Abstract
Introduction
Epidemiological data on the use of eye-related emergency services by children are limited. The objective of this study was to determine how COVID-19 affected the epidemiological trends of pediatric ocular emergencies.
Methods
We performed a retrospective chart review of children under the age of 18 years who visited our eye-related emergency department between March 17 and June 7, 2020 and between March 18 and June 9, 2019. This was a descriptive and comparative analysis of the two study periods based on the demographic characteristics of patients and the diagnosis reported by the ophthalmologist in the digital medical charts. One of the investigators performed a second reading of the files to homogenize the diagnosis classification based on the most frequently found items.
Results
In total, 754 children were seen in our eye-related emergency department during the 2020 study period versus 1,399 in 2019, representing a 46% decrease. In 2019, the four main diagnoses were traumatic injury (30%), allergic conjunctivitis (15%), infectious conjunctivitis (12%), and chalazion/blepharitis (12%). In the 2020 study period there was a significant decrease in the proportion of patients presenting with traumatic injuries (p<0.001), infectious conjunctivitis (p=0.03), and chalazion/blepharitis (p<0.001). Consultations for chalazion/blepharitis were the most affected by the pandemic, followed by traumatic injuries (−72% and −64%, respectively). The proportion of patients who required surgery after trauma was higher in 2020 than in 2019 (p<0.01), but the absolute number of severe trauma cases remained stable.
Conclusions
The COVID-19 pandemic was accompanied by a decrease in the overall use of a pediatric eye-related emergency services in Paris. Visits due to benign causes and ocular trauma also decreased, but visits for more severe pathologies were not affected. Longer-term epidemiological studies may confirm or refute a change in eye emergency department use habits.
Keywords: Pediatrics, Ophthalmology, Traumatology, COVID-19
1. Introduction
The COVID-19 pandemic significantly modified social interactions because of a fear of infection or due to several governmental constraints. These changes have affected the field of epidemiology [1] and led to a decrease in the transmission of other infectious diseases but also to the emergence of new clinical pictures, such as ocular injuries due to hand sanitizer exposure [2,3]. Although some studies reported a significant decrease in visits to general emergency departments, ophthalmologists have also observed, during and after lockdown periods, some changes in visits for ocular emergencies, such as reduced overall number of visits, more likely for less severe conditions [4,5]. However, some series reported a higher rate of severe retinal detachment, which suggested that COVID-19 potentially delayed the search for medical help by individuals with retinal tears and retinal detachment.
In France, only medical physicians are authorized to prescribe drugs (including eyedrops), glasses, or contact lenses. Before the pandemic, the use of telemedicine was limited to some general medicine consultations. Thus, because most of the ophthalmologists in private practice were unable to work during the lockdown periods, visits to eye-related emergency departments should have been increased in France.
The literature on pediatric ocular emergencies is limited. Regarding the COVID-19 pandemic, some studies reported a significant decrease in visits to emergency departments for pediatric eye-related issues [6,7] without detailing whether this decrease affected all diagnoses similarly.
Thus, we conducted this study to provide detailed data on the pre-COVID pediatric visits to a French eye-related emergency department and to describe how the COVID-19 pandemic affected the management of pediatric ocular emergencies.
2. Methods
Electronic records of all children under the age 18 years who consulted the emergency department of a referral ophthalmological center between March 17 and June 7, 2020 were reviewed by using Softalmo (Corilus, Belgium). This period ranging from week 12 to week 23 (ISO week date system) covered the French lockdown (from week 12 to week 19) and the four following weeks (from week 20 to week 23). Similarly, we reviewed records of children who visited this center from week 12 to week 23 of 2019 (from March 18 to June 9, 2019). The following data were collected: age, sex, spontaneous consultation or patient referred by another practitioner, consultation after an ocular trauma, circumstances of the trauma, final diagnosis, in- or out-patient management, medical or surgical management, and delay between the first visit and surgery. The diagnosis was usually found in the “Conclusion” section of the medical file. Data were collected by seven ophthalmologists, who first attended the same training to agree on how to report the data, especially the diagnoses. However, at the end of the data collection, a single investigator took a second look at the data to homogenize and limit the number of diagnoses.
