populations under study or to a decreasing trend in these causes in developed countries.22

Supervision continues to be an area in need of improvement. Up to one third of eye injuries in our series were not witnessed by an adult, a proportion that was higher than reported in the previous literature,20,21 although similar to the proportion observed in other types of unintentional injuries in Spain.24 This was even more frequent in children aged more than 10 years, and both of these factors (unwitnessed injury and age) were associated with a higher risk of immediate sequelae.

The initial assessment and correct management of patients with ocular trauma are essential to the prevention of severe sequalae. In many instances, adequate care requires consultation with other specialities, such as ophthalmology, to improve risk stratification and provide adequate treatment and follow-up of these injuries. In our study, we found a frequency of consultation that was similar to the frequency described by other authors,15 although only one of the participating hospitals had an ophthalmologist on site around the clock. Although the frequency of consultation could vary if continuous access to a specialist were more common, it does reflect the reality of care delivery in Spanish PEDs.

In our series, open-globe injuries (2.1% of cases, compared to 85.4% of cases of closed- globe injuries) were markedly less frequent compared to other studies, which report ratios of 1:1019 or even greater in developing countries.22

Schneider et al. reported hospital admission in up to 15% of cases,15 much higher compared to our case series. However, that figure included patients subjected to some form of procedure such as surgical repair of the injury, which would explain the greater frequency of admission compared to our sample. We did not find data in the reviewed literature on the frequency of admission in patients that seek care at the PED and do not require surgical intervention.2,3,25,26

Immediate sequelae were identified in 6.8% of patients, a proportion consistent with previous reports,6 most frequently acute vision loss. In the multivariate analysis, age more than 10 years, blunt trauma and the presence of refractory errors were independently associated with an increased frequency of immediate sequelae.

Since patients aged more than 10 years are the group at highest risk of sequelae, we should focus our education and prevention strategies on this population, developing interventions to be delivered in schools or parks, which are the settings where, based on our findings, most of the injuries occur in this age group. It is also important to address sports, keeping in mind the recommendations of different paediatrics associations and agencies for the safe practice of sports,14 which should be known to parents and coaches of children that play organized sports or play sports frequently.

Open-globe injuries are rare in paediatrics but are associated with a higher risk of vision loss, as observed in our study and previous studies, and poorer vision outcomes.27

Our study demonstrates injuries caused by blunt objects, such as toys, carry a higher risk of immediate sequelae. Although there are regulations to promote home safety that apply to furniture or toys, such as the Toy Safety Directive in Europe28 and the Royal Decree on the safety of toys published in the Boletín Oficial del Estado in Spain,29 which details the regulations pertaining to the manufacturing of toys to minimise physical injuries, we must emphasise the importance of providing a safe environment for children to play.

Refractive errors are a common disorder in the paediatric population, with an estimated prevalence of 1.5% to 5.5%,30 and our analysis found that their presence was associated with an increased risk of immediate sequelae. One possible explanation is that patients with refractive errors may wear corrective lenses that could make the injury worse, although we did not collect any data on this aspect. However, Kuhn et al. suggested that wearing glasses at the time of the injury could have a protective effect.1

These authors have proposed a score to predict the final visual outcome of eye injuries (Ocular Trauma Score)31,32 that has been validated, but we could not use it in our study because the particular circumstances of the paediatric emergency setting, the characteristics of paediatric patients and the lack of continuous access to an ophthalmologist in some of the hospitals precluded the assessment of visual acuity in all patients, which may have led to underdiagnosis.

In addition to what we have already mentioned, there are several limitations to our study. It may have underestimated the actual incidence of ocular trauma due to the collection of data exclusively in the PED setting, excluding patients managed at the primary care level, in outpatient urgent care clinics or in ophthalmology clinics. Nevertheless, we believe that obtaining data from the paediatric emergency care setting is essential for the purpose of developing prevention measures. Also, although the study was conducted in several PEDs, the participating hospitals were located in only 4 of the autonomous communities of Spain, so the epidemiological findings should be extrapolated with caution to other regions that were not represented in the sample. In addition, variations in the assessment and the absence of an ophthalmologist at the hospital could have had an impact on the visual sequelae that were detected. Lastly, we did not document the reason why consent was not sought in the cases that it was not, and this may mask missing cases of critical injuries that required care urgently.

One of the strengths of the study is that we achieved the estimated sample of ocular trauma cases, and therefore we consider that the identified risk factors can be generalised to the rest of the population and guide the development of preventive strategies. As we mentioned above, we did not find any other studies in the literature that carried out a similar analysis.

To conclude, ocular trauma is an important problem in the paediatric emergency setting given its potential ophthalmological sequelae. The setting and mechanism of eye injuries vary based on age. Age greater than 10 years, pre-existing refractive errors, blunt trauma and open-globe injuries seem to be predictors of immediate ophthalmological sequelae. An awareness of these risk factors is essential for the purpose of implementing preventive measures and prevent sequelae.

The authors have no conflicts of interest to declare.