Bilateral blindness due to trauma in Cambodia

The Ayounkon project: visual impairment, eye diseases and unmet eye care needs in the Syrian refugee population and the hosting community in Lebanon

AIM

To report on the distribution of eye diseases, aetiologies of severe visual impairment/blindness (SVI/BL) and unmet eye care needs of the Syrian refugee population and the Lebanese host community.

METHODS

This retrospective study analysed the data of patients that were examined during the Ayounkon project -an eye health care project offering medical and surgical treatment for Syrian refugees and Lebanese host community in the Bekaa Valley in Lebanon. The project took place in three different primary health care centres and involved cooperation between several NGOs and ophthalmologists working on a voluntary basis. Data was analysed for distribution of eye diseases and aetiologies responsible for monocular and binocular SVI/BL.

RESULTS

A total of 2067 patients were included, 677 were children < 18 years. The most frequent pathologies were ocular allergy (10%), and cataract (7.4%). 158 patients (7.6%) were referred for surgery. Glasses were prescribed for 1103 patients (53.4%), of whom 242 (21.9%) were children of school age. SVI/BL was found in 276 patients (13%). The condition was bilateral in 116 patients (42%). SVI/BL was significantly more frequent in the Syrian population than in the Lebanese (186 patients, 14.8% versus 86 patients, 11.3%; p = 0.04). The main causes for SVI/BL were cataract, keratoconus/corneal decompensation and amblyopia.

CONCLUSION

The Syrian refugee population and the Lebanese host community have a high prevalence of ophthalmic pathologies and SVI/BL. Visual impairment is more prevalent in the refugee population. Our findings underscore the importance of targeted interventions and access to eye care services for these populations.

Evaluation of the Effects of Biohcly in an In Vivo Model of Mechanical Wounds in the Rabbit Cornea

PURPOSE

Biohcly is a type of acidic nanoclustered water shown to exert an antimicrobial effect and play a role in the tissue-healing process in previous experiments. This study was performed to evaluate the in vivo effects of Biohcly treatment on mechanical corneal wound healing.

METHODS

Rabbit cornea "acute" mechanical wounds were created with an 8-mm hydraulic pressure trephine. The corneal wounds were treated with either Biohcly (left eye) or sterile saline (right eye) 4 times per day. To determine the state of the wounds, the wound healing rate (WHR), inflammatory index (IF), neovascularization, and anterior segment optical coherence tomography (AS-OCT) were evaluated. The expression of inflammatory factors was examined by quantitative real-time reverse transcriptional polymerase chain reaction, enzyme-linked immunosorbent assay, and immunohistochemical staining.

RESULTS

Biohcly was more effective than saline in healing corneal ulcers as demonstrated by the WHR calculated on the 9th and 14th days after surgery (P < 0.05). The histological and AS-OCT examinations revealed better regeneration and reduced corneal scars in the Biohcly-treated corneas. No neovascularization formed in the corneas treated with Biohcly, whereas 25% of the saline-treated wounds developed this complication. In addition, the IF scores of the Biohcly-treated wounds were significantly lower than those of the saline-treated wounds. Compared with the right-eye corneas, the left-eye corneas had much lower protein and mRNA levels of matrix metalloproteinase-9 (MMP-9) after the injury.

CONCLUSIONS

Biohcly plays a role in wound healing and anti-inflammation in the treatment of corneal wounds. The downregulation of MMP-9 in the Biohcly-treated corneas might have been responsible for this effect.

Population trends related to injury from explosive munitions in Lao PDR (1964-2008): a retrospective analysis

Background

The presence of landmines and explosive remnants of war (ERW) including unexploded ordnance (UXO) poses a serious public health risk for populations living in conflict-affected and contaminated areas. Current analysis, however, provides only a partial view of the burden. In this study, we examined the multivariable relationship between year of injury, activity at the time of the incident, case fatalities and casualty rates in order to provide decision-makers with a more fine-grained understanding of landmines and ERW injuries in the Lao PDR.

Methods

Using data from a retrospective, national household survey, frequency tables, logistic and Poisson regressions were performed using STATA 13 to predict the case fatality and population-standardized incidence rates for ERW casualties.

Results

The findings indicated that most casualties were male (86.75%), with the majority of incidents (74.7%) occurring during the conflict period (1964–1979). The odds of death for the conflict period was 1.5 times that of the post-conflict period (1980–2008). The highest odds of death during the conflict period was associated with big bombs (OR = 1.38, 95% CI: 1.243–1.522, p < 0.01), and landmine injuries were more common during conflict compared to the post-conflict period (IRR = 1.42, 95% CI: 1.368–1.477, p < 0.01). Post conflict, cluster munitions had the highest incidence rate for death or injury (IRR = 1.07, 95%CI: 1.006–1.143, p = 0.03). Scrap collection which is often the target of mine risk education and thought to be one of the main activities at time of injury had the second lowest incidence rate of the activities related to incident during post-conflict period.