Diagnoses were classified in the following groups: lesions after a related ocular trauma; infectious conjunctivitis; allergic conjunctivitis; chalazion and/or blepharitis; strabismus; neurological conditions (including migraines, optic neuritis, intracranial hypertension, and other causes of papilledema); functional symptoms related to ametropia (myopia, hyperopia, astigmatism); cellulitis or dacryocystitis; infectious keratitis; uveitis; normal examination; and rare diagnoses classified as “other” (endophthalmitis; retinal detachment; trigeminal varicella zoster virus; subconjunctival hemorrhage and/or punctate superficial keratitis and/or corneal ulcer and/or corneal foreign body without any related trauma; malformation or congenital conditions such as congenital cataract; scleritis and episcleritis; patient visiting the emergency department after a previous visit for the same reason or after ocular surgery).
The study followed the tenets of the Declaration of Helsinki, the French regulation on consent and sharing, and was approved by the institutional ethics committee (CE_20200602_5_CVT). Consent to participate in epidemiological studies was obtained orally from parents. Statistical analysis was performed with R (The R Foundation) using chi-squared, Fisher exact, and Student t tests. A value of p<0.05 was considered statistically significant.
3. Results
3.1. Epidemiological trends in pediatric ocular emergencies
Overall, 754 children were seen in our eye-related emergency department in 2020 and 1,399 in 2019, representing a 46% decrease in visits (Table 1 ). The decrease mainly occurred during the first 4 weeks of the lockdown period (Figure 1 ). The mean age of patients did not significantly differ between the two periods, but the proportion of boys was significantly higher in 2020 than in 2019 (60% vs. 53%, p<0.01). More patients visited the eye-related emergency department spontaneously in 2020 than in 2019 (p<0.0001).
Table 1.
Comparison of eye-related pediatric emergencies in an emergency department before and during COVID-19: 2019 and 2020
| 2019 | 2020 | p | |
|---|---|---|---|
| Pediatric visits:n (%) | 1399 (100) | 754 (100) | |
| Age: mean (SD), years | 7.05 (4.7) | 6.66 (4.9) | 0.07 |
| Males:n (%) | 747 (53) | 450 (60) | < 0.01* |
| Referred patients:n (%) | 231 (17) | 45 (6) | < 0.001* |
| Diagnosis | |||
| Trauma: n (%) | 422 (30) | 152 (20) | < 0.001* |
| Allergic conjunctivitis: n (%) | 205 (15) | 137 (18) | 0.04* |
| Infectious conjunctivitis: n (%) | 170 (12) | 67 (9) | 0.03* |
| Chalazion/blepharitis: n (%) | 170 (12) | 48 (6) | < 0.001* |
| Strabismus/ametropia/neurological condition: n (%) | 104 (8) | 53 (7) | 0.79 |
| Cellulitis/dacryocystitis: n (%) | 31 (2) | 22 (3) | 0.39 |
| Infectious keratitis: n (%) | 17 (1) | 19 (2) | 0.04* |
| Uveitis: n (%) | 11 (1) | 14 (2) | 0.04* |
| Other: n (%) | 186 (13) | 200 (27) | < 0.001* |
| Normal examination:n (%) | 83 (6) | 42 (6) | 0.81 |
SD: standard deviation
Figure 1.
Evolution of the weekly attendance in a pediatric ocular emergency department.
The number of visits was lower in 2020 (light blue) compared to 2019 (dark blue). The first 4 weeks of the lockdown were the most impacted.
