Home is where the harm is: changing trends in eye injuries

New research on eye trauma sustained during the COVID-19 pandemic, coupled with the launch of an international live registry of eye injuries, is building a bigger picture on patterns and emerging trends, as RHIANNON BOWMAN discovers.

WARNING: The following article contains content regarding domestic violence and graphic images.

There aren’t many trends COVID-19 hasn’t upended; fertility rates are falling, regional property prices are booming, universities are in deficit with more than 40,000 staff losses, and supply of illicit drugs has been disrupted. Eye trauma hasn’t escaped the clutches of the pandemic either, but not necessarily in ways one might expect.

Investigations into intimate partner violence-related ocular injuries in the US, a resurgence of bow-and-arrow-related ocular trauma in India, and paediatric eye injuries in Western Australia have all been examined through the lens of the COVID-19 pandemic.

In the WA study, researchers found the number of eye injuries during lockdown was stable compared with pre-pandemic numbers, but the nature of those injuries changed, from outdoor sports injuries to in-home injuries. A drop in non-accidental injuries – a clinical term to describe intentional abuse – came as a surprise to the researchers who thought this number would go up.

Now, such ocular injuries and others — resulting from household and DIY accidents, fireworks, car accidents, falls, alcohol-fuelled incidents and more — can potentially be documented in a new international online registry.

A registry may also illustrate the impact of previous “social change” on eye injuries, demonstrated in research that has shown that fewer orbital fractures were treated at St Vincent’s Hospital after lockout laws were introduced in Sydney in 2014, for example.

One of the leading experts behind the concept and creation of the registry is Australia’s own Annette Hoskin, Research Fellow from the Save Sight Institute (University of Sydney) and Lions Eye Institute (University of Western Australia).

Passionate about preserving sight by preventing eye injuries, Hoskin is also Essilor’s global standardisation manager, and Optometry Australia’s representative on Standards Australia’s committees for eye protection, spectacles and sunglasses.

She recently spoke at the Asia Pacific Ophthalmic Trauma Society (APOTS) symposium, titled ‘COVID-19 and Ophthalmic Trauma: Lessons Learnt and the Way Forward’, as part of a virtual Asia Pacific Academy of Ophthalmology (APAO) 2021 congress held in September.

Hoskin says there has been new data published on changes in trends in eye injuries associated with lockdown, including her own work on the new registry called the International Globe and Adnexal Trauma Epidemiology Study (IGATES).

IGATES

IGATES is a secure online registry available internationally for the collection of ocular trauma data. In ocular trauma, injuries can be initially classified as adnexal (eyelids, conjunctiva, lacrimal and orbital soft tissue), closed-globe or open-globe, where an open-globe injury is defined as a full-thickness wound. From there, an open-globe injury (OGI) can be described as secondary to blunt trauma or due to a laceration.

“We have made significant advances with IGATES, resulting in two papers published recently,” Hoskin says.

A patient with hyphema, defined as the presence of blood within the aqueous fluid of the anterior chamber. Image: LEI/Chris Barry.

One paper is on eye injuries from fireworks used during celebrations and the associated vision loss, and the other is on epidemiology and outcomes of open- globe injuries. Although neither paper is specifically reporting on COVID-related injuries, the latter study’s purpose was to utilise an ocular trauma registry to determine the demographics, nature of injury, and associations of severe visual loss for OGI.

Thirteen hospitals in seven countries use the IGATES platform. Patients presenting between April 2009 and 2020 with OGI, with or without adnexal involvement or intraocular foreign body, were included.

From a cohort of 746 patients, OGI occurred more frequently in males in industrial settings and females at home. However, overall, those who were aged 61 years or older, female, and suffered an eyelid injury or foreign body, were at higher risk of severe vision loss from OGI.

Hoskin and Dr Rupesh Agrawal, a senior consultant ophthalmologist at National Healthcare Group Eye Institute at Tan Tock Seng Hospital in Singapore, who has been working on IGATES for six years, believe the registry enables fast and easy tracking and analysis of eye injuries internationally and are keen to collaborate.

“We have developed an international online registry for eyecare practitioners to collate and analyse eye injuries,” Hoskin says.

“We took the first registry as a test case, published the data from that, and then reviewed and revised it, to make improvements. We have now re-launched as a brand new entirely online platform that is more flexible, and more targeted.”

Hoskin says the registry will live-document changes in types of eye injury, which the IGATES team will continue to monitor. They hope future studies with more rigorous methodology, and including a larger number of institutions internationally, will enable trends associated with OGIs to be identified to inform strategies for prevention of these injuries.

