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 Table of Contents  
Year : 2017  |  Volume : 110  |  Issue : 2  |  Page : 65-70

The effect of behavior disorders on ocular trauma and visual outcome in children in Middle Delta, Egypt

1 Department of Ophthalmology, Tanta University Hospital, Gharbia Governorate, Egypt
2 Department of Psychiatry and Neurology, Tanta University Hospital, Gharbia Governorate, Egypt

Date of Submission15-Oct-2016
Date of Acceptance09-May-2017
Date of Web Publication20-Jul-2017

Correspondence Address:
Rabab Elseht
Department of Ophthalmology, Tanta University Hospital, 6 Moheb Street, Tanta - 31111, Gharbia Governorate
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ejos.ejos_16_17

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We sought to study the potential effects of child behavior disorders as well as the psychological profile and parenting style in children with ocular trauma and evaluate their effects with other traumatic associates on the visual outcome.
This study was conducted at Tanta University Eye Hospital, Middle Delta.
Study design
This was a nonrandomized cohort study.
Patients and methods
This study included all children at least 6 years with ocular trauma admitted to the Ophthalmology Department, Tanta University, from June 2015 to January 2016. Children were evaluated with regard to age, sex, time of seeking treatment, type, site of injury, and causative agent of trauma. Psychological assessment was carried out at the child psychiatry unit objectively using Western Psychological Services programs after trauma. Best-corrected visual acuity was detected at the last follow-up visit after trauma and was correlated to the behavioral disorders of children and the traumatic associates.
In this study, we included 62 children aged 6–16 with an average±SD of 9.45±2.8 years. Among them, 71% were boys and 29% were girls (P<0.0001). Open globe injury was found in 37 eyes (59.7%), closed in 22 eyes (35.5%), and adnexal in three (4.8%). Single entry was a significant type of injury (P=0.0001), and sharp causative agents were many and variable. Certain psychiatric and parenting style problems were significantly associated with moderate and severe vision loss such as inattention, aggressive behaviors, attention deficit hyperactivity disorder (P=0.01), and oppositional defiant disorder with P=0.03.
Child behavior disorders and abnormal parenting style were significantly associated with ocular trauma in children. In addition, certain types and characters of trauma were effective in the visual outcome.

Keywords: behavior disorders, ocular trauma, vision loss after trauma

How to cite this article:
Elseht R, Seleem MA. The effect of behavior disorders on ocular trauma and visual outcome in children in Middle Delta, Egypt. J Egypt Ophthalmol Soc 2017;110:65-70

How to cite this URL:
Elseht R, Seleem MA. The effect of behavior disorders on ocular trauma and visual outcome in children in Middle Delta, Egypt. J Egypt Ophthalmol Soc [serial online] 2017 [cited 2018 Jul 21];110:65-70. Available from: http://www.jeos.eg.net/text.asp?2017/110/2/65/211140

  Introduction Top

Ocular trauma especially penetrating type is an important preventable public health problem worldwide [1]. Various studies have reported that 20–50% of ocular injury admissions were children [2]. Ocular injuries in children can be devastating and may result in the severe visual impairment that can affect the future of these children. Direct and indirect costs of ocular trauma are known to run into millions of dollars annually [3]. The incidence of self-inflicted injury has been reported to be as high as 1% of all childhood injuries [4]. McGwin et al. [5] stated that perhaps factors such as immature motor skills, carelessness, and uncontrolled emotions that are inherent in young children may cause injury compared with more preventable causes. Child neglect is defined as failure to provide needed, age-appropriate care, although financially able to do so. Children below the age of 15 years are frequently the victims of physical abuse or neglect requiring medical care and intervention by social services [6]. We aimed in this study to investigate the psychological profile of and parenting style followed for traumatized children and the circumstances of ocular trauma.

  Patients and methods Top

This nonrandomized cohort study included all children with ocular trauma aged 6–16 years admitted to the Ophthalmology Department at Tanta University Hospital in the period from June 2015 to January 2016. Children with minor ocular injuries were treated as outpatients, and those with past history of ocular operations or previous trauma were excluded from the study. Children aged less than 6 years were excluded according to the recommendation of the Western Psychological Tests.