All cases were classified in one of the diagnosis categories. In 2019, the four main diagnoses were traumatic injury (30%), allergic conjunctivitis (15%), infectious conjunctivitis (12%), and chalazion/blepharitis (12%). Although the number of patients presenting with traumatic injuries, infectious conjunctivitis, and chalazion/blepharitis was significantly decreased in 2020 (Figure 2 ), these four diagnoses still ranked as the most frequent. Visits for chalazion/blepharitis showed the greatest decrease, followed by traumatic injuries (−72% and −64%, respectively). The proportion of children presenting with allergic conjunctivitis was significantly higher in 2020 than in 2019 (18% vs. 15%, p=0.04) as was the proportion presenting with infectious keratitis or uveitis (p=0.04), but the absolute numbers of these conditions remained stable (19 vs. 17 and 14 vs. 11, respectively). The proportion of patients presenting with cellulitis or dacryocystitis remained stable. The proportion of admissions versus discharges did not significantly differ between the 2 years (3.3% in 2020 vs. 2.9% in 2019, p=0.6). However, the proportion of patients admitted for an infectious condition (cellulitis, dacryocystitis, infectious keratitis) was significantly lower in 2020 than in 2019 (12% vs. 35% of admitted patients, p=0.04).
Figure 2.
Evolution of the weekly attendance for traumatic injuries, infectious conjunctivitis, allergic conjunctivitis, and chalazion/blepharitis
The number and proportions of visits for each diagnosis in 2020 (blue) are compared with 2019 (green).
3.2. Focus on pediatric eye trauma
During the two periods in 2019 and 2020, traumatic ocular injuries were predominantly seen in boys (60% and 65%, respectively) (Table 2 ). The mean age of children presenting with a traumatic injury was significantly lower in 2020 than in 2019 (5.5 vs. 6.9 years, p<0.001). The proportion of children who underwent surgery for a traumatic injury was significantly higher in 2020 than in 2019 (14% vs. 6%), but the absolute number of these cases remained stable (21 vs. 24). The proportion of surgeries that were postponed for more than 1 day after the first visit was significantly higher in 2020 than in 2019 (38% vs. 17%, p<0.01). Most of the injuries were due to mechanical causes, with a predominance of hits (22%), falls (14%), and toy-related trauma (11%) in 2019. The proportion of hits was significantly lower in 2020 than in 2019 (13% vs. 22%, p=0.02), whereas that of plant/branch-related trauma was higher (15% vs. 8%, p=0.02). The proportion of chemical eye splashes did not significantly change, but that of injuries due to detergent or household product splashes was lower in 2020 than in 2019 (−47% and −50%, respectively).
Table 2.
Comparison of traumatic eye-related pediatric emergencies before and during COVID-19: 2019 and 2020
| 2019 | 2020 | p | |
|---|---|---|---|
| Post-trauma visits:n (%) | 422 (100) | 152 (100) | |
| Age: mean (SD), years | 6.9 (4.3) | 5.5 (4.4) | < 0.001* |
| Males:n (%) | 252 (60) | 98 (65) | 0.35 |
| In-patients:n (%) | 23 (6) | 13 (9) | 0.25 |
| Surgeries:n (%) | 24 (6) | 21 (14) | < 0.01* |
| Delayed surgeries:n (% of surgeries) | 4 (17) | 8 (38) | < 0.01* |
| Mechanical trauma:n (%) | 368 (87) | 124 (81) | 0.11 |
| Chemical eye splashes:n (%) | 50 (12) | 27 (18) | 0.09 |
| Thermal ocular burns:n (%) | 4 (1) | 1 (1) | 1 |
| Details of mechanical trauma: | |||
|
94 (22) | 20 (13) | 0.02* |
|
60 (14) | 23 (15) | 0.89 |
|
46 (11) | 10 (7) | 0.16 |
|
34 (8) | 23 (15) | 0.02* |
|
27 (6) | 7 (5) | 0.54 |
|
10 (2) | 9 (6) | 0.07 |
| Details of chemical eye splashes: | |||
|
15 (4) | 8 (6) | 0.50 |
|
10 (2) | 5 (3) | 0.56 |
|
5 (1) | 6 (4) | 0.08 |
SD: standard deviation
4. Discussion
This study reports the epidemiological features of pediatric ocular emergencies in a referral center in Paris, over a 12-week period in 2020 during COVID-19 and the corresponding time period in 2019. The study allows for an overview of the “pre-COVID” epidemiological trends and for a comparison with the “under-lockdown” observations. We report a 46% decrease in total number of visits during the lockdown period in our eye-related emergency department. A decrease in the absolute number of presentations of the same magnitude was reported in Europe [5], the United States [6,7], and Israel [8] at the onset of the pandemic.
