Abstract
Objective
To determine the frequency, demography, aetiology and mechanisms of ocular injuries associated with childhood traumatic cataract in Nigeria.
Methods
A retrospective multicentre study conducted across ten child eye health tertiary facilities in Nigeria between January 2017 and December 2021. Clinic records of all children aged 0–17 years who had been diagnosed with cataract at the various participating centres were reviewed. Information collected include: biodata, mechanism of injury; laterality, place of injury; object responsible; person responsible; duration before presentation and surgical intervention.
Results
A total of 636 out of 1656 children (38.4%) had traumatic cataracts during the study period. Their mean age was 109.4 ± 45.2 months with a male-to-female ratio of 2:1. Most injuries were unilateral, two (0.3%) children had bilateral involvement. Only 78 (15.3%) children presented within 4 weeks of the injury. Closed globe injuries were responsible for the traumatic cataract in 475 (74.7%) children, while open globe injuries were more likely to present within 24 h (P < 0.001). The commonest objects of injury were cane, sticks, plant, wood and play materials. Self-inflicted injuries occurred in about 82 (13%) children while 407 (64.0%) were caused by close relatives and contacts. The location where trauma occurred was home in 375 (59.8%) and school in 107 (16.8%) children.
Conclusion
This multicentre study demonstrates that more than one-third of all childhood cataracts in Nigeria are trauma-related and majority are due to closed globe injuries. Public health interventions to reduce the occurrence of ocular trauma and to encourage early presentation after trauma are advocated.
Subject terms: Paediatrics, Trauma, Epidemiology, Eye manifestations
Introduction
Ocular trauma is the leading cause of unilateral blindness globally as well as in children [1, 2], and traumatic cataract is one of the major pathways to blindness following ocular trauma. The demography, mechanism and aetiology of ocular injuries leading to traumatic cataract vary from region to region [3].
Generally, ocular injuries occur more frequently in boys than girls [3–7]. However, across various geographical regions, there are similarities in the reported age of children with traumatic cataract. In a hospital-based study in upper Egypt, traumatic cataract in the paediatric age group was observed more commonly in children below 10 years of age [4]; which is similar to the mean age at occurrence in Eastern China and Nepal of 6.3 years and 9.46 years respectively [5, 6].
As regards mechanism of injuries, various objects have been reported in published literature. Sticks and sharp objects were the most common in a review of published literature, followed by fireworks, bows and arrows in India during festivals like Diwali [3] while in China [5] sharp metal objects, toys and sticks were the main causative agents. Place of domicile was also reported to affect prevalence of traumatic cataract as a review article noted that some studies reported higher prevalence in rural communities while others reported a higher prevalence in urban communities [3]. This lack of uniformity makes documenting local data important.
There is also no uniformity across studies on the association between types of trauma and occurrence of paediatric traumatic cataract. While some studies noted that cataract was more prevalent in eyes with open globe injury [4, 5, 8], a study from Nepal [6] and two reports from southwest Nigeria [9, 10] noted preponderance of closed globe injuries among the eyes that developed paediatric traumatic cataract.
Apart from the permanent disability, ocular trauma has a great impact on both the patient and society at different levels such as psychological trauma, cosmetic disfigurement, socioeconomic cost, and the need for specialized medical care and rehabilitation [4, 5]. The visual outcome of paediatric cataract surgery is grossly influenced by a number of factors notably, post-operative intraocular inflammation, posterior capsular opacification, amblyopia, and the presence of related eye injuries [4, 7]. Traumatic cataracts have a relatively higher risk of inflammation both before and after cataract surgery [7].
Understanding local causes and patterns of eye injuries has been recommended as an important step in the prevention of eye injuries [11]. Although a few hospital based studies have been conducted in Nigeria, a multicentre study provides nationwide generalizable evidence on the epidemiology of childhood traumatic cataract in Nigeria. This study, therefore, determines the frequency, as well as the demography, aetiology and mechanisms of ocular injuries associated with childhood traumatic cataract in Nigeria. The findings of this study will provide data that could inform the need to enact policies that could help in the prevention of ocular injuries in children in general and traumatic cataract in particular, as the majority of ocular injuries are potentially preventable [12].
Materials and methods
This was a multicentre retrospective study conducted across ten child eye health tertiary facilities in Nigeria from January 2017-December 2021. There was a uniform geographical spread with at least one centre from each of the six geopolitical regions of Nigeria. Children aged 0–17 years diagnosed with cataract at the various participating centres were included.
Ethical approval to conduct the study was obtained from the ethical review committee of all participating institutions and the study adhered to the declaration of Helsinki.