All children were subjected to the following:

Detailed history taking (from parents or caregivers) including age, sex, place, and cause of trauma, causative agent, and time between occurrence of trauma and presentation to the hospital. Ophthalmological examination of the traumatic eye and further investigations such as ultrasound, ultrasound biomicroscopy, computed tomography scan, and MRI (in selected cases).

Data on the following were collected:

  1. The different types and characteristics of trauma whether closed or opened.
  2. Open globe injury was further subdivided according to the site of injury: zone I, an isolated corneal wound; zone II, full-thickness wound involving the sclera within 5 mm from the limbus; and zone III, full-thickness scleral wound posterior to zone II ([Figure 1]) [7].
    Figure 1 Yellow zone I: cornea wound, Red zone II: full-thickness sclera wound within 5 mm from the limbus, Blue zone III: full-thickness scleral wound posterior to zone II. Cited from Am J Ophthalmol 1997 [7]

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The best-corrected visual acuity

It was recorded indecimal form at the last follow-up visit 6 months after trauma in the affected eye using the Snellen chart. The visual outcome was categorized as follows: normal vision (0.8–1), mild vision loss (<0.8–0.3), moderate vision loss (<0.3–0.1), severe vision loss (<0.1–0.05), profound vision loss (<0.05–0.02), close to blindness (<0.02–0.01), and no light perception (NLP) [8].

The psychological profile and parenting style assessment

All children with ocular trauma and their parents were referred to the psychiatric specialists at Tanta University Hospital and they underwent the following tests:

  1. A validated Arabic version of the Child Behavior Checklist (CBCL) and validated version of the Conflict Tactic Scale − Parent–Child version were applied from Western Psychological Services by the authors to evaluate the study sample. It was translated into Arabic by the second author (M.A.S.) of the study. Both Arabic translation and blind back translation to English were presented and approved by the author before using the Arabic translation. Test–retest reliability was checked (after a 1-month period).
  2. The Arabic translation of the Stanford–Binet Intelligence quotient was used to access the intelligence quotient of children [9].
  3. The Fahmy and El-Sherbini scale [10] were used to collect demographic and socioeconomic data of families.

Statistical analysis

Statistical package for social sciences version 14.0 (SPSS Inc., Chicago, Illinois, USA) was used for analyses. Comparison of categorical variables was performed using the χ2-test and Fisher’s exact test. A value of P less than 0.05 was considered statistically significant.

  Results Top

We studied 62 children with ocular trauma, aged 6 to below 16 years with an average±SD of 9.45±2.8 years. They were 44 boys and 18 girls with a significant difference (P<0.0001). The different types of ocular injuries were as follows: closed globe injuries were found in 22 children (hyphema, subluxated cataractous lens, iridodialysis, choroidal effusion, and optic nerve avulsion), 37 cases had open globe injury, whereas the remaining three cases had adnexal trauma with low significant incidence (P=0.0001) (Plate 1)


The etiological types of open globe injury in 37 eyes were as follows: laceration in nine, a single entry in 25, blunt trauma in one case, intraocular foreign body (IOFB) trauma in one case, and IOFB with double perforation in another case. There was a higher significant incidence of the single inlet injury (P=0.0001) ([Figure 2]).
Figure 2 Different etiological types of open globe injuries

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The locations of open globe injury in 37 patients were as follows: zone I was detected in 16 eyes (43.3%), zone II was detected in 12 eyes (24.3%), and zone III was detected in nine cases (32.4%) with a nonsignificant predominant zone (P=0.3) (Plate 2 and [Table 1])

Table 1 Different types of ocular trauma in the study group

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The causative agents in ocular trauma

Sharp agents were the causative agents of trauma in 44 cases: knife (eight), glass (six), gun shots (two), animal bites (four), pencil (two), syringe (two), fireworks (two), falls (six), tree branches (two), iron nails (four), metal key (one), scissors (one), and bricks (four) ([Figure 3]).
Figure 3 Different types of sharp causative agents in penetrating ocular trauma

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Blunt agents were the causative agents of trauma in 18 cases: stones (four), balls gun (10), and wood sticks (four). Sharp agents were a significant cause of trauma compared with blunt ones (P=0.0009).

Circumstances related to ocular trauma

There was no significant difference with respect to place of trauma occurrence, indoors (26 children) or outdoors (36 children) (P=0.2). The places of trauma occurrence outdoors included streets, school, work places, wedding parties (fireworks), farms, and trains. The time between trauma occurrence and presentation to the hospital was early (first 24 h after trauma) in 34 children; however, late (after the first 24 h) presentation was found in 28 children with no significant difference in the time of presentation to the hospital.