Conclusions

As the first study of this nature in Lao PDR, this research provides information essential for planning services and prevention. This study suggests more effort needs to be directed towards addressing the geographical regions and population subgroups experiencing increased casualty numbers and odds of death. Further research is required to improve the documentation and understanding of the health and socio-economic consequences of landmine and ERW injuries.

Longitudinal Evaluation of Wound Healing after Penetrating Corneal Injury: Anterior Segment Optical Coherence Tomography Study

PURPOSE

Ocular imaging can enhance our understanding of wound healing. We report anterior segment optical coherence tomography (ASOCT) findings in penetrating corneal injury.

METHODS

Serial ASOCT was performed after repair of penetrating corneal injury. Internal aberrations of wound edges were labeled as "steps" or "gaps" on ASOCT images. The wound type was characterized as: type 1: continuous inner wound edge or step height ≤ 80 µm; type 2: step height > 80 µm; type 3: gap between wound edges; and type 4: intraocular tissue adherent to wound. Surgical outcomes of different wound types were compared.

RESULTS

50 consecutive patients were included (6 females, 44 males; mean age 33 ± 12 years). The average size of wound was 4.2 ± 2.6 mm (type 1, 8 eyes; type 2, 27 eyes; type 3, 12 eyes; type 4, 3 eyes). At the end of 3 months, 70% (n = 35) of the wounds were type 1. At the end of 6 months, all type 1 wounds had healed completely, whereas about half of type 2 (48.1%) and type 3 (50%) wounds had recovered to type 1 configuration. The wound type at baseline affected the height of step (p = 0.047) and corneal thickness at 6 months (p = 0.035).

CONCLUSIONS

ASOCT is a useful tool for monitoring wound healing in cases with penetrating corneal injury. Majority of the wound edges appose between 3 and 6 months after trauma. In our study, baseline wound configuration affected the healing pattern.

Burden of Injury From Explosive Remnants of Conflict in Lao PDR and Cambodia

In postconflict settings, a substantial number of injuries and related disabilities are caused by land mines and explosive remnants of war. This article reviews the literature on the prevalence of these injuries and subsequent disabilities in Cambodia and Lao PDR. Three major electronic databases were systematically for publications on the prevalence of these injuries. Six studies met the inclusion criteria. Five of these were in Cambodia and 1 in Lao PDR. None of these studies could estimate national prevalence rates of these injuries; only 2 considered the broader impact of related disabilities. The different methodological approaches and limitations of the studies prevented statistical synthesis. The studies reviewed suggested accurate estimates of the prevalence of war injuries and consequent disabilities are missing. There is a need for a comprehensive epidemiological research to quantify the burden that results from such injuries.

Mental health survey among landmine survivors in Siem Reap province, Cambodia

Many survivors of the Khmer Rouge period in Cambodia and the subsequent war with Vietnam have now returned to Cambodia. In this two-stage household cluster survey in Siem Reap Province in Cambodia, we explored the mental health consequences on 166 landmine injury survivors selected from 1000 household in 50 clusters and an oversample of all landmine survivors. We found a prevalence of anxiety of 62% for all respondents, 74% for depression, and 34% for post-traumatic stress disorder (PTSD). These prevalences were statistically significantly higher than among the adult population who had not been injured by landmines. These data underscore the importance of providing mental health care services for the people in Siem Reap Province in Cambodia who have been injured by landmines.

Prevalence and incidence of ocular trauma in North China: the Beijing Eye Study

PURPOSE

To determine the prevalence and incidence of ocular trauma and proportion of trauma-related visual impairment in the population of Greater Beijing.

METHODS

The population-based Beijing Eye Study included 4439 subjects in 2001, of whom 3251 subjects returned for follow-up examination in 2006 (response rate: 73.3%). The subjects underwent a comprehensive ocular evaluation. Prospective information on ocular trauma and type of treatment was recorded with questionnaires in face-to-face interviews.

RESULTS

A history of ocular trauma was reported by 72 (1.6 ± 0.2%) subjects (age-standardized prevalence: 1.7 ± 0.01%). Prevalence of ocular trauma history was associated with male gender (p = 0.02), rural residence (p = 0.04) and alcohol consumption (p = 0.01). Trauma as underlying cause for visual impairment (best-corrected visual acuity < 20/60 and ≥ 20/400) was found in 4 (6.6%) eyes and as underlying cause for blindness (best-corrected visual acuity <20/400) in three eyes (4.2%). In the survey of 2006, 116 (3.6 ± 0.3%) participants had a self-reported history of ocular trauma, which was associated with male gender (p = 0.002), low income (p = 0.01) and alcohol consumption (p = 0.016). The 5-year incidence of ocular trauma was 2.6 ± 0.3%, which was associated with male gender (p = 0.02), younger age (p = 0.037) and lower income (p = 0.009).