Paediatric eye injuries in WA

In a separate study last year, a group of researchers in Hoskin’s hometown of Perth set out to evaluate accidental and non-accidental eye injuries in children presenting to Perth Children’s Hospital (PCH), the only public paediatric centre with specialist ophthalmology services in the state, during the nationwide COVID-19 lockdown.

With both accidental and non-accidental eye injuries a significant cause of long term visual impairment in children, the researchers wanted to determine whether the frequency or nature of these injuries differed from pre-pandemic presentations.

Colleagues Professor David Mackey, Dr Maria Franchina and Ms Magda Blaszkowska, from the Centre for Ophthalmology and Visual Science at The University of Western Australia, joined forces with Mr Joel Lewis, Dr Alice Johnson, Dr Antony Clark, and Dr Geoffrey Lam from the Department of Ophthalmology at Perth Children’s Hospital.

“Understanding when and how such injuries occur is key to developing adequate prevention strategies,” the cohort wrote in their paper, published online in Clinical and Experimental Optometry in August.

The research team conducted a retrospective review of the medical records of paediatric patients presenting to the emergency department and specialist ophthalmology clinic at PCH with an ocular injury and those presenting to the hospital Child Protection Unit with physical injuries during March to August 2020, and the same period in 2019.

They theorised that the prolonged period of school and playground closures and a reduction in after-school activities due to COVID-19 restrictions would significantly alter the epidemiology of accidental eye injuries in the paediatric population.

In their view, the unparalleled recent circumstances arising from the COVID-19 pandemic provided a unique opportunity to evaluate the risks associated with prolonged time spent in isolation and activity restriction.

They found there was no significant difference in the total number of accidental eye injury presentations during the lockdown period (110 during March-May 2020 compared to 123 during March–May 2019) despite a significant decrease in emergency department attendance overall.

“We were expecting a reduction in eye injuries overall given that sports and other outdoor activities were not taking place. However, injuries continued to occur (and increased) in the home environment, so overall there was no difference in frequency,” Mackey and Franchina said.

Their review showed closed-globe injuries were the most common accidental eye injury presentation during lockdown (70/110, or 64%), followed by adnexal injuries (39/110, or 35%) and open-globe injuries (1/110, or 1%).

An eye that sustained acid burns. Image: Lions Eye Institute/Chris Barry

More males than females attended with an accidental eye injury (75/110, or 68%), with a mean age of 6.2 years.

Mackey, Franchina and their colleagues noted the nature of the ocular trauma did change, with fewer sports-related injuries and more household- related injuries, including three minor chemical eye injuries through misuse of hand sanitiser.

“Injuries at home involved backyard sport, sticks, common household items such as knives, forks and pencils, and foreign bodies entering the eye such as sand, wood, glitter and small plastics,” the authors said.

In contrast, the authors noted, referrals to the hospital Child Protection Unit for suspicious injuries declined during lockdown.

“The drop in non-accidental injuries was a surprise as we thought it would go up,” Mackey says. They shared concerns raised in public health literature that stringent social distancing and lockdown measures during the COVID-19 pandemic could lead to possible increased rates of child abuse and intimate partner violence due to increased parental and economic stress, reduced social support and financial instability.

Instead – and in contrast to reports of increased family violence in WA during the height of the pandemic – the overall number of referrals to the Child Protection Unit for investigation of non-accidental injury decreased during the lockdown period.

But even during times of unprecedented social isolation and restrictions, accidental eye injuries continue to occur.

“Although eye injury presentations have changed in other parts of the world since the start of the pandemic, during COVID-19 lockdown in Western Australia, accidental paediatric ocular and adnexal trauma sustained at home continues to be a significant cause for hospital attendance,” Mackey, Franchina and their colleagues wrote.

Evolution of clinical registries

Last year Sydney-based ophthalmologist Professor Tim Roberts, a consultant at Royal North Shore Hospital and clinical associate professor at the University of Sydney, noticed a distinct change in eye-related injury patterns during the peak of the COVID-19 lockdown in 2020.

“Typically, ophthalmic emergencies at Royal North Shore Hospital result from car accidents, alcohol-related incidents, and falls,” he says.

“But during COVID-19 [last year], we saw fewer of these types of emergencies, and an increase in DIY and home-based accidents. For example, a yoga mishap with a theraband resulted in a bleed in the eye for one patient.”

Twelve-months later, Roberts can only assume yoga enthusiasts have improved their technique, as these injuries have been largely absent from the emergency department this year.

Professor Tim Roberts, a consultant at Royal North Shore Hospital and clinical associate professor at the University of Sydney.

“A local hospital emergency department reflects the local demographic in lockdown, and we’re seeing a noticeable reduction in presentations with eye injuries,” Roberts says.

