Abstract
Purpose
To evaluate demographic trends of open globe injuries (OGIs) using a large dataset representative of United States population.
Methods
Retrospective cross-sectional observational study using the National Inpatient Sample (NIS) database from 2002 to 2013. Only patients with a primary admitting diagnosis of OGI were included. Data included age (in years), gender, race, type of OGI, death rate and length and cost of stay.
Results
During the 12-year period, 27,467 adults (age > 20) with acute OGIs were admitted to the US hospitals. The incidence of OGIs in the adult US population was 10.6 cases per 1,000,000 persons. The mean age was 50.4 years (SD 21.52); the average ages of men and women were 44.34 (SD 17.63) and 65.69 (SD 22.77), respectively. Men accounted for 71% of all cases, with 84% of patients under 60. A decrease in the number of OGIs was seen with advancing age in men, whereas the opposite was true for women. Men, elderly over 80 and Blacks were at the highest risk of sustaining an OGI. The most and least common types of injuries were penetrating injuries (73%) and IOFBs (11%), respectively. Over half of young adults in the 21–40 cohort and 43% of men were uninsured (p < 0.001). The average length of hospital stay increased with age and was significantly much higher in women than men (3.4 vs 2.5 days).
Conclusions
Racial, gender and age disparities are prevalent in patients with OGIs. Although the majority of cases were seen in Whites and young men age 21–40 years, the incidence of OGIs per 1,000,000 persons per year was the highest in Blacks and Hispanics, elderly over 80, and men. One-third of all cases were uninsured. These disparities should be the basis of future public health safety measures.
Subject terms: Epidemiology, Education
Introduction
An estimated 200,000 globe injuries occur annually [1]. There are ~2.3 million people with bilateral blindness and 19 million with unilateral blindness or low vision as a result of ocular trauma in the developed world [1]. Previous studies have shown that most open globe injuries (OGIs) occur in young adults. Assaults, recreational and work-related injuries account for most ocular trauma in younger patients while falls are the main culprit for globe injuries in elderly patients. The incidence of OGI is much higher among men than women, especially young black men [2–5].
Most reports on ocular trauma are from individual tertiary care centres, mostly Level I trauma centres in urban settings across the United States. The reported outcomes may, therefore, lack broad applicability across different socioeconomic and geographic settings. Our aim with this retrospective observational study is to evaluate a representative sample of the United States population using the National Inpatient Sample (NIS) data from various community hospitals and tertiary care centres to describe the demographics, characteristics, types and incidence of OGIs throughout the United States.
Design
Retrospective observational study.
Participants
Data from the NIS.
Methods
This report is a retrospective cross-sectional observational study of adult subjects (age > 20 years) with a primary diagnosis of OGI in the NIS dataset who were hospitalised between calendar years 2002 through 2013. The NIS is created and operated by the Agency for Healthcare Research and Quality. The database contains discharge data from a sample of ~40 states, 1044 hospitals and more than 35 million hospitalisations. The database is gathered from the Healthcare Cost and Utilisation project, which is the largest collection of hospital care data in the United States with representation of more than 97% of the United States population. Data available in this database include ICD codes, patient demographics, primary and secondary diagnoses of admission, procedures performed during hospital stay, comorbidities, type of hospital setting, cost and payment source, length of stay and severity and comorbidity measures.
This population-based study focused on observations obtained from discharge data of inpatients with primary ICD-9 diagnosis of OGIs from 2002 through 2013. Only admissions with primary diagnosis of acute OGI and a concurrent procedure of globe closure or enucleation during the specific hospitalisation were included. Other variables recorded were patient age, gender, race, type of OGI (penetrating injury, intraocular foreign body (IOFB)) or rupture as described by the Birmingham Eye Trauma Terminology (BETT) classification [6], cost and source of payment and mortality during hospitalisation. The data were then adjusted using a weighting variable provided by the NIS Database (Link: https://www.hcupus.ahrq.gov/db/nation/nis/trendwghts.jsp). This correction is performed to account for unevenness in variables and to produce a more balanced representation of demographics and size of the groups. Chi-square, t-test and ANOVA analyses were completed as appropriate to check for differences in types of injuries and other variables of interest with regards to age, gender and race. The p value < 0.05 was chosen as threshold for statistical significance.