The incidence of pediatric emergency department-treated eye injuries decreased even further in our center, with a 64% decrease between the study periods of 2019 and 2020 (422 vs. 152 cases). Halawa et al. reported a 25.9% decrease in the estimated incidence of emergency department-treated eye injuries in the United States over the whole year of 2020, especially in children [4], whereas Cavuoto et al. reported a smaller decrease in emergency department-treated eye injuries than overall consultations: 34% vs. 44% [7]. The incidence of emergency department-treated general injuries in children also decreased by 62% [9].
Out of the context of COVID-19, the most recent study on pediatric eye emergencies [10] reported a 44.4% rate of trauma, with a predominance of males (1.48:1) and an 8% proportion of trauma requiring surgery. In our series, the rate of trauma was slightly below that previously reported (30%) and might be explained by center characteristics [11]. We reported a similar sex ratio in this category (male:female 1.34:1). The male predominance in ocular trauma was close to that reported (1.34:1) and remained stable throughout the pandemic [10]. In 2019, we found a 6% proportion of trauma patients requiring surgery, which is close to the 8% reported by Ramsay et al. In 2020, we observed a significant increase in the proportion of emergency department-treated eye injuries requiring surgery (14%). However, the absolute number remained close and nonsignificant (24 vs. 21 cases). Halawa et al. reported an overall decrease in the number of eye injuries in the United States in 2020 versus prior years [4], especially in children, but a higher incidence of severe cases (ruptured globes, hyphemas, lacerations, orbital fractures). As reported in the study of Halawa et al., in France, patients with mild eye trauma were probably less likely to present to the emergency department because of the pandemic. However, because we did not find a significant increase in the absolute number of severe ocular trauma, we cannot conclude on any impact of certain potential changes in behaviors during the lockdowns. This observation could be due to a decrease in the overall number of visits, mostly affecting less severe trauma. We also observed a higher proportion of delayed surgeries in 2020 than 2019, probably because of the reduced availability of the operating room and anesthesiologists in our institution, who were recruited for the intensive care of patients with COVID-19.
After the pandemic outbreak, a few specific causes of general trauma were increased among children: domestic accidents involving firearm injuries [12], poisonings [9], burns [13], or dog bites [14] as well as cycling-related injuries [9,15]. Similarly, new risks for children's eyes might have arisen at this time. We found fewer cases of hits and more cases of trauma with branches, whereas the proportion of falls and toy-related trauma remained stable. The social restrictions may have limited altercation-related eye injuries. However, we did not distinguish the circumstances in which these injuries occurred (domestic, sporting events, altercation) because of lack of data, thus preventing the formulation of explanatory conclusions on potential behavioral changes during the lockdowns. Of note, we found a decrease in the number of ocular splashes related to detergent and household products in 2020, despite the longer time spent at home. This finding might be explained by a national prevention campaign by manufacturers, urged by multiple health alerts [16].
