The term Blindness was defined in 1972 by the World Health Organization (WHO) according to which “blindness is visual acuity of 3/60 or less in better eye or the visual field less than 10 degrees, irrespective of the level of visual acuity”. The current estimation sums up to 45 million bilaterally blind individuals worldwide and roughly 135 million people have severely impaired vision in both the eyes in the world [1]. The corneal disease contributes as the second major cause of blindness worldwide [2]. 1.5 to 2 million of new cases of corneal blindness occur annually due to ocular trauma and corneal ulceration [3]. Thus, it is now evolving to be a silent epidemic especially in the developing countries that contributes to ninety percent of the cases [4]. Around 6.8 million people have corneal blindness in at least one eye with their vision less than 20/200 in India alone. Moreover, among these group around a million have bilateral corneal blindness. By 2020 the number of people with corneal blindness in India is estimated to reach up to 10.6 million [5]. Around 9% of all blind individuals are due to corneal lesions as per a recent national survey by the Government of India [6].

Direct ocular trauma is a major cause of unilateral visual loss in developing countries. Perhaps up to 5% of bilateral loss of vision are also due to ocular trauma. Blindness in trauma is mainly due to perforation of the cornea or even the corneosclera which leads to healing by scar formation [3]. These traumatic ulcers can be even due to farming related minor agricultural injuries. Majority of these trauma in developing countries cause bacterial and fungal infections. Viral infections of the cornea are relatively rare and is mainly due to herpes, either in the form of herpes simplex or herpes zoster. Rarely parasitic involvement can also be seen by Acanthamoeba species usually in contact lens wearers or in individuals with corneal exposure to contaminated water/mud/soil. Thus, detailed knowledge regarding corneal injuries and their management is required especially in developing countries to help reduce the load of future treatable blindness.

Aims:

Clinical profile of corneal trauma and management in pediatric age group patients at tertiary health care center- single centre analysis.

An observational study was conducted in the department of ophthalmology in a tertiary hospital. 132 walk-in patients in the pediatric age group with a history of corneal trauma by vegetative material were included in the study. Trauma by agricultural materials like husks, leaves, wooden sticks, chips, insect exposure, Tail of animals, finger nails were included. Patients were examined in detail and their ocular manifestations, clinical course and prognosis were assessed from the month of November till the month of subsequent April. Detailed documentation of duration of symptoms, predisposing factors, slit lamp biocromscopic findings, associated ocular conditions, other systemic diseases, therapy received prior to presentation, visual acuity at the time of presentation, treatment given, response to treatment and the clinical outcome were done and analyzed.

The corneal trauma was seen more in males in our study compared to female population. Most of the patients presented in the age group of 8-12 years followed by 12-16 years of age. Majority of them belonged to rural population with 41% being farmers. The injuries were seen more during the months of October-December. [Table 1]

Table 1. Demographics of Corneal Ulcer patients

Among the modes of injuries paddy husks or leaves were the most common followed by wooden sticks or chips (Table 2).

Table 2. Association of fungal and bacterial infection with different kinds of vegetative and organic material corneal trauma.

Among the cases corneal ulcer was the most common presentation i.e. in 100 patients (75.76%) followed by Laceration in 19.69% and abrasion in 4.55% (Table 3).

TABLE 3. Post Traumatic Presentation

 On slit lamp examination 55 (41.66%) patients had clear contents followed by hypopyon in 48 patients (36.36%). (Table 4).

Table 4. Anterior chamber content in the study

86 patients (65.15%) required medical management where as 46 patients (34.85%) required surgical management. 72 patients (54.55%) showed healing with some opacity. (Table 5). The visual prognosis is depicted in Table 6.

