original articleMädchen (23 = 22,1 %, p < 0,001). Ein geschlechterspezifischerUnterschied trat auch im Verletzungsalter auf:Die verletzten Mädchen waren deutlich jünger als dieverletzten Buben (Median sechs und elf <strong>Jahre</strong>, p = 0,001).Wir operierten 76 (73,1 %) penetrierende Verletzungen,19 (18,3 %) mit intraokularem Fremdkörper, sechs(5,8 %) Rupturen und drei (2,9 %) perforierende Verletzungen.Die häufigsten Verletzungsobjekte waren Werkzeuge( n = 21, 20,2 %), Stecken und Pfeile ( n = 18, 17,3 %)und Glassplitter ( n = 12, 11,5 %). Von den 88 Patientenmit dokumentiertem Endvisus betrug die Sehschärfebei 52 (59,1 %) zumindest 0,5, 14 (15,9 %) erblindeten.Der Endvisus war signifikant besser als <strong>der</strong> Aufnahmevisus( p < 0,001).Schlussfolgerung Die Mehrzahl <strong>der</strong> Verletzten warenmännliche Teenager, die häufigsten VerletzungsobjekteWerkzeuge. Die Mädchen waren zum Zeitpunkt <strong>der</strong> Verletzungsignifikant jünger als die Buben.Schlüsselwörter Augenverletzung · Bulbuseröffnend ·Penetrierend · Intraokularer Fremdkörper · Kin<strong>der</strong>IntroductionInjury is a major source of visual impairment in theindustrialized world. In the United States, 35 % of all eyeinjuries are estimated to occur in children aged 17 yearsand younger [1 –3 ].Th e classification of eye injuries has been veryheterogeneous until the Birmingham Eye TraumaTerminology (BETT) [ 4 ] provided a standardized terminology.According to it, open globe injuries are definedas injuries with at least one full-thickness wound ofthe eyewall (cornea and sclera). They are subdividedinto four groups: penetrating and perforating injuries,ruptures, and injuries with an intraocular foreignbody (IOFB). A penetrating injury is characterized byone or more entrance wounds, but no exit wound. Ifan IOFB remains in the globe, the injury is called IOFBinjury. A perforating injury is characterized by at leastone entrance wound plus one or more exit wounds. Arupture is a break of the eye wall at its weakest pointthrough an inside-out force vector resulting fromcompression.Over the past decades, preventive health care hascome into sharp focus in general medicine as well asin ophthalmology. Societies like Prevent Blindness inAmerica were founded, and call for further epidemiologicalstudies concerning eye injuries [ 3 ]. The WHO definedinjury prevention as an objective of the program Vision2020 [ 5 ].Pediatric preventive care still has to be expanded [ 6 – 8 ],to prevent unilateral childhood blindness [ 2 , 9 – 15 ].Pediatric open globe injuries in Europe have rarelybeen analyzed so far [ 16 – 18 ], but the pre-existing literatureshows that injury circumstances and prognosis varystrongly with the culture in which they occur [ 19 – 30 ].The present study provides data from a mixed urban andTable 1 Age distributionAge-groups (years) n (%)0–5 29 (27.9)6–10 32 (30.8)11–14 16 (15.4)15–17 27 (26.0)Total 104 (100.0)rural Middle-European patient collective, focusing ongen<strong>der</strong> differences.MethodsWe conducted a retrospective study, scanning the medicalcharts of the Department of Ophthalmology of theMedical University of <strong>Graz</strong> for all the records of childrenwith open globe injuries who were operated on betweenSeptember 1, 1992, and July 31, 2011. Children weredefined as individuals younger than 18 years of age andcategorized into four age-groups (Table 1 ).We excluded patients without a follow-up of at least1 year from the analysis of the visual outcome. Thepatients’ records were reviewed for the following criteria:age, gen<strong>der</strong>, injury type, operations, final visual acuity(FVA), anatomical results, factors influencing the visualoutcome, and aggression or child abuse.The terms “open globe injury,” “penetrating injury,”“perforating injury,” “rupture,” and “intraocular foreignbody injury” are used in accordance with the BETT [ 31 ].Blindness is defined as a visual acuity of less than 3/60,according to the definition of the WHO [ 1 , 32 ].A thorough examination in general anesthesia wasperformed, if slit lamp examination did not reveal all relevantinjury details.The FVA is grouped as follows: no light perception(NLP), light perception and hand movements (LP/HM),1/200 to19/200, 20/200 to 20/50, and 20/40 or better.Visual acuity testing was performed with Snellen charts,letter charts, and picture charts, depending on age andcompliance.Suture removal and eye examinations un<strong>der</strong> anesthesiaare not ranked among operations.Th e statistical analysis was performed using the statisticalsoftware SPSS 19.0 (SPSS Inc, Chicago, IL). Continuousdata are presented as mean and standard deviationor as median and interquartile range (IQR), minimumand maximum, and categorical data as absolute andrelative frequencies. To test whether the frequency ofopen globe injuries is equally distributed across gen<strong>der</strong>and age-groups (0–5, 6–10, 11–14, and 15–17 years),chi-square tests were used. Group comparisons wereconducted using Mann–Whitney U test, Kruskal–Wallistest, and Fisher’s exact test. For comparison of initialvisual acuity (IVA) and FVA, Wilcoxon signed ranktest and Spearman’s correlation coefficient were used.A p -value of < 0.05 was consi<strong>der</strong>ed to indicate statistical306 Gen<strong>der</strong> differences in open globe injuries in children 1 3