Regarding non-traumatic ocular emergencies, we did not find any study with pediatric epidemiology details before 2020. In our series, the four main diagnoses were similar to those reported in a French study [17] of adults (54.7% of trauma, 11% of infectious conjunctivitis, 6.3% of allergic conjunctivitis, and 4% of blepharitis). In the United States, ocular trauma accounted for 34%–52% of adult visits to eye-related emergency departments [11,18], followed by conjunctivitis (33.8%) and chalazions/hordeolum (4%), which remains close to our findings. An American pediatric series [6] assessing ocular emergencies over a 3-month period in 2020 reported similar leading diagnoses as in our study, without comparing the incidences with a similar period in 2019. We found a significant decrease in the proportion of visits for infectious conjunctivitis, most likely explained by the decrease in social interactions. The decrease in chalazion/blepharitis and normal examinations was accompanied by a higher proportion of visits for infectious keratitis and uveitis, albeit remaining stable in absolute numbers. These findings, as well as the higher proportion of severe ocular trauma discussed earlier, highlight that the pandemic and the lockdown policies seemed to have affected visits for benign ocular pathologies without leading to a decrease in visits for more severe conditions. This observation was also found for adults in a multicenter Italian study [5].
In our study, the proportion of in-patients was stable, although we could have expected more admissions in relation to the higher proportion of trauma requiring surgeries. This stability can be explained by a decrease in the proportion of children with infectious conditions admitted to hospital. During the COVID-19 period, cellulitis and infectious keratitis were more likely to be treated at home, probably because of the lack of availability of human and material resources in hospitals. This change does not seem to have been associated with any complications or poor outcome of these infectious conditions.
4.1. Limitations
The main limitation of the study is that it reports the data for a single center. In Paris, three referral hospitals have an eye-related emergency department open 24/7 to meet the needs of 2 million Parisians and 12 million inhabitants of the Ile-de-France region. An unpublished study conducted in 2017 reported that 67.5% of the children seen in these three emergency departments had in fact visited our hospital. Therefore, our data may represent a good sample of the pediatric eye-related emergency care given in Ile-de-France. However, the organization in other regions of France differs from that in Ile-de-France, with fewer specialized emergency departments and more frequent use of general emergency departments and general practitioners and ophthalmologists from private practice as primary care, even for emergencies. Moreover, our results are not transferrable to other countries, because every health system differs, as did the political management of the pandemic during the COVID-19 period.
Another acknowledged limitation is that the diagnoses were not homogenized in a limited list at the time of the visit, which leads to a risk of misinterpretation of the medical conclusions by the investigators reading the file afterward. This situation could explain the high proportion of diagnoses classified in the “other” section, as seen in most of the retrospective series reporting on the epidemiology of general and specialized emergencies. A comparison with an average of several years would have been more relevant than a comparison with 2019 alone. We could not consider this option, however, because of the time needed to check for the diagnosis in each medical chart. Nevertheless, Halawa et al. showed that the epidemiological trends in emergency department-treated eye injuries in 2020 significantly differed from the average during 2011–2019.
Comparing the observations between centers is difficult. The changing local characteristics of lockdown policies and enforcement added a level of complexity. In a single-center Israeli retrospective study of the general population, the patient demographics, distribution of diagnoses, and rate of admissions during COVID-19 did not change as compared with pre-COVID-19 data [8]. A multicenter Italian retrospective study of the general population found a larger proportion of males, lower proportion of eye inflammation, headaches, conjunctivitis, and blepharitis, and a higher proportion of trauma-related diagnoses during COVID-19 than during the pre-COVID-19 period but no significant change in the rate of admissions [5]. An American registry study estimated a higher incidence of severe injuries in March than in May 2020, probably because of the closure of schools and sports fields [6]. These discrepancies could be the result of varying methodologies or the effect of changing behaviors according to patient demographics and the surrounding epidemic, cultural, or political environment.
5. Conclusions
Our data indicate that pediatric ocular emergencies during COVID-19 seemed to follow the same epidemiological trends reported for adults. The COVID-19 pandemic affected the use of health resources in pediatric ophthalmology, lowering the number of consultations for benign causes, without affecting the number of presentations for more severe pathologies. This observation suggests that some public health educational campaigns could improve the management of benign pathologies, redirecting patients to general practitioners and ophthalmologists from private practice, thus saving specialized emergency departments for more severe conditions. During COVID-19, some infectious ocular pathologies were probably treated at home, with good results. It would be interesting to follow the evolution of these trends in the upcoming years.
Declaration of Competing Interest
None
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