  Table 5. Showing structural prognosis of corneal trauma

Table 6. Showing visual prognosis of patient with corneal trauma

Of the total 132, patients 92 (69.70%) were males and 40 (30.30%) were females with corneal trauma. Males were more prone to corneal trauma because of their nature of work and outdoor occupation. Thylefors et al. (7), Males tend to have more eye trauma than females. Gothwal et al. (8), males (86.8%) were affected. Vijaya S. Rajmane et al (9), found the maximum

number of cases were in the middle decades of age group between 8-12yrs. Patel S et al. (10), (43.9%). Srinivasan M et al. (11), (43.4%). R.C. Gupta et al. (12), (35.8%), all found that among various type of traumatic agent, paddy leaf was most common. In this study, paddy leaf (51.51%) appears to be most common mode of corneal trauma, however in the study by R Nath et al. (13), fungal keratitis was demonstrated in 65.2% patients which was higher as compared to our study. It was observed that, fungal keratitis was associated with paddy leaf trauma were 51(38.64%).

In study done by Omolase et al (14), Thylefors, B. (7) corneal ulcer was the commonest traumatic lesions (48.2%) In this study, majority were presented with corneal ulcer, 100 patients (75.76%) at the time of their first presentation in our hospital. Among the corneal ulcer group, majority were farmers (44.70%) and labourers (11.36%). Other were, corneal laceration (26 patients, 19.69%), all of them underwent to surgical intervention (primary repair).

Out of 26, 22 were students and 21 were of age group <20 yrs. In the study by R Nath et al. (13) Fungal keratitis was demonstrated in 65.2% patients which was higher as compared to our study. It was observed that, fungal keratitis was associated with paddy leaf trauma were 51(38.64%) followed by wooden stick/ chip trauma 11(8.33%). It was also observed that, Insects, cow tail, finger nail were not associated with fungal keratitis. 76(56.58%) patients showing good response to management, whereas 56(42.42%) were showing poor response. Out of poor responsive, 52 patients had some of predisposing factors, dacryocystitis 13(9.85%) & Topical steroid 9(6.82%) was most common local factor and diabetes mellitus 19(14.39%) was systemic factor. Bharathi MJ et al. (15).

In our study was that, most of the patients with corneal trauma were managed medically (86 patients, 65.15%), out of them 72(54%) patients heal with some degree opacities due to corneal ulcer involving the deeper layer of cornea, 10(7.58%) patient needed glue and BCL. Other left was managed surgically (46 patients, 34.85%). Most of them were primary repaired (26, 19.69%), others were evisceration (11, 8.33%), penetrating keratoplasty (9, 6.82%). Patel S. et al. (10), 70% patients healing of corneal trauma occurred with dense leucomatous opacity. Bibhudutta Rautaraya et al. (16) Clinical outcome of healed scar was achieved in 35.6%. 19.7% required therapeutic PK, 3.4% went for evisceration, 18.9% received glue application with bandage contact lens (BCL) for impending perforation. Saha S et al. (17) (40.55%) patients healed with corneal scar formation with medical treatment whereas 44 cases (59.45%) required therapeutic keratoplasty.

Corneal trauma healing outcome was slightly higher (54%) in our study as compared to the studies of Bibhudutta Rautaraya et al. (16) & Saha S et al. (17) whereas it was lower to Patel S. et al (10) study. Evisceration (8.33%) was higher in our study as compared to Bibhudutta Rautaraya et al. (16) i.e. 3.4%, because most of the patients in our setup came with scleral involvement and large corneal perforation. In our study, post management 72.73% patients had vision <3/60 in affected eye due to dense opacity. Patel S. et al. (10) 70% patients healing of corneal trauma occurred with dense leucomatous opacity which result to vision in affected eye, no perception of light to finger counting (58%).

Fungal ulcers were more common than bacterial ulcers. Fungal ulcers should be suspected in every patient with a corneal lesion occurred by vegetative and organic material and should be ruled out before commencing topical medication. Early diagnosis with prompt identification of the pathogenic organism is mandatory to initiate appropriate therapy for corneal injuries to restores good vision. Fungal ulcers should be suspected in every patient with a corneal lesion occurred by vegetative and organic material and should be ruled out before commencing topical medication. Fungal ulcers were more common than bacterial ulcers. The community need to be educated and informed about the importance of preventive measures including protective eye devices like protective glasses while working, so that it works as preventive measure against traumatic lesions. Patients should be encouraged to present early following ocular injury. It was seen that, response to medical treatment is poor in patients with late presentation.

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