An electronic data survey collection tool (https://forms.gle/RGYeodL9RdoQthQP9) designed for the study was used to collect information from the clinical records of all children aged 17 years and below diagnosed with cataract. Information collected include: biodata, mechanism of injury; laterality, place of injury; object responsible; person responsible; duration before presentation and surgical intervention if done. Recognizable patient information was anonymised by using codes generated for the study instead of using the actual hospital records before entering into the survey forms.
Data analysis
The data was analysed using the StataÒ version 14.2. The proportion of eyes/persons with trauma-related cataract was obtained. This was subjected to analysis by age and sex to determine if there are any observable variations in pattern. Statistical significance was set at p < 0.05.
Results
A total of 1656 children aged 17 years and below were diagnosed and managed for childhood cataract during the period under review. Six hundred and thirty-six children (636) were diagnosed with trauma-related cataract accounting for 38.4% of all childhood cataracts. The mean age was 109.4 months SD ± 45.2 (age range: 1–220 months). Sixty-eight percent (n = 438) of the trauma-related cataracts were in males giving an overall Male: Female ratio of 2:1. Whereas, the ratio was 4:1 among children who were 15 years and above (Table 1)
Table 1.
Age-Sex distribution of children diagnosed with traumatic cataract in the study sites during the study period.
| Sex | Age group (years) n (%) | ||||
|---|---|---|---|---|---|
| 0–4 | 5–9 | 10–14 | 15+ | Total | |
| Male | 45 (10.4) | 179 (41.2) | 181 (41.7) | 29 (6.7) | 434 (68.2) |
| Female | 30 (14.8) | 81 (40.1) | 84 (41.6) | 7 (3.5) | 202 (31.8) |
| Total | 75 (11.8) | 260 (40.9) | 265 (41.7) | 36 (5.7) | 636 (100) |
| Ratio M:F | 1.5:1 | 2:01 | 2:01 | 4:01 | 2:01 |
Over eighty percent of the trauma-related cataracts were in children aged 5 to 14 years (82.6%; n = 525) Table 1. Most injuries were unilateral, left eye was affected in 339 (53.3%), right eye in 295 (46.4%) while both eyes were involved in two (0.3%) children. One of the bilateral cases was a male aged 14 years and the other a 6-year-old female; their injuries occurred from play materials handled by their friends during play at home.
Ninety one percent of children (n = 523) were taken to either a secondary or tertiary health care facility as first point of care while the remaining 9.0% were taken to either a primary health care facility (6.4%) or a patent medicine store (2.6%). The interval between injury and presentation to a tertiary eye care facility where definitive care is available ranged between 6 days and 12 years and a median of 380.6 days. Only 14.0% (n = 71) reported within 6 days; and 15.3% (n = 78) within 4 weeks. The commonest category of time of presentation was between one and 11 months after the injury (48.9%; n = 249) followed by presentation more than a year after the injury (21.8%; n = 111).
There were more cases of blunt ocular injuries as the cause of traumatic cataracts 475 (74.7%) than open globe injuries 160 (25.2%). There was one case of chemical eye injury 0.1% resulting in a cataract. Open globe injuries were more likely to present within 24 h (15%; 24 of 160) than closed globe injuries (6.9%; 33 of 475). This gave a statistically significant difference at 95% confidence interval (c2 = 83.57; P < 0.001).
The commonest objects of injury were cane, sticks, plant, wood and play materials 391 (61.5%) causing blunt eye injuries in 75% of children. The persons handling the objects were mainly close relatives and contacts 407 (64.0%) such as friends, family members and school staffers. Self-inflicted injuries occurred in about 82 (13%) children- Tables 2 and 3.
Table 2.
Persons responsible for the injuries and the objects causing the injuries.
| Object responsible | Person responsible n (%) | Total | |||||
|---|---|---|---|---|---|---|---|
| Friend | Family member | Self | School staffers | Uncertain | Others | ||
| Cane/stick/plant/wood | 66 (10.4) | 49 (7.7) | 31 (4.9) | 42 (6.6) | 34 (5.3) | 3 (0.5) | 225 (35.4) |
| Play materials | 142 (22.3) | 9 (1.4) | 10 (1.6) | 1 (0.2) | 4 (0.6) | 0 (0) | 166 (26.1) |
| Stone/Tiles/Wall | 18 (2.8) | 2 (0.3) | 6 (0.9) | 0 (0) | 8 (1.3) | 0 (0) | 34 (5.3) |
| Metal/needle | 11 (1.7) | 4 (0.6) | 13 (2) | 0 (0) | 5 (0.8) | 1 (0.2) | 34 (5.3) |
| Fist/hand | 19 (3) | 5 (0.8) | 0 (0) | 0 (0) | 4 (0.6) | 0 (0) | 28 (4.4) |
| Bag/Rope/plastic/Ball | 7 (1.1) | 2 (0.3) | 1 (0.2) | 0 (0) | 1 (0.2) | 0 (0) | 11 (1.7) |
| Belt | 2 (0.3) | 4 (0.6) | 0 (0) | 1 (0.2) | 1 (0.2) | 0 (0) | 8 (1.3) |
| Pen/pencil | 5 (0.8) | 0 (0) | 1 (0.2) | 0 (0) | 1 (0.2) | 0 (0) | 7 (1.1) |
| Others | 2 (0.3) | 2 (0.3) | 1 (0.2) | 0 (0) | 2 (0.3) | 4 (0.6) | 11 (1.7) |
| Unknown | 6 (0.9) | 8 (1.3) | 19 (3) | 0 (0) | 77 (12.1) | 2 (0.3) | 112 (17.6) |
| Total | 278 (43.7) | 85 (13.4) | 82 (12.9) | 44 (6.9) | 137 (21.5) | 10 (1.6) | 636 (100) |
Table 3.