A fraction of the cases had missing demographic and pertinent characteristic data, including 0.8% cases without gender documentation, 21% without data on race, 0.7% without medical insurance status and 1.8% with no information on the type of OGI. The aetiology and the setting of injury are not given in the NIS database.
Results
During the period between 2002 and 2013, a total of 27,467 adult inpatients with primary diagnosis of OGI were identified. The mean age (in years) of all patients with OGIs was 50.42 (SD 21.52), with the average age of men, 44.34 (SD 17.63) that was much lower than that for women, 65.69 (SD 22.77).
Almost three-fourths (71%) of all OGIs seen in the 12-year period 2002–2013 were in males. The distribution of OGIs showed a decreasing trend in the number of OGIs with age in men but an increasing trend in the number of OGIs with age in women. Over three-fourths of adult patients with OGIs under 60 years were men, and three-fourths of seniors over 80 with OGIs were women [Table 1]. Adjusting for United States population, for age cohorts, 21–40, 41–60 and 61–80 years, the incidence of OGIs per 1,000,000 persons per year was 10.1, 8.2, 9.0, respectively; the incidence, however, dramatically increased for seniors over 80 years, to 34.1 per 1,000,000 seniors per year [Table 2]. Also, men were three times more at risk for open globes than women as evidenced in the incidence of acute OGIs per million persons per year to be 15.4 in men compared to 5.9 in women [Table 2].
Table 1.
Trends in race and gender by age group.
| Race | Gender | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| White | Black | Hispanic | Asian Pacific Islander | Native American | Other | p Value | Men | Women | p Value | |
| Age Group in years (n) | ||||||||||
| 21–40 (10,995) | 3303 (30.0%) | 1841 (16.7%) | 2641 (24%) | 149 (1.4%) | 114 (1.0%) | 520 (4.7%) | <0.001 | 9327 (84.8%) | 1558 (14.2%) | <0.001 |
| 41–60 (8118) | 3341 (41.2%) | 1543 (19.0%) | 992 (12.2%) | 149 (1.8%) | 70 (0.9%) | 271 (3.3%) | <0.001 | 6613 (81.5%) | 1412 (17.4%) | <0.001 |
| 61–80 (4461) | 2337 (52.4%) | 595 (13.3%) | 393 (8.8%) | 112 (2.5%) | 6 (0.1%) | 119 (2.7%) | <0.001 | 2426 (54.4%) | 2026 (45.4%) | <0.001 |
| 80+ (3893) | 2576 (66.2%) | 234 (6.0%) | 202 (5.2%) | 84 (2.2%) | 5 (0.1%) | 88 (2.3%) | <0.001 | 1017 (26.1%) | 2876 (73.9%) | <0.001 |
| Totals (27,467) | 11,557 (42.1%) | 4213 (15.3%) | 4228 (15.4%) | 494 (1.8%) | 195 (0.7%) | 998 (3.6%) | – | 19,383 (70.6%) | 7872 (28.7%) | – |
Table 2.
