【摘要】 小儿获得性单眼盲值得急切的关注。这类盲通常是由于眼球机械性损伤所致，说明机械性损伤是其首要的致盲原因。 绝大多数眼外伤是意外的，而且是机械性的损伤。鞭炮是一个潜在的单眼盲的原因。其损伤类型多样，有的比较轻微，有的则比较严重，有穿通伤、钝挫伤、化学烧伤或热烧伤。 常导致不可逆的视力损害，而这是可以预防的。增强公众对此的防范意识是预防鞭炮导致眼损伤的一个主要措施。
【关键词】 鞭炮；眼外伤；爆炸伤；儿童
AbstractAcquired uniocular blindness in pediatric group deserves an urgent attention. The blindness usually results from mechanical injury to the globe. It is one of the leading causes of acquired blindness in this group. Most of the ocular injuries were accidental and resulted from mechanical trauma. Firecracker is one of the potential causes for acquired uniocular blindness. The nature of injury varies from mild to severe, penetrating or blunt trauma, chemical or thermal. The irreversible nature of the visual loss is preventable. Public awareness will be one of the main contributors in preventing the ocular morbidity.
KEYWORDS: firecrackers; ocular trauma; explosion injury; children
INTRODUCTION
Pediatric patients is the commonest group that is vulnerable to any injury including ocular injury[1]. It can be minimal or serious which eventually will lead to decrease in vision, cosmetic imperfection and devastating psychological event. Despite introduction of new methods of treatment and improvement of management, ocular injury is still the leading cause of acquired uniocular blindness in children. It accounts about 814% of total injury in children[2,3]. We presented a series of ocular injury of variant severity that is caused by firecrackers. It resulted in ocular morbidity that can lead to psychosocial impact and cosmetic imperfection.
CASE 1
A 10yearold boy alleged firecracker injury when it exploded and suddenly hit his left eye, while he was passing by a group of children playing firecrackers. He presented blurring of vision of the left eye associated with pain and redness. Ocular examinations showed visual acuity of counting finger and presence of hyphema of more than half of the anterior chamber that partially blocked the visual axis (Figure 1). There was no phacodonesis or iridodonesis. He was admitted and treated conservatively with topical steroid and topical antibiotic (guttae chloramphenicol). The hyphema was settled after one week and his visual acuity came back to normal value of 6/6.
Gonioscopy showed 360° angle recession. We continued to follow him up and during 2 years followup, there was no sign of glaucoma and the lens remained clear.
CASE 2
A 9yearold boy alleged injury to the right eye after he passed through a group of children playing firecrackers. He sustained corneoscleral laceration with iris prolapse. Anterior lens capsule had breach. Emergency toilet, iris repositioning, suturing and lens aspiration were performed under general anesthesia. In view of good visual potential, secondary intraocular lens was implanted later. His postoperative best corrected visual acuity was 6/12.
CASE 3
A 7yearold boy alleged firecracker injury after trying to light up the firecrackers which was put in a coconut shell. It suddenly exploded. He presented with reduced vision and painful red eye. Ocular examinations revealed visual acuity of 6/60 with positive relative afferent pupillary defect. There was presence of traumatic mydriasis and hyphema which occupied one third of the anterior chamber. Fundus examinations showed preretinal hemorrhage and retinal fold with choroidal rupture inferiorly. Laser was done at the retinal fold. He developed traumatic cataract at one year after the trauma and underwent lens aspiration with intraocular lens implantation later. His best corrected vision was 6/45.
CASE 4
An 8yearold boy alleged firecracker injury while the attempted to lighten a plastic bottle containing explosive material (carbaite). The bottle suddenly exploded and struck his eyes. He sustained both eyes with thermal injury(Figure 2, 3). The left eye was revealed visual acuity of light perception with total corneal opacity and 360° limbal ischemia. The right eye visual acuity was 6/12 with presence of minimal epithelial defect and grade II chemical injury. Amniotic membrane graft was done in the left eye. However, he developed ankyloblepharon with secondary trichiasis. The visual acuity remained perception to light.
CASE 5
An 11yearold boy with history of alleged firecracker injury to his right eye when it suddenly burst and hit his eye. The accident happened when he was looking directly at the firecracker at near distance while trying to kindle it (Figure 4). He sustained right corneoscleral laceration with vitreous prolapse and the vision at presentation was light perception. There existed total hyphema with shallow anterior chamber. Type B ultrasonography done to assess the posterior segment showed vitreous hemorrhage with inferior retinal detachment. Skull X ray revealed no opaque foreign body. However, CT scan demonstrated hypoechoic intraocular foreign body at right nasal area of the retina. The boy underwent primary corneoscleral toilet and suturing and was treated with intravenous Ciprofloxacin together with topical antibiotics. Pars plana vitrectomy was performed later in the right eye. Intraoperatively, there was vitreous hemorrhage with retinal dialysis and inferior retinal detachment. Removal of the foreign body, cryotherapy and scleral buckling were performed (Figure 5).His vision of right eye improved to hand movement postoperatively. He was still under followup with best corrected visual acuity of counting finger over the right eye.
DISCUSSION
Injury to the eye can be minimal or serious. It can occur in acute or sudden form at the onset, without any warning. The eye injury varies from abrasion to laceration, simple hyphema to globe rupture or even chemical and thermal injuries.
Other studies have identified that boys tend to be affected more commonly than girls due to their aggressive nature and this is consistent with our case series[4]. Children less than 3yearold have a relatively low incidence because of close family supervision. At the age of 6 years and above, children are immature but more independent, easily influenced by surrounding and adventures, which may make them more vulnerable to any injury[4].
