A comparison of pediatric ocular injuries based on intention in patients admitted with trauma

Pediatric trauma, from both accidental and intentional causes, is a leading cause of morbidity and mortality [1, 2]. A recent study found that approximately 1 in 10 pediatric patients admitted for trauma in the US were assault victims [3]. In 2014, an estimated 702,000 children were physically abused [4]. These patients had three times greater risks of mortality when they had severe head injury [3]. Given its anatomic location, the eye is at risk of damage in head trauma thus ocular trauma is a significant cause of morbidity in the pediatric population [5, 6, 7]. Visual impairment in childhood can have marked longterm effects on daily functioning and psychosocial development [8]. The incidence of ocular injury serious enough to result in hospiatlizaion ranges from 8.85 to 15.2 per 100,000 children [9, 10].

Some of the most concerning forms of ocular injuries are those attibutable to assault injuries in infants who are in an active stage of development. Epidemiology and investigations into diagnostic accuracy of ocular findings in Non-Accidental Trauma (NAT) remain active areas of research [11, 12, 13]. A study evaluating non-ophthalmologist accuracy in the diagnosis of retinal hemorrhages found that 13% were incorrectly documented as normal [14]. While retinal findings in NAT are widely reported, there are limited studies of other ophthalmic injuries resulting from assault [15]. Outside the ophthalmic literature, several studies have investivated the epidemiology of assault in children, comparing resulting injuries to unintentional trauma, to identify disparate patterns [1, 3, 16, 17, 18, 19]. In this study, we used a large national database to evaluate pediatric ophthalmic injuries in patients admitted for trauma in order to elucidate if specific patterns of injuries based on intention exist.

In this study of the NTDB (2008–2014), our results reaffirm findings of previous trauma reports. There was an increasing trend in age from unintentional to assault and self-inflicted trauma with a corresponding increase in injury severity, association with and degree of traumatic brain injury (TBI), hospital stay and mortality rate (Tables 1, 2 and 3). There were strong associations between types of injuries and age groups based on intention with the younger ages suffering sight-threatening injuries, including open adnexa wounds, open globe, orbital and optic nerves and visual pathways injuries from both unintentional trauma and assault injuries while older groups had sight-threatening injuries mostly following assault-related injuries. Self-inflicted trauma showed greater association with open globe and optic nerve and visual pathway injuries in the youngest and oldest age groups respectively. There was further disparity between race and ethnicity with Whites more likely to suffer unintentional and self-inflicted trauma and Blacks and Hispanics, assault-related trauma.

Most studies addressing intention in pediatric trauma have focused on NAT in infants [12, 13, 14]. Several studies had focused on intention of trauma in broader pediatric ages [28, 29, 30, 31]. In a recent study of children between 0 and 19 years, Ballesteros et al. demonstrated similar findings to our study with male and adolescent predominance and unintentional trauma outnumbering assault and self-inflicted trauma [28]. Also, they noted that the youngest children were at greatest risk of succumbing to their injuries. Blacks and Hispanics were disproportionately represented in the assault group and whites in the self-inflicted group [28]. Considering all races/ethnicities, they demonstrated a bimodal age distribution for all intentions that, in our study, was most obvious only in the assault group. These differences might have resulted from surveying different databases, over different time periods. Our data also included the 19-21 year group and had lower proportions of American Indians and Alaskan Natives. However, variance between the common demographic groups we both surveyed were borne out. Other studies who noted this race/ethnic disparity have attributed these differences to socioeconomic constraints, exposure to crime and/or suicide and limited resources [32, 33].

Barampas et al. utilized the NTDB (2007–2011) to examine pediatric assault-related injuries [3]. Similarly, they found male predominance and disproportionate Black victims but also noted infants having the highest association with TBI. Although the rate of assault was slightly lower than in this study (16% vs 10%), their mortality rate of 8% was similar to our assault cohort [3]. Estroff et al. compared the epidemiology of accidental and non-accidental trauma (NAT) over four years and found that victims of NAT had a significantly higher mortality rate and injury severity [16]. These findings comport with the increased injury severity, TBI and mortality rate in the 0-3 year age group following assault injuries in our study.

While ocular injuries commonly occur in adult and pediatric patients admitted with major trauma few have reported the epidemiology of pediatric ocular trauma [34, 35, 36, 37]. Guly et al., to our knowledge, conducted the only study of ocular injuries in major trauma that included intent in its analysis [37]. They studied patients of all ages and noted that assault resulted in 10.5% and “non-accidental injury” in 4.4% which together were slightly lower than the 16.3% we found [37]. They did not comment on the risk of mortality nor associate demographic groups, types of injury and mechanisms with intent.

Garcia et al. performed the only studies, to date, of pediatric ocular injury in major trauma [35, 36]. One used the National Pediatric Trauma Registry to study 7497 patients and demonstrated strong male predominance with over 70% being victims of various vehicular accidents. This was greater than the proportion of all vehicular accidents (43.9%) in this study [35]. Again, these disparities likely reflect the different databases sourced. Our study, additionally, showed variances in trauma severity and association with TBI. Assault was associated with the highest risk of TBI and mortality in the 0-3 year group while self-inflicted trauma had the highest risk of TBI and mortality in older children. This was expected since the most common mechanism was firearms. Although there was a lower injury severity and rate of TBI, unintentional trauma was most associated with mortality in the 19-21 year group. This may have resulted from a combined MVTO and other vehicular injuries accounting for the largest group of mechanisms overall. An important finding in this study, is that amongst victims of MVTO, an alarmingly low 36.8% were wearing restraints. It has been shown that non-compliance with seatbelts leads to increased injury severity and mortality and longer hospitalizations [38, 39, 40]. Clearly, compliance with and enforcement of seatbelt laws is one avenue of intervention aimed at reducing pediatric ocular trauma and mortality.

This study demonstrated the impact of intention of trauma on types of pediatric ocular injury, injury severity, associated TBI and mortality. While affirming previous findings of male predominance and gender and racial/ethnic disparities, we noted that visually-threatening injuries occurred in both assault and unintentional trauma in the younger children while being more common in assault and self-inflicted injuries in older age groups. Most patients in all trauma intentions groups survived their injuries and greater injury severity and TBI were most common in infants and associated with assault and self-inflicted trauma.