Incidence of Open Globe Injuries (OGIs) by age, race, and gender.
| Average number of OGIs per year (2002–2013) | Average NIS United States population (2002–2013) | Incidence (per 1,000,000 persons per year) | |
|---|---|---|---|
| Age group (years) | |||
| 21–40 | 916 | 82,315,638 | 10.1 |
| 41–60 | 676 | 82,576,119 | 8.2 |
| 61–80 | 372 | 41,180,442 | 9.0 |
| 80+ | 324 | 9,500,179 | 34.1 |
| 20+ | 2289 | 215,572,378 | 10.6 |
| Race | |||
| White | 963 | 139,882,981 | 4.9 |
| Black | 351 | 26,332,635 | 9.5 |
| Hispanic | 352 | 33,178,967 | 7.5 |
| Asian/Pacific Islander | 41 | 10,074,817 | 2.9 |
| Native American | 195 | 1,582,932 | 7.3 |
| Other | 998 | 3,571,378 | 16.5 |
| Gender | |||
| Women | 7872 | 111,376,337 | 5.9 |
| Men | 19,383 | 104,807,723 | 15.4 |
Average NIS United States population was calculated by averaging the population in that age/racial/gender group over the 12 years of the study.
The highest number of OGIs in the United States in the 12-year study period was seen in Whites (42%) followed by Blacks and Hispanics at 15% [Table 1]. However, when cases were adjusted for population in each cohort, the annual incidence of OGIs per million persons was observed to be the highest in Blacks at 9.5, followed by Hispanics at 7.5, Native American at 7.3, Whites at 4.9 and Asians at 2.9 [Table 2]. Blacks were at the highest risk of an OGI of all ethnicities.
Type of Injury
In all age groups, penetrating injuries accounted for ~70% or more of all OGIs. Penetrating injuries were also the most common type of injury in all racial groups and in both genders (p < 0.001). There was a slight predominance of rupture-type injuries in women vs. men (p < 0.001). The IOFB injuries were fourfold more prevalent in men (13.6%) than women (2.8%) (p < 0.001) [Table 3]. Of all races, Hispanics had the highest proportion of IOFBs (p < 0.001). This type of injury decreased with age and older patients over age 80 had IOFBs in only 1% of OGIs (p < 0.001).
Table 3.
Open Globe Injuries (OGIs) between 2002 and 2013 by age group, race, and gender.
| Total number of OGIs | Penetrating OGIs without IOFBs | IOFBsa | Ruptures | |
|---|---|---|---|---|
| Age group (years) | ||||
| 21–40 | 10,995 | 7647 (69.5%) | 1716 (15.6%) | 1444 (13.1%) |
| 41–60 | 8118 | 5795 (71.4%) | 961 (11.8%) | 1177 (14.5%) |
| 61–80 | 4461 | 3462 (77.6%) | 162 (3.6%) | 754 (16.9%) |
| 80+ | 3893 | 3157 (81.1%) | 37 (1.0%) | 649 (16.7%) |
| p value (column) | – | <0.001 | <0.001 | <0.001 |
| Race | ||||
| White | 11,557 | 8344 (72.2%) | 1166 (10.1%) | 1825 (15.8%) |
| Black | 4212 | 3130 (74.3%) | 268 (6.4%) | 722 (17.1%) |
| Hispanic | 4228 | 2978 (70.4%) | 703 (16.6%) | 486 (11.5%) |
| Asian/Pacific Islander | 494 | 365 (73.9%) | 41 (8.3%) | 76 (15.4%) |
| Native American | 195 | 145 (74.4%) | 10 (5.1%) | 40 (20.5%) |
| Other | 998 | 760 (76.2%) | 82 (8.2%) | 141 (14.1%) |
| p value (column) | – | 0.004 | <0.001 | <0.001 |
| Gender | ||||
| Women | 7872 | 6216 (79.0%) | 224 (2.8%) | 1307 (16.6%) |
| Men | 19,383 | 13,707 (70.7%) | 2632 (13.6%) | 2673 (13.8%) |
| p value (column) | – | <0.001 | <0.001 | <0.001 |
aIntraocular foreign body.
The sum of penetrating injuries, IOFB and ruptures may not equal the total number of OGIs because some OGIs were not coded for type of injury.