CONCLUSIONS

In the adult population of Greater Beijing with an age of 40+ years, the prevalence of ocular trauma was 1.6 ± 0.2% and was associated with male gender, rural residence and alcohol consumption. The age-standardized ocular trauma prevalence of 1.7 ± 0.01% was comparable with figures from Caucasian populations. The 5-year incidence of ocular trauma of 2.6 ± 0.3% was associated with male gender, younger age and lower income.

Landmine associated injuries in children in Turkey

This study aims to examine trends of injuries due to landmines and unexploded ordnance (UXO) and to determine problems during and after the treatment of children and adolescent victims in Turkey. Data from the records of 23 children injured from landmines and UXO were analyzed from April 2001 to October 2008. Cases consist of 21 (91.3%) males and two (8.7%) females with a mean age of 12.8 years. Cause of injury was landmine explosion in 20 (87.0%) and UXO in three (13.0%) cases. Injuries in upper and lower extremities were determined in eight (34.8%) children. Hand amputation was the result in 10 (43.5%) children where in two cases a leg, in one case an eye, in one case a hand and arm, in two cases a hand and leg, in one case an eye and a leg and in three cases a hand and eye were lost. One case of death was recorded from UXO with an autopsy performed. Contaminated areas in our region should be cleared according to international contracts to prevent injuries in children, centers providing rehabilitation services should be established and policies regarding social support for child victims should be ascertained.

Ocular trauma in a rural south Indian population: the Aravind Comprehensive Eye Survey

PURPOSE

To determine the rate of ocular trauma in a rural population of southern India and its impact on vision impairment and blindness.

METHODS

A population-based cross-sectional study of 5150 persons 40 years or older in a randomly chosen rural population of 3 districts of southern India. Prospective information on trauma, type and agent of injury, setting of injury, and details of treatment sought for the last episode was recorded with questionnaires after face-to-face interviews. All interviewed subjects underwent a comprehensive ocular examination, including vision estimations, slit-lamp biomicroscopy examinations, and dilated posterior segment examinations.

RESULTS

We elicited a history of ocular trauma in either eye from 229 (4.5%) persons, including 21 (0.4%) persons with bilateral ocular trauma. Blunt injuries (n = 124; 54.9%) were the major cause for trauma reported in this population. The most common setting where the ocular trauma occurred was during agricultural labor (n = 107; 46.9%). Nearly three quarters (n = 170; 74.2%) of those reporting ocular trauma sought treatment from an eye specialist (n = 104; 57.8%) and one fifth (n = 37; 20.6%) from a traditional healer. The age-adjusted (adjusted to the population estimates for India for the year 2000) prevalence for blindness in any eye caused by trauma was 0.8% (95% confidence interval [CI], 0.4-1.1). The odds ratios (OR) for trauma were higher for males (OR, 2.2; 95% CI, 1.6-3.0) and laborers (OR, 1.7; 95% CI, 1.2-2.4) and lower for literates (OR, 0.7; 95% CI, 0.5- 0.9). Seeking treatment from a traditional eye healer for trauma was not associated with vision impairment (OR, 1.0; 95% CI, 0.3-3.2) or with blindness (OR, 3.4; 95% CI, 0.2-56.5).

CONCLUSIONS

Eye care programs may need to consider ocular trauma as a priority in this population, because the lifetime prevalence of ocular trauma is higher than that reported for glaucoma, age-related macular degeneration, or diabetic retinopathy from this population. Simple measures such as education regarding the use of protective eyewear could possibly significantly decrease this preventable cause of visual disability.

Penetrating Keratoplasty in Nepal

PURPOSE

To identify indications and outcomes in a large series of penetrating keratoplasty surgeries performed in Nepal.

METHODS

A retrospective case series of 472 consecutive penetrating keratoplasty surgeries (408 patients) performed at Tilganga Eye Center, Kathmandu, Nepal from June 1994 to September 1999.