Different categories of visual outcome after trauma

The final best-corrected visual acuity was detected in 62 children: normal and/or mild low vision in 18 cases, moderate low vision in 18 children, and severe low vision in 19 eyes. Profound low vision was detected in four eyes and NLP in only three eyes. These NLP cases included two eyes with double perforation and one eye with optic nerve avulsion. Cases with severe, profound low vision and NLP were merged into the severe group because of a small number of cases.

Psychiatric and behavioral problems were explored after trauma and compared across the three groups of visual outcome categories using the CBCL. Children with severe low vision showed significantly more problems with inattention and more aggressive tendencies as compared with those with mild and moderate vision loss (P=0.03).

Regarding CBCL problem parameters, children were more susceptible to be diagnosed with attention deficit hyperactivity disorder (ADHD) and ODD, which is characterized by displaying anger and irritable moods, as well as argumentative and vindictive behavior. These children had significant severe vision loss than mild and moderate loss (P=0.03 and 0.01, respectively).

Regard the ‘Conflict Tactic Scale − Parent–Child’ scores, families of children with severe visual impairment tended to use less nonviolent discipline in their lifetime than those in the mild and moderate groups (P=0.01). Using punishment that includes physical assault was associated with moderate and severe visual impairment in children with eye trauma (P=0.001) ([Table 2]).
Table 2 The significant educational and psychological disorders of children in relation to visual outcome categories after trauma

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There was a correlation between the different variables related to ocular trauma and the demographic data with different visual loss categories. Children with normal or mild vision loss were the younger (aged 6.6±2.9 years; P=0.003). Severe vision loss was significantly caused by sharp traumatic agents (P=0.001). The early presentation to hospital was significantly associated with severe vision loss. Intelligence quotient was normal in children, within the normative data for each age group, and it had no relation to the visual outcome after trauma (P=0.2) ([Table 3]).
Table 3 The visual outcome categories in relation to the demographics and different circumstantial variables of trauma

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  Discussion Top

This study included children exposed to ocular trauma with an average age of 9.45±2.8 years. This age range was reported to be at high risk of ocular trauma as detected by Thompson et al. [2], who also described a cohort study on children with ocular trauma aged 7 months to 14 years with full-thickness penetration eye injury. Their study results are similar to the results by Nelson et al. [11] and Moreira et al. [11],[12] that included children aged 0–7 years who were at a greatest risk of exposure to trauma. A study performed in Assiut, Egypt, by El-Sebaity et al. [13] found that the majority of ocular injuries in 150 children occurred in the age range from 2 to 7 years. The explanation was provided in a recent survey performed in Egypt, suggesting that 91% of Egyptian children aged 2–14 years experienced some sort of violent discipline (psychological aggression and/or physical punishment).

Harrison and Telander [14] suggested that the reason why children are predisposed to an eye injury was their gradual developing coordination and often daring manner of play rendering them more vulnerable to accidental trauma of all types.

Regarding cause of trauma, in our study, the percentage of self-assault was 82.3%; however, the value reported by others was 17.7% of cases. The higher incidence was due to a significant association of eye trauma and inattention, as well as the diagnosis of ADHD and ODD in the current study might be considered as a replication of the results founded by Bayar et al. [1].

In our study, boys with ocular trauma were significantly higher than girls; this is similar to a study by Ethier et al. [15], where boys with ADHD tended to pay attention and act without thinking. In addition, ODD shares many features, including aggression, impulsivity, and risk-taking behavior, with those subjected to child physical abuse. Ford [16] estimated that 91% of children with combined ADHD and ODD had a history of trauma. This observation is presumable as boys in our country are allowed to go outdoors more and also they undertake to certain hard jobs with the high physical contact.

The common causative agents of trauma recorded by Harrison et al. [14] were sharp agents such as knifes and scissors; this was coincident with our study that included 71% of sharp agents. These types of sharp agents were related to many scatter areas in our community and the availability of these tools without enough care or close supervision of children. In addition, there was a lack of care of using harmful toys in festival seasons or feast days and wedding parties such as balls guns and fireworks.