He says the number of open-globe and closed-globe injuries and lid lacerations are roughly the same – and that’s encouraging.

“The good news, figuratively speaking, is that patients are still coming to emergency, as it has been anecdotally documented that some patients are avoiding coming to hospital for fear of contracting COVID. There is enormous hesitancy, especially amongst the elderly population,” Roberts says.

“We can conclude from the numbers presenting to emergency that, hopefully, people are still coming to the emergency department if they have sustained a serious eye injury.”

Roberts says the pattern of eye injuries is consistent with lockdown restrictions; where pre-COVID he treated injuries arising from falls, workplace accidents, and sporting mishaps, now, the majority of injuries stem from accidents at home, like a foam dart fired from a toy gun.

Roberts’ observations are in line with a study published last year that showed that during COVID-19 lockdown, ocular trauma amongst adults was more likely to be sustained at home and more likely to result in a delayed presentation for emergency care.

Concurrent with changing patterns in injuries, is an evolution in collating and analysing collective data on said injuries, Roberts notes.

“We tend to find over the last decade there has been an increase in international collaboration, and interestingly, over the last two years, in lieu of international conferences and meetings that can’t take place, there has been a rise in online meetings and data-sharing.”

In Roberts’ opinion, the benefit of an international registry, like IGATES, is that it promotes goodwill to share knowledge and benchmark results.

A scan showing an intraocular foreign body. Image: Lions Eye Institute/Chris Barry

“It can be complex, time-consuming and sometimes cost-prohibitive to run a large prospective study, but registries can overcome this to some extent, with data that reflects clinical practice, albeit not in a controlled study setting,” he says.

“It can be very hard to benchmark results, aside from peer-reviewed publications. One advantage of a registry is it acts as de facto benchmarking, allowing surgeons to better analyse their individual outcomes.”

Increase in domestic violence

Mackey, Franchina and colleagues took family violence into consideration in their WA study pertaining to paediatric eye injury and noted there is indirect evidence to suggest an increase in the wordlwide incidence of domestic violence since the start of the pandemic.

While, on paper, non-accidental injury decreased during the lockdown period, Mackey et al. raised the possibility that the incidence of non- accidental injury did not decrease but that children who suffered injuries were not identified due to the closure of day-care centres and lack of interaction with extended family, friends and education providers who commonly report child abuse.

Citing research, the colleagues also note parental drug use is a well- recognised risk factor for non-accidental injury.

“Given that the pandemic has interrupted drug supply chains, this has likely led to less use amongst vulnerable parents,” Mackey et al wrote.

“It is also possible that perpetrators of family violence may have transferred abuse from children to intimate partners.”

Roberts agrees that lockdown magnifies normalcy of life, so alcohol consumption or an already volatile relationship is exacerbated.

Three oculoplastic surgeons in the US — Dr Dane Slentz, Dr Andrew Joseph, and Dr Shannon Joseph — co-authored a paper on intimate partner violence–related oculofacial injuries during the COVID-19 pandemic, published in JAMA Ophthalmology in May 2021.

Citing survey data from the US Centers for Disease Control and Prevention, the surgeons reported that prior to the COVID-19 pandemic, one in four women and one in 10 men experienced intimate partner violence in the US.

In March 2020, law enforcement agencies observed an increase in domestic violence calls to US police departments by 27% in some regions after stay-at-home orders were implemented, according to Slentz, Joseph and Joseph.

They said the medical community has also observed a rise in the incidence and severity of intimate partner violence-related physical injuries, including head trauma, facial fractures, and visceral organ damage.

They wrote: “The stay-at-home orders intended to curb the spread of COVID-19 may have inadvertently isolated many individuals who experience intimate partner violence with their abusers and/or triggered the development of new instances of violence.”

Slentz, Joseph and Joseph believe that ophthalmologists and oculofacial plastic surgeons can play a particularly vital role in strategies to effectively screen for and prevent intimate partner violence.

“Intimate partner violence-related ocular injuries can be vision-threatening and include intraocular haemorrhages, traumatic cataract, retinal detachment, and globe rupture,” they wrote.

“In addition, intimate partner violence-related physical injury is responsible for 7.6% to 10.2% of orbital and zygomaticomaxillary complex (ZMC) fractures in women.”

The surgeons argue the effects of the pandemic are expected to be long-lasting. They anticipate a substantial number of individuals in the US will continue to spend a significant portion of their time at home, which they attribute to a high unemployment rate and the fact many school systems are continuing to practise virtual learning.

With Australia’s unemployment rate at 4.6% as of July, and remote- learning the status quo in some states, many Australian’s may also be spending a significant portion of their time at home.

The impact this has on eye trauma trends may be revealed in IGATES data in years to come.

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