original articlesignificance. All p -values were regarded in an explorativesense.ResultsWe identified a total number of 104 children, who metour inclusion criteria. On average, 5.6 injuries occurredper year, with a range from 1 in 2002 to 11 in 1993.Th e mean patient age was 9.4 (± 5.0) years, with an agerange from 7 months to 17 years. An age peak was notobserved ( p = 0.132, Table 1 ).We observed a prepon<strong>der</strong>ance of boys ( p < 0.001) inour patient collective, which included 81 (77.9 %) boysand 23 (22.1 %) girls. The female patients were significantlyyounger than the male patients ( p = 0.001). Themedian age of the girls was 6 years (IQR = 4, 0–16 years),and the median age of the boys was 11 years (IQR = 9,1–17 years), as illustrated in Fig. 1 . There were 44 (54.3 %)boys and 22 (95.7 %) girls younger than 12 years of age.Th e visual outcome ( p = 0.4), the type of injury ( p = 0.7),and the proportion of self-inflicted injuries ( p = 0.4) didnot vary by gen<strong>der</strong>.Th e patients sustained 76 (73.1 %) penetrating injuries,19 (18.3 %) IOFB injuries, 6 (5.8 %) ruptures, and 3(2.9 %) perforations. There were 80 sharp object injuries(76.9 %), 14 (13.5 %) blunt injuries, 6 (5.8 %) caused bybullets from guns, and 3 (2.9 %) caused by rockets; oneobject could not be categorized by shape.The most frequent injury objects were tools, accountingfor 21 injuries (20.2 %, Table 3 ). All these tools weresharp. Of them, 15 (14.4 % of all injuries) were one ofthe following four objects: hammers, nails, drills, andscrewdrivers. Sticks and arrows accounted for 18 injuries(17.3 %). There were 12 (11.5 %) injuries produced by glassfragments, 9 (8.7 %) by rockets or gun bullets, 7 (6.7 %) bypencils, 6 (5.8 %) by wires, another 6 (5.8 %) by knives and1 by fork, 5 (4.8 %) by stones, 1 (1.0 %) by an animal, and 15(14.4 %) by others; 4 objects were unknown. As far as thefunction of the injury object is concerned, 52 (50 %) weretools or toys, 28 (26.9 %) objects of utility, and 16 (15.4 %)objects of nature (pieces of wood, stones) and animals.Two objects could not be categorized by function, andtwo further (1.9 %) injuries occurred during car accidents.Regarding the bullet injuries, five (83.3 %) were causedby soft guns and one (16.7 %) by a captive bolt pistol of afarmer. Most of the objects of utility were made of glass(10 of 28 = 35.7 %). During most of the tool injuries, thechildren used these tools themselves (13 of 21 = 61.9 %);in five (23.8 %) cases, they watched somebody working.Three tool injuries happened during unclearcircumstances.Th ere was a gen<strong>der</strong>-specific difference of injuryobjects: 20 (24.7 %) boys, but only 1 (4.3 %) girl, were hurtby tools ( p = 0.11); 16 boys (19.8 %) were hurt by sticksand arrows, compared with 2 girls (8.7 %). Injuries withglass fragments were approximately equally frequent inboys and in girls, accounting for nine injuries in boys andthree injuries in girls.Fig. 1 Age distribution of patients according to gen<strong>der</strong>Table 2 Frequency of injury types, shapes of injury objects,and wound locationType of injury, n = 104Table 3 Frequencies of categorized injury objects forn = 104 childrenCategorized injury objects n (%)Tool 21 (20.2)Stick/arrow 18 (17.3)Glass 12 (11.5)Gun/rocket injury 9 (8.7)Pencil 7 (6.7)Knife/fork 6 (5.8)Wire 6 (5.8)Stone 5 (4.8)Animal 1 (1.0)Other 19 (18.3)n (%)Penetrating 76 (73.1)IOFB 19 (18.3)Rupture 6 (5.8)Perforating 3 (2.9)Shape of the injury object, n = 103Sharp 80 (76.9)Blunt 14 (13.5)Gun bullets 6 (5.8)Rockets 3 (2.9)IOFB intraocular foreign bodyThe right eye was wounded in 61 cases (58.7 %), andthe left eye in 43 cases (41.3 %). Five children developeda secondary glaucoma after the injury, and three developedan endophthalmitis.Altogether, 201 operations were conducted in 100patients. Four patients were excluded from the analysis1 3Gen<strong>der</strong> differences in open globe injuries in children 307
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