Abstract
Background
Ocular prosthesis rehabilitation has an important social, psychological, esthetic, and functional role. Congenital factors, trauma, and tumors, among others, can cause anophthalmia, and it is essential to identify the etiology to guide its prevention and treatment.
Methods
The aim of this study was to retrospectively investigate the records of patients treated from 2013 to 2020 by the Oral and Maxillofacial Prosthesis Group, aiming to identify the prevalence of patients with anophthalmia and the etiology of their anophthalmia. After approval by the Human Research Ethics Committee, two calibrated researchers evaluated 520 records, identifying those from patients with anophthalmia. The inclusion criteria were records with complete and legible information from patients with anophthalmia and a description of their etiology. Descriptive statistics were performed, and etiological factors were categorized into trauma, congenital cause, end-stage eye disease, and tumor. Spearman's correlation was performed to verify the relation between gender and anophthalmia etiology, with a 5% significance level. Seventy-two records were included in the study.
Results
It was observed that 33.4% of patients were women and 66.6% were men. The etiologies were physical trauma (52.4%), tumor (21.8%), end-stage eye disease (16.6%), and congenital cause (9.2%), and there was no correlation between gender and these etiologies (p = .301).
Conclusion
Most of the cases identified were of traumatic origin, which allows the establishment of preventive and educational measures to avoid new cases of anophthalmia.
Keywords: Eye, Ocular prosthesis, Artificial eye, Anophthalmia, Eye diseases
Introduction
Facial deformities, such as anophthalmia, compromise esthetics and cause functional impairments, decreasing the quality of life and social acceptance of individuals. Traumatic injuries are the most frequent cause of anophthalmia, but other etiologies such as tumors, eye diseases (such as glaucoma), and congenital factors (such as microphthalmia) are also widely reported.1, 2, 3 Ocular prostheses can rehabilitate most of these cases, offering support for the remaining anatomical structures and satisfactory esthetic results.4
Modugno et al1 retrospectively evaluated 8018 patients with anophthalmia treated from 1927 to 2011 at a referral center in Rome, Italy. Most patients were men, and trauma was the most frequent etiology (63%).1 Wang et al5 analyzed the clinical characteristics of 2009 patients with anophthalmia treated for traumatic injuries from 2010 to 2014 in southern China. Traumas due to work accidents were the most frequent cause (39.6%), most of which were preventable.5
These diseases affect the population in general, but there are few studies that document the distribution of this problem in other regions of the globe, such as in smaller population centers.6 A detailed documentation of these patients about the etiologies leading to anophthalmia and the prevalence of those who use ocular prosthesis may indicate the places of need for intervention on preventive and educational policies, aiming to highlight this public health problem to the population.5,6
In this retrospective study, an epidemiological survey was performed, aiming to identify the prevalence of patients with anophthalmia and the etiology of their anophthalmia. For this, records of patients treated from 2013 to 2020 by the Oral and Maxillofacial Prosthesis Group were investigated.
Materials and methods
This study was approved by the Human Research Ethics Committee. A written informed consent was taken from all patients. Records of 520 patients treated from 2013 to 2020 by the Oral and Maxillofacial Prosthesis Group were analyzed. Two calibrated researchers were responsible for collecting the information from records of patients with anophthalmia. The following information was extracted from the records for data analysis: age, gender, and etiology that resulted in anophthalmia. Etiological factors were categorized into trauma, congenital cause, end-stage eye disease, and tumor.1
The inclusion criteria were records with complete and legible information from patients with anophthalmia and a description of their etiology. The exclusion criteria were incomplete records and absence records with absence of clinical data.1,7
Descriptive statistics were performed to analyze demographic data and to obtain the percentage of each anophthalmia etiology. Spearman's correlation was performed to verify the relation between gender and anophthalmia etiology, with a 5% significance level, by using a statistical software program (IBM SPSS Statistics, version 24.0).
Results
Among the 520 records of patients treated by the Oral and Maxillofacial Prosthesis Group, 112 were of patients with anophthalmia. After evaluating the inclusion and exclusion criteria, 72 records were included in the study. It was observed that 24 of them were women (33.4%) and 48 were men (66.6%), with an average age of 51 years.
Distribution of patients with anophthalmia according to etiology
Trauma injuries were the most common etiology for anophthalmia, affecting 37 patients (52.4%). Tumor was the second most common etiology, affecting 16 patients (21.8%), followed by end-stage eye disease with 12 patients (16.6%) and congenital cause with 7 patients (9.2%) (Fig. 1).
Fig. 1.
Etiological factors of anophthalmia in the patients included in the study.
Distribution of etiologies according to gender
When comparing the prevalence of etiological factors according to gender, a higher percentage of men were observed in all factors, except for tumor, which had a higher percentage of women (56.2%). Traumatic injuries showed the greatest percentage difference between genders, with a percentage of 67.6% for the male group (Fig. 2).
Fig. 2.