Malaysia is a multiracial country which is rich with festivals. Every year, many Malaysians celebrate these festive occasions with firecrackers. The lighting of the firecracker will give out beautiful sparkles that can attract children but they are not aware of the danger of it. Firecrackers during these festivals have led to the loss of many eyes year after year.
In clinical setting, the examination of patient with ocular injury poses a challenge to the ophthalmologist. Patience and gentle ness will be the key to the examination of an injured eye in this age group[5]. Although it is important to assess extent of the injury, forceful examination is forbidden since it will cause further damage to ocular structure[4]. Forceful examination also will lead to psychological trauma to the child. In most of the cases, the children with ocular injury will be submitted for examination under general anesthesia for a complete evaluation of the extent of injury and in planning further management. Early primary repair will be the priority.
Our case series of ocular injury due to firecracker during the onemonth period of the Eidulfitri celebration in one of the state in Malaysia showed that there were 5 cases who were treated. All of the cases involved boys, aged 7 to 11 years old.
Among five cases, one of them had hyphema with 360° angle recession and the other three sustained ocular penetrating injury which required primary toilet and suturing. Out of these three, one of them had a plastic intraocular foreign body with vitreous hemorrhage and retinal dialysis, and he required vitrectomy surgery following the primary repair. The other patient had extensive thermal injury to his left eye and moderate burn over the right eye.
In case 1, the patient with hyphema and 360° angle recession, although his final visual acuity was good, he was still at risks of developing glaucoma and secondary cataract. Previous studies showed that patients with gross traumatic hyphema will have angle recession and later 6%10% of these will develop glaucoma[6]. It is believed that the pathophysiology of the glaucoma is not due to the recession itself, but it is secondary to trabecular meshwork damage. Although at 2 years post trauma his intraocular pressure is still within normal limits, the risk of developing angle recession glaucoma in future is high as he has more than 180° angle recession.
The other four cases had best corrected vision of 6/45 or less. It is due to involvement of posterior segment, which gives a poor prognosis. Penetrating ocular injury contributes to poor visual outcome and ocular survival[7]. Poor visual outcome is also related to multiple ocular structure injury and severity of initial injury[7].
Patient with penetrating ocular injury is also at risks of developing infection such as endophthalmitis, panophthalmitis and sympathetic ophthalmia. The reported case of posttraumatic endophthalmitis is high, especially after open globe injury[8]. It carries about 2.4%17%[9]. Therefore, prompt treatment is crucial to saving the vision. Delayed in diagnosis, infection and presence of intraocular foreign body will affect visual prognosis[9].
Visual impairment in children is significant and has a major impact on social and psychological development of the victim[10]. Other difficulties include parents who refuse the followup, optical correction in traumatized eye and risks of developing amblyopia[11]. It is important to determine the magnitude of the problem, identify the major cause and suggest the preventive measures. The role of health education is to promote awareness among the public, parents and children. First aids knowledge is almost always compulsory and knowing the potential danger of certain event to the eye can help in preventing further damage.
The children should be educated regarding the events that can cause eye injury from preschool age[12]. They should be exposed or informed regarding the complications that can arise from the ocular injury. Teachers, public, mass media such as radio, television or even news papers should highlight this matter. At home, all children must be supervised[12]. Creating a safe environment will be one of the preventive measures. Legislation to ban the usage of firecracker by adults and children would help in saving a lot of eyes.
Pediatric ocular trauma is a major cause of ocular morbidity in children, yet having not received the attention they deserve. Ocular injuries occur without any warning. One moment a child can have perfectly normal eyes, and the next moment the child may be blind or in severe pain. All precautions should be taken to prevent injury and remain the priority. It is always true that prevention is better than cure.
【参考文献】
1 Zhong WD,Jiang B,Gao MJ.Ocular injury of children in Spring Festival period. Int J Ophthalmol(Guoji Yanke Zazhi) 2004;4(3):550551
2 Scribano PV, Nance M, Reilly P, Sing RF, Selbst SM. Pediatric nonpowder firearm injuries: outcomes in an urban pediatric setting. Pediatrics 1997;100(4):E5
3 Takvam JA, Midelfart A. Survey of eye injuries in norwegian children. Acta Ophthalmol(Copenh) 1993;71(4):500505
4 Kaur A, Agrawal A. Pediatric ocular trauma. Current Science 2005;89(1):4346
5 Dasgupta SS,Mukherjee RR,Ladi DS,Gandhi VH,Ladi BS.Pediatric ocular trauma: a clinical presentation. J Postgrad Med (serial online) 1990;36(1):2022
6 Cho J, Jun BK, Lee YJ, Uhm KB. Factors associated with the poor final visual outcome after traumatic hyphema. Korean J Ophthalmol 1998;12(2):122129
7 Mohd A, Jamal AL, Retrospective analysis of pediatric ocular trauma at Prince Ali Hospital. Middle East J Family Med 2007;5(2):4245
8 Sun HY,Zhang MH,Han YJ,Liang TW,Yong ZP.Efficacy of vitrectomy for traumatic endophthalmitis of children. Int J Ophthalmol(Guoji Yanke
Zazhi) 2006;6(4):911912
9 Meredith TA. Post traumatic endophthalmitis. Arch Ophthalmol 1999;117:520521
10 BoldtHC, Pulido JS, Blodi CS, Folk JC, Weingeist TA. Rural endophthalmitis. Ophthalmology 1989;96:17221726
11 Jaison SG, Silas SE, Daniel R, Chopra SK. A review of childhood admission with perforating ocular injuries in a hospital in northwest India. Indian J Ophthalmol 1994;42:199201
12 Seimon R. Preventing blindness from eye injuries through health education. Community Eye Health 2005;18(55):106107
|