The average length of hospital stay was 2.79 days which progressively increased from a mean of 2.22 days for the 21–40 age group to 4.07 days for the over 80 group (p < 0.001). Women stayed significantly longer in the hospital than men (3.39 vs. 2.55 days) (p < 0.001) [Table 4]. Large disparity was apparent in the status of medical insurance with respect to age, gender and race. Only 46% of patients between 21 and 40 years of age and 56% between 41 and 60 had medical insurance compared to 92.6% of 61–80 and 98% of the over 80 group. By race, 59% of Hispanics, 38% of Blacks and 25% of Whites admitted with OGI lacked medical insurance. Only 60% of men compared to 88% of women were medically insured (p < 0.001). The average death rate during hospitalisation for a primary diagnosis of OGI was the highest, 0.8%, in the 61-80-year age group and less than 0.2% for all other adult age groups (Table 4). This rate was fourfold higher in women than men (0.85% vs. 0.2%; p < 0.001)
Table 4.
Length of hospital stay, insurance status, and mortality by age group, race, and gender.
| Total OGIs | Length of stay (days) | Insured | Uninsured | Death during hospitalisation | |
|---|---|---|---|---|---|
| Age group (years) | |||||
| 21–40 | 10,995 | 2.22 | 5056 (46.0%) | 5826 (53.0%) | 15 (0.1%) |
| 41–60 | 8118 | 2.51 | 4669 (57.5%) | 3400 (41.9%) | 5 (0.1%) |
| 61–80 | 4461 | 3.55 | 4130 (92.6%) | 316 (7.1%) | 35 (0.8%) |
| 80+ | 3893 | 4.07 | 3815 (98.0%) | 69 (1.8%) | 5 (0.1%) |
| Totals (row not included in Chi Square) | 27,467 | 2.79 | 17,670 (64.3%) | 9611 (35.0%) | 60 (0.2%) |
| p value (column) | – | <0.001 | <0.001 | <0.001 | <0.001 |
| Race | |||||
| White | 11,557 | 3.00 | 8551 (74%) | 2934 (25.4%) | 55 (0.5%) |
| Black | 4212 | 3.17 | 2547 (60.5%) | 1606 (38.1%) | 11 (0.3%) |
| Hispanic | 4228 | 2.44 | 1739 (41.1%) | 2489 (58.9%) | 5 (0.1%) |
| Asian/Pacific Islander | 494 | 2.06 | 359 (72.7%) | 135 (27.3%) | 0 (0%) |
| Native American | 195 | 2.56 | 110 (56.4%) | 80 (41%) | 0 (0%) |
| Other | 998 | 2.86 | 517 (51.8%) | 476 (47.7%) | 4 (0.4%) |
| p value (column) | – | <0.001 | <0.001 | <0.001 | 0.009 |
| Gender | |||||
| Women | 7872 | 3.39 | 6900 (87.7%) | 948 (12.0%) | 61 (0.8%) |
| Men | 19,383 | 2.55 | 10,639 (54.9%) | 8581 (44.3%) | 30 (0.2%) |
| p value (column) | – | <0.001 | <0.001 | <0.001 | <0.001 |
The average incidence of hospitalised OGIs per million persons per year between 2002 and 2013, as shown in Table 2, was much higher in men compared to women 15.4 vs. 5.9. Patients over 80 age had the highest incidence at 34.1 per million persons per year while patients 41–60 years of age had the lowest, at 8.2.
Discussion
The results obtained from this NIS population study are similar to findings from numerous unicenter studies across the country [2–4, 7–13]. Males accounted for a large majority, 71%, of all OGIs during the years 2002–2013. The highest proportion of OGIs was noted to occur in the age group 21–60 years. Males accounted for ~83.4% of OGIs in patients younger than 60 years of age; females accounted for three-fourths of all OGIs over 80 years of age. A possible explanation for this finding is due to the higher elderly female population compared to males in the age group over 80 per United States census data [14], though the higher incidence of OGIs after falls in elderly females cannot be dismissed as a contributing factor [15–20]. The overall incidence of acute OGI in men was 2.6-fold higher than that in women.