Percentage distribution of each assessed etiology, according to gender.
However, there was no correlation between gender and the studied etiologies (p = .301).
Discussion
Many studies report that world over trauma is the major cause of injuries to the eye, especially in large industrialized countries.1,5,8,9 The percentage found in this study (52.4%) is close to percentages reported in the literature - nearly 54% - although the present study was performed in a regional reference center. Traumatic injuries are associated with accidents that are often preventable, such as piercing with sharp materials, accidents with fireworks, and firearm injuries.1,5,10 The prevalence of trauma etiology was higher in men (67.5%), which can be explained due to a higher male performance in high-risk environments, such as extreme sports, automotive competitions, and tasks that require physical strength.1,6,11, 12, 13 However, some studies indicate that elderly women tend to have a greater chance of ocular trauma, when compared with men of the same age, due to a greater propensity for falls, which is related to a higher incidence of joint diseases and osteoporosis in women.5,14 In children, domestic accidents are the main cause of ocular trauma, while car accidents and sports are more frequent in young adults.15, 16, 17
The majority of traumatic eye accidents are usually due to negligence in the use of personal protective equipment (PPE) during labor work. Therefore, the instruction of employees and the provision of the necessary PPE are of great value to prevent future accidents and, consequently, anophthalmia. Lectures for the population and in the industrial environment can inform listeners on the importance of preventing this public health issue. For children, it is essential to avoid offering or allowing easy access to sharp instruments, such as knives, forks, scissors, or sharp surfaces.15,21 In the present study, the second most frequent cause of anophthalmia was ocular tumor (21.8%), with no correlation between gender and the etiologies (p = .301), corroborating with Modugno et al.1
Goiato et al4 evaluated the records of all patients with anophthalmia treated by the Oral and Maxillofacial Prosthesis Group from 1998 to 2010 in the same Oral Oncology Center evaluated in the present study. It was observed that patients with an ocular disease etiology showed a greater psychosocial improvement after rehabilitation with ocular prostheses when compared with patients with anophthalmia mutilated by traumatic causes. It is related that the first presented greater concerns in healing and avoiding the spread of ocular diseases and this may be one of the reasons that resulted in this more expressive improvement in their satisfaction and psychosocial profile.
For patients mutilated by trauma, the feelings of sadness, fear, and insecurity were the most reported. In this study by Goiato et al,4 a total of 40 medical records were analyzed, with 40% being women and 60% men. It was found that the etiological trend of eye loss over the period was 70% due to traumatic causes and 30% due to ocular diseases, a fact that agrees with the current survey. Thus, ocular trauma was the most common etiology reported until the year 2020.
However, several other ocular etiologies can result in this very important health problem, anophthalmia. Retinoblastoma and melanoma are the most frequent ocular tumors in patients with anophthalmia who use ocular prostheses and affect both genders. In the present study, the tumor types were not analyzed.
Terminal eye diseases were the third most frequent cause of anophthalmia (16.6%). Goiato et al15 found that glaucoma was the most frequent cause of anophthalmia in patients treated between 2001 and 2003 at the same treatment center evaluated in the present study. Glaucoma is a multifactorial eye disease caused by progressive damage to the optic nerve, which can increase intraocular pressure. It is one of the main causes of blindness and is also associated with etiologies of anophthalmia.2,10,18,19 Goiato et al15 also observed that congenital diseases (8%), retinoblastoma (4%), and toxoplasmosis (2%) were etiologies of anophthalmia. Therefore, it is possible to observe a change in the pattern of the distribution of anophthalmia etiological factors in the mentioned treatment center over the years. Possibly, this is due to the increase awareness about the center being a rehabilitation center where treatments are being carried out. These facts may have resulted in an increase in patient demand over the years and in a change in epidemiological data.
Congenital malformations were the fourth most frequent cause of anophthalmia (9.2%). Very common in neonates, malformations are diagnosed in the first days of life to avoid major disorders and, thus, blindness.20,21 Congenital cataracts and retinopathy of prematurity are important causes of blindness in children.1,20,21 Microphthalmia is also an important clinical condition, and, although it has a low incidence in the population, its early diagnosis is essential to reduce comorbidities and to improve children's quality of life.20 Thus, avoiding progression and treating these diseases early are necessary precautions to avoid future anophthalmia.20, 21, 22
It is important to understand that many of these injuries can be avoided and the public must be informed about this health problem. Preventive programs and media advertising are essential to prevent new cases of anophthalmia in the world.
Conclusion
Based on the research conducted, traumatic injuries were the most frequent etiological factor in patients with anophthalmia.
Disclosure of competing interest
The authors have none to declare.
Acknowledgements
(a) The authors thank FAPESP (Foundation for Support to Research of the State of Sao Paulo) (2019/07295-2) for the scholarship granted to the first author.
(b) This study was approved by the Human Research Ethics Committee of Aracatuba Dental School - UNESP (Number 16769219.0.0000.5420).
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