Other studies recommended that houses, playgrounds, and schools must be made safe and common items that can cause trauma such as sharp objects, household lime, and acids must be kept out of reach of children [17]. In the present study, there were two children injured by motor vehicle accidents such as crushed injury. In addition, none of the children were while practicing sports, in contrast to a study carried out in Italy that reported that 30% of pediatric eye injuries occurred during sports [18]. This may be explained by a lack of practicing sports in our community. Moreover, there may be a lack of awareness of prompt referral to ophthalmologists when needed than to emergency departments. Cases with late presentation were detected in large numbers. This was because children are less capable of identifying injury without bleeding. They are less likely to notice or report change of vision. Moreover, there was no importance on seeking early medical help by parents, teachers, and guardians.

In our study, the percentages of cases with mild and moderate low vision were similar, and severe vision loss was in higher (42%). This could be due to a high association of many psychological behavior disorders with children with ocular trauma and also the presence of higher percentage of open globe injuries with sharp agents. Others study in Iran was associated with lower incidence of severe low vision (<0.1%), and they explained this by the low aggressive behavior of children [19].

  Conclusion Top

Child behavior disorders and abnormal parenting style in children were associated significantly with ocular trauma. ODD and ADHD were significantly associated with moderate and severe vision loss. Certain types such as open trauma with sharp agents or IOFB were significantly associated with severe vision loss.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Bayar H, Coskun E, Öner V, Gkcen C, Aksoy U, Okumus S et al. Association between penetrating eye injuries and attention deficit hyperactivity disorder in children. Br J Ophthalmol 2015; 99:1109–1111.  Back to cited text no. 1
Thompson CG, Kumar N, Billson FA, Martin F. The etiology of perforating ocular injuries in children. Br J Ophthalmol 2002; 86:920–922.  Back to cited text no. 2
Adams G, Ainsworth J, Butler L, Bonshek R, Clarke M, Doran R et al. Update from the ophthalmology child abuse working party: Royal College Ophthalmologists. Eye 2004; 18:795–798.  Back to cited text no. 3
Nordberg E. Injuries as a public health problem in sub-Saharan Africa: epidemiology and prospects for control. East Afr Med J 2000; 77:1–43.  Back to cited text no. 4
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Colenbrander A. The functional vision score: a coordinated scoring system for visual impairments, disabilities, and handicaps. In: Kooijman AC, Looijestijn PL, Welling JA, Van der Wildt GJ, editors. Low vision: research and new developments in rehabilitation. Studies in health technology and informatics. Amsterdam: IOS Press; 1994: 552.  Back to cited text no. 8
Melika L. The Stanford-Binet Intelligence Scale, in Arabic Examiner’s Handbook. Cairo: Dar El Maref Publishing; 1998. 48–50  Back to cited text no. 9
Fahmy S, El-Sherbini AF. Determining simple parameters for social classifications for health research. Bull High Inst Public Health 1983; 13:95–108.  Back to cited text no. 10
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El-Sebaity DM, Soliman W, Soliman MA, Fathalla AM. Pediatric eye injuries in upper Egypt. Clin Ophthalmol 2011; 5:1417–1423.  Back to cited text no. 13
Harrison A, Telander DG. Eye injuries in the young athlete: a case-based approach. Pediatr Ann 2002; 31:33–40.  Back to cited text no. 14
Ethier LS, Lemelin JP, Lacharite C. A longitudinal study of the effects of chronic maltreatment on children’s behavioral and emotional problems. Child Abuse Negl 2004; 28:1265–78.  Back to cited text no. 15
Ford JD. Child maltreatment, other trauma exposure, and post-traumatic symptomatology among children with oppositional defiant and attention deficit hyperactivity disorders. Child Maltreat 2000; 5:205–17.  Back to cited text no. 16
Chakrabortil C, Giri D, Pal Ch, Mondal M, Datta J. Pediatric ocular trauma in a Tertiary Eye Care Center in Eastern India. Indian J Public Health 2014; 58:278–80.  Back to cited text no. 17
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Hosseini H, Masoumpour M, Keshavarz-Fazal F, Razeghinejad MR, Salouti R, Nowroozzadeh MH, Clinical and epidemiologic characteristics of severe childhood ocular injuries in Southern Iran. Middle East Afr J Ophthalmol 2011; 18:136–40.  Back to cited text no. 19


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3]


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