RESULTS

Mean recipient age was 39.2 years (+/- 19.7 years). Main indications for PKP were corneal scar (37%), adherent leukoma (35%), perforation or impending perforation (9%), pseudophakic bullous keratopathy (6%), keratoconus (4%), and aphakic bullous keratopathy (3%). Mean duration of follow-up was 27.6 +/- 25.1 months. Sixty-five percent of available grafts were clear at 6 months, and 70% of available grafts were clear at 3 years. Six months postoperatively, 15% of patients had acuity better than 6/18, 37% had acuity between 6/18 and 6/60, and 17.7% had acuity between 6/60 and 3/60. Common causes of graft failure were endothelial failure (43%), increased intraocular pressure (15%), ulcer (14%), and trauma (7%).

CONCLUSIONS

The corneal diseases and indications for transplant surgery in Nepal are different from those in the Western world. Despite these differences, penetrating keratoplasty is a successful and reasonable way to reduce corneal blindness in developing nations.

The epidemiology of ocular trauma in rural Nepal

AIMS

To estimate the incidence of ocular injury in rural Nepal and identify details about these injuries that predict poor visual outcome.

METHODS

Reports of ocular trauma were collected from 1995 through 2000 from patients presenting to the only eye care clinic in Sarlahi district, Nepal. Patients were given a standard free eye examination and interviewed about the context of their injury. Follow up examination was performed 2-4 months after the initial injury.

RESULTS

525 cases of incident ocular injury were reported, with a mean age of 28 years. Using census data, the incidence was 0.65 per 1000 males per year, and 0.38 per 1000 females per year. The most common types of injury were lacerating and blunt, with the majority occurring at home or in the fields. Upon presentation to the clinic, 26.4% of patients had a best corrected visual acuity worse than 20/60 in the injured eye, while 9.6% had visual acuity worse than 20/400. 82% were examined at follow up: 11.2% of patients had visual acuity worse than 20/60 and 4.6% had vision worse than 20/400. A poor visual outcome was associated with increased age, care sought at a site other than the eye clinic, and severe injury. 3% of patients were referred for further care at an eye hospital at the initial visit; 7% had sought additional care in the interim between visits, with this subset representing a more severe spectrum of injuries.

CONCLUSIONS

The detrimental effects of delayed care or care outside of the specialty eye clinic may reflect geographic or economic barriers to care. For optimal visual outcomes, patients who are injured in a rural setting should recognise the injury and seek early care at a specialty eye care facility. Findings from our study suggest that trained non-ophthalmologists may be able to clinically manage many eye injuries encountered in a rural setting in the "developing" world, reducing the demand for acute services of ophthalmologists in remote locations of this highly agricultural country.

[Blast injury. Acute blindness caused by thoracoabdominal compression trauma]

Blindness can be the consequence of trauma, which until now had only been described in cases involving direct facial or cranial trauma. In our case a 53-year-old street worker became irreversibly blind after a thoracoabdominal compression trauma. The investigations performed were inconclusive regarding the cause of blindness. We postulate a massive increase in venous blood pressure with capillary stasis and consequent optic nerve damage. Fat emboli syndrome or posterior ischemic optic neuropathy could be causes, but unrealistic for this case. It still comes into question why such a mechanism has not been seen in other blast injury cases. In the end, the additional factor that resulted here in complete irreversible blindness remains unclear.

Childhood blindness

PURPOSE

The objective of this study was to summarize available data regarding pediatric blinding diseases worldwide and to present the most up-to-date information on childhood blindness in the United States.

METHODS

We obtained data from a complete search of the world literature and from direct contact with each of the schools for the blind in the United States.

RESULTS

Five percent of worldwide blindness involves children younger than 15 years of age; in developing countries 50% of the population is in this age group. By World Health Organization criteria, there are 1.5 million children worldwide who are blind: 1.0 million in Asia, 0.3 million in Africa, 0.1 million in Latin America, and 0.1 million in the rest of the world. There are marked differences in the causes of pediatric blindness in different regions, apparently based on socioeconomic factors. In developing countries, 30% to 72% of such blindness is avoidable, 9% to 58% is preventable, and 14% to 31% is treatable. The leading cause is corneal opacification caused by a combination of measles, xerophthalmia, and the use of traditional eye medicine. There is no national registry of the blind in the United States, and most of the schools for the blind do not keep data regarding the cause of blindness in their students. From those schools that do have this information, the top 3 causes are cortical visual impairment, retinopathy of prematurity, and optic nerve hypoplasia. There has been a significant increase in both cortical vision loss and retinopathy of prematurity in the past 10 years.

CONCLUSIONS

There are marked regional differences in the prevalence and causes of pediatric blindness, apparently based on socioeconomic factors that limit prevention and treatment schemes. In the United States the 3 leading causes of pediatric blindness are cortical visual impairment, retinopathy of prematurity, and optic nerve hypoplasia. There is a need for more complete and more uniform data based on the established World Health Organization reporting format.