Types of the injuries associated with traumatic cataract in the study subjects.
| Age group (years) | Type of injury n (%) | Total | ||
|---|---|---|---|---|
| Close globe injuries | Open globe injuries | Chemical injury | ||
| 0–4 | 49 (65.3) | 26 (34.7) | 0 (0) | 75 (11.8) |
| 5–9 | 181 (69.6) | 78 (30) | 1 (0.4) | 260 (40.9) |
| 10–14 | 217 (81.9) | 48 (18.1) | 0 (0) | 265 (41.7) |
| 15+ | 28 (77.8) | 8 (22.2) | 0 (0) | 36 (5.7) |
| Total | 475 (74.7) | 160 (25.2) | 1(0.1) | 636 (100) |
The settings where the trauma occurred were home 375 (59.8%) and school 107 (16.8%); during activities such as play 261 (41%) and flogging 88 (13.8%). Forty of these 88 children were flogged by school staffers and the others by family members-Table 4.
Table 4.
Settings where eye injuries occurred among the study subjects.
| Age group (yrs) | Settings where the injuries occurred n (%) | Total | ||||||
|---|---|---|---|---|---|---|---|---|
| Home | School | Farm | RTA | Market | Others | Unknown | ||
| 0–5 | 48 (7.5) | 7 (1.1) | 0 (0) | 1 (0.2) | 1 (0.2) | 0 (0) | 18 (2.8) | 75 (11.8) |
| 5–9 | 164 (25.8) | 51 (8) | 1 (0.2) | 1 (0.2) | 0 (0) | 2 (0.3) | 41 (6.4) | 260 (40.9) |
| 10–14 | 149 (23.4) | 47 (7.4) | 6 (0.9) | 1 (0.2) | 0 (0) | 2 (0.3) | 60 (9.4) | 265 (41.7) |
| 15+ | 14 (2.2) | 2 (0.3) | 1 (0.2) | 0 (0) | 1 (0.2) | 2 (0.3) | 16 (2.5) | 36 (5.7) |
| Total | 375 (59) | 107 (16.8) | 8 (1.3) | 3 (0.5) | 2 (0.3) | 4 (0.6) | 135 (21.2) | 636 (100) |
Objects of injury categorized as others include bottles, cow horns, and detergent. In older children (15+ years), skill learning workshops and places of worship (during play) were other places where injury occurred.
Discussion
This multicentre study demonstrates that about a third (38.4%) of all childhood cataracts in Nigeria are trauma related. This is higher than 18.8%, 27.1% and 25.6% previously reported from single centre studies in Calabar [7], Lagos [9] and Madagascar [13]. This disparity may be due to the multi-centre nature of this study compared to the previous studies. Also, contrary to our study, a higher figure of 63% has been reported from Ethiopia [14]. The retrospective nature of this study is associated with the limitation of missing records and therefore a prospective multicentre study will be useful in buttressing this finding as reported.
A preponderance of traumatic cataract among boys observed in this study is consistent with the literature that boys are more likely to have ocular injuries [4–16]. The unanimity in the literature may be connected with the fact that boys are more likely to engage in daring activities and rough play which may predispose them to eye injury. Over 80% of the children with traumatic cataract were between the ages of 5 years and 14 years (mean of 9.1 years). Similar mean ages of 9.1 years, 10.1 years and 9.4 years were reported among children with traumatic cataract by Musa et al. [9], Ugalahi et al. [10] and Randrianotahina et al. [13], respectively.
In this study, three-quarter of the traumatic cataracts were due to closed globe injuries. Previous studies from Nigeria also reported closed globe injuries to be more associated with childhood traumatic cataract. On the contrary, open globe injuries were reported to be more associated with paediatric traumatic cataract in studies from Egypt [4], China [5, 15], India [8], Turkey [16] and Malaysia [17]. This disparity may be a reflection of the variation in the common agents of injury which the children are exposed to in different geographical regions.