Racial analysis showed that the highest number of OGIs in the representative United States population sampled by the NIS data between 2002 and 2013 occurred in Whites (42%) followed by ~15 % in Hispanics and Blacks and 1.8% in Asians. This finding is in contrast to what is reported in the literature, that most OGIs occur in African Americans, especially among young patients in the 21–40 age group [2–5]. This discrepancy exists because our study analysed a population that is representative of the entire United States rather than one drawn from a single large tertiary care trauma centre. Number of OGIs yearly per million persons of a specific ethnic group is a better way to compare the risk of sustaining open eye injury amongst races. The average incidence of acute OGI per 1,000,000 persons, per year, by race, was the highest in Blacks (9.5), followed by Hispanics (7.5), Native Americans (7.3), Whites (4.9) and Asians (2.9). The racial disparity of OGI incidence, which is approximately twofold higher in Blacks and 1.5 times higher in Hispanics as compared to Whites, likely reflects socioeconomic differences in the groups that this study is unable to address.
The ICD-9 codes in the NIS data used the BETT classification diagnoses. The most common type of OGI was penetrating injuries (73.0%), and IOFBs were the least common type (11.9%). The penetrating type injuries occurred mostly in the 21–40 age group and in men. This finding is in concordance with reports in the literature that describe a predominance of penetrating injuries in young adults. In their exploration of assault and work-related OGIs, Bauza et al. found that three-fourths of their subjects with OGIs were males with penetrating injuries, and they were much younger compared to their female counterparts (mean age 35.66 vs. 50.43 years) [21, 22].
IOFBs were seen in 15% of cases in young adults (21–40 age group) and the incidence decreased with advancing age groups to account for only 1% of OGIs over age 80. The relatively low incidence of IOFBs in OGIs has previously been reported in the literature with rates ranging from 4% to 20.3% [23, 24]. The data from NIS show that over 90% of IOFB injuries tend to occur in patients younger than 60 years of age. OGIs in males had a fivefold higher chance to have an IOFB than OGIs in females. Racial stratification shows that Hispanic patients had the highest proportion of IOFB injuries (15.8%). The male predominance in ocular injuries with FBs is in line with previous studies. In their reviews, Li et al. and Liu et al. reported almost all (95–97%) of IOFB injuries in males. Such injuries typically occur in construction-related trauma, or in gun-related injuries. The setting of injury and the use of protective eyewear information are not available from the NIS data.
The length of hospital stay increased with increasing age, almost doubling for patients over age 80 compared to younger age cohorts. Women had significantly longer hospital stays than men (3.4 days vs. 2.5 days, respectively). By race, Asians had the shortest average length of hospital stay at 2 days, with Hispanics and Native Americans at 2.4 days, Whites at 3.0 days and Blacks at 3.2 days. This discrepancy may reflect previous healthcare data that have shown a higher prevalence of systemic comorbidities (e.g., strokes, prior myocardial infarctions, dyslipidaemia, diabetes and hypertension) in Blacks and Hispanics [25]. Furthermore, these disparities can be exacerbated by disproportionate healthcare access (lack of medical insurance, transportation to medical clinics, etc.) to underprivileged groups. Tielsch et al. found socioeconomic status to be an important predictor of visual function [26, 27]. The difference in prevalence and severity of comorbidities are seen in elderly with respect to gender and race [28]. This compounded with the higher incidence of fall related OGIs in the elderly female cohort [15–20] could explain the prolonged hospital stays in women compared to men.