Late presentation was observed in this study with seventy percent of the children presenting months/years after the injury. Likewise, late presentation was a prevalent phenomenon in previous similar studies from Nigeria [7, 9, 10], This calls for concern as the possibility of developing stimulus deprivation amblyopia in these children is worsened by such delay with associated poor visual outcome following surgery [7]. Therefore, there is a need for eye health education campaigns to raise awareness on the need for early presentation and eye examination by an eye care provider when children have eye injuries and when parents/caregivers notice any whitish speck in the eye of a child [12]. Children with penetrating injuries were more likely to present within 24 h compared to closed globe injuries in this study. This could be due to the possibility of associated distortion of the eyeball and herniation of intraocular structures like uvea which could be frightening to the parents and caregivers.
Cane, stick, plants or wood were the most common agents of injury in this study. Similar objects were reported by Musa et al. [9] and Ugalahi et al. [10] as the agents responsible for paediatric traumatic cataract. In addition, friends were mostly responsible for the injuries followed by family members and self. Therefore, there is a need for parents and caregivers to ensure that children do not play with objects that could potentially cause injury to the eyes, especially at schools and at home, which were the most common injury settings in this study. Also, parents, teachers and caregivers should be encouraged to use non-corporal punishment instead of corporal punishment as a punitive measure when a child errs.
The outcome of surgery for traumatic cataract is not always optimal and has been reported as ranging from poor [18, 19] to satisfactory [16, 20]. Outcomes are worse in eyes with penetrating injuries [21] as well as other associated ocular injuries [22, 23], which may include corneal opacities, glaucoma, iris injuries and retinal detachment. In the bag implantation of intraocular lenses is also a challenge [24] in traumatic cataract with resultant complications of fibrinous uveitis. Occasionally such eyes may require multiple surgeries which increases the economic burden on the families and society as a whole.
The frequency of 38.4% of childhood cataract attributable to traumatic cataract observed in this study is high and has economic implications, which can be reduced by instituting preventive measures to reduce incidence of ocular injuries. Interventions such as promoting supervised play, public education and enlightenment campaigns targeted at both community and schools, and policies or legislation dissuading the uncontrolled use of cane at home and in school obviously will go a long way in preventing traumatic cataract in our environment.
In conclusion, traumatic cataract remains an important cause of childhood cataract in Nigeria. However, because patients with cataract resulting from trauma are more likely to present for treatment due to the pain which occurs following trauma, this may have contributed to the high number of patients with traumatic cataract compared to other aetiological causes such as congenital cataract. Cane, sticks, plants or wood were the most common agents of injury in this study and most injuries were sustained at home and in the school. A policy position that encourages non-corporal punishment and avoidance of play with objects both natural and synthetic that can cause ocular injuries is recommended nationally to reduce the incidence of childhood eye injuries and traumatic cataracts.
Summary
What was known before
Traumatic cataract, a complication of ocular injury, is one of the major pathways leading to blindness in children following ocular trauma. Although ocular injuries occur more frequently in boys, the reported age of children with traumatic cataract appears to be similar across various geographical locations.
Reported mechanisms of injury, objects causing injury, place of domicile where injury occurred, as well as association between types of trauma and paediatric traumatic cataract lack uniformity in documentation as regarding regional variations.
What this study adds
This multicentre study provides a proper documentation of the epidemiology of childhood traumatic cataract in Nigeria thereby giving the needed information which can be used to enact policies aimed at preventing the occurrence of paediatric ocular trauma in general and childhood traumatic cataract specifically.
Understanding the local causes and patterns of eye injury is an important step in the prevention of ocular injuries. Supervised play at home and enforcing non-corporal punishment in school will contribute significantly to reducing the occurrence of ocular injuries and traumatic cataract in children.
Author contributions
DAP was responsible for designing the study protocol, writing the proposal and report, extracting and analysing data, interpreting results and creating tables. NM was responsible for designing the study protocol, writing the proposal and report, extracting and analysing data and interpreting results. AM extracted and analysed data, interpreted results and provided feedback on the report. PW was responsible for designing the study protocol, writing the proposal and report, extracting and analysing data. IE was responsible for designing the study protocol, writing the proposal and report, extracting and analysing data. KOM was responsible for designing the study protocol, writing the proposal and report, extracting and analysing data and interpreting results. MU, EDN, NU and CNE contributed to data extraction and writing of the report. VWO was responsible for designing the study protocol, writing the proposal and report, extracting and analysing data and interpreting results. OAD, TEP, CRO, NME, AAS and HDM contributed to data extraction and providing feedback for the report. TO and BO also extracted and analysed data, interpreted results and provided feedback on the report.
Data availability
Data is available upon reasonable request
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data is available upon reasonable request