The proportion of OGI patients medically insured increased with increasing age. Over 90% of patients over 60 years of age were insured, whereas approximately half of patients under the age of 60 years had no medical insurance. The NIS data are in concordance with United States Census regarding the racial and age disparities seen in medical insurance coverage. Medical insurance was noted in only 41% of Hispanics with OGIs, compared to 56% of Native Americans, 60% of Blacks, 73% of Asians and 74% of Whites in this study. The average insurance coverage from 1999 to 2010 per Census data [29] noted that average uninsured percent of population was highest for Hispanics (31.4%) followed by blacks (19.0%), Asians (16.3%) and lowest at 14.1% for Whites. The average percent of uninsured persons for age cohort over 65 was 1.4% with dramatic increase to 12% for persons 55–64 years of age, 14.2% for persons 45–54 years of age, 17.7% for 35–44 years cohort and 24.5% for individuals 25–34 years of age between 1999 and 2010 (United States Census). Men were also more likely to be uninsured than women in all age groups. The racial and age disparity seen in the NIS data could potentially be attributed to disparities in healthcare access and the lower socioeconomic status of these individuals who sustain OGIs in construction-related jobs or participate in high risk behaviours [30].
The parallel between increasing risk of sight threatening conditions and ocular trauma with decreasing socioeconomic status has been reported in the literature [27, 28]. Racial and socioeconomic backgrounds were noted to be independent determinants of visual impairment by Tielsch et al. and Sommer et al. [27, 28]. These findings have also been seen outside of the United States population. In studies of hospital admissions with ocular trauma in Scotland, Low et al. noted that patients with the least access to healthcare were twice as likely to present with ocular trauma and there was an increasing trend of ocular injury with increased socioeconomic deprivation [31]. Finally, a previous systematic review of the literature from 1946 to 2016 by Lane et al. also demonstrated the association of sight threatening conditions including ocular trauma with low socioeconomic background [32]. The potential socioeconomic factors of the population sampled should be considered in policy making efforts.
Death during hospitalisation acute OGI cases had a higher prevalence in women than men (0.8% vs. 0.2%), in the 60–80 age group compared to other groups (0.8% vs. 0.1%), and in Caucasians (0.5%) compared to Blacks (0.3%). The cause of death was not identified in the dataset. We suspect both pre-existing systemic comorbidities along with the event that led to OGI would have contributed to mortality.
The incidence of acute OGI per million persons per year was over 3 times higher for the over 80 group compared to the 21–40 group. In the literature, most OGIs in the older population are thought to be a result of falls [15–20]. Tahreem et al. notably observed an increase in the rate of fall related OGIs between 2006 and 2015 in their study from the National Emergency Department sample. The average age of patients presenting with falls is ~65 years and most fall related OGIs are seen in women [17–19]. These patients tend to present with longer wounds, suffer more severe complications, and have poorer visual outcomes.
Study limitations
The accuracy of the data depends on the coding personnel and can be error prone. Diagnostic and demographic data (age, gender, race, insurance status) were not consistently entered for all patients, for example, 20% of missing racial data in this study, can introduce bias in the results. This potential pitfall is however mitigated by the large sample size, and we expect the findings in this study can be replicated and is applicable to the United States population. We excluded any acute OGIs that were not simultaneously coded with globe repair or primary enucleation; this may have undercalculated the incidence of acute OGIs if the procedures were not coded or if the OGIs self-sealed. The laterality of the two eyes was not coded and our assumption that all codes referred to the injured eye may have introduced some error as well.
Conclusion
Young adults in the 21–40 age group sustained the highest number of acute open eye injuries in the United States in the 12-year study period, however, taking the cohort population into consideration, the elderly, over 80, were at the highest risk of being hospitalised for an acute OGI; the incidence rate of acute OGIs being threefold in the elderly (over 80) compared to young adults, age 21–40 years. The risk of acute OGIs in Black and Hispanic population was almost 1.5–2.0-fold that of in White. Most Hispanics and Blacks in young adult cohort with OGIs do not have medical insurance. These race and age disparities should be taken into consideration for future public health safety measures.
Summary
What was known before
High frequency of open globe injuries in blacks.
High frequency of open globe injuries in young.
What this study adds
Highest number of open globe injuries in whites however incidence is highest in Blacks and Hispanics.
High frequency in young <60 years of age and elderly >80.
Young males and elderly females are most affected.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
Footnotes
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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