Journal of Emergencies, Trauma, and Shock
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Year : 2012  |  Volume : 5  |  Issue : 1  |  Page : 16-22
Different causes of referral to ophthalmology emergency room

Department of Ophthalmology, School of Medicine, Tehran University of Medical Sciences, Eye Research Center, Farabi Hospital, Tehran, Iran

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Date of Submission24-Aug-2010
Date of Acceptance24-Jul-2011
Date of Web Publication22-Feb-2012


Background: Eye-related complaints compose approximately 1-6% of complaints of patients referring to general emergency ward around the world. Eye injuries are the most common cause of referral to eye emergency ward. To understand the impact of eye injuries in Iran and to plan preventive strategies, it is important to understand the complete magnitude of the problem with regard to true population-based data and standard reproducible definitions. Aim: The main goal of this study was to identify the major causes of referrals to eye emergency ward in patients with eye-related complaints in an eye referral Hospital in Iran. Settings and Design: In a cross-sectional study, 3150 patients who referred to Farabi Hospital emergency ward, Tehran, Iran, from January to December 2007 were included in the study and their detailed information were recorded. Materials and Methods: The patients' demographic data, medical history and final diagnosis were recorded in a questionnaire. Results: The mean age of patients was 33.2±16.8 years and 2380 patients (75.6%) were males. While 299 patients (9.5%) were referred for non-urgent reasons, work-related injuries were the most common cause of referral (955 patients; 30.3%). In patients referred due to trauma (1950 patients), work-related injuries occurred in 955 patients (49%) and occurred accidentally (by chance) in 819 patients (42%). The majority of patients referred with traumatic injuries were males (1708 patients; 87.6% versus 242 patients; 12.4%). The most common etiologies of eye trauma (1950 patients) were metal filings (814 patients; 41.8%), blunt trauma (338 patients; 17.3%), fireworks (236 patients; 12.1%) and sharp objects (222 patients; 11.4%). Globe injury was diagnosed in 1865 patients (95.7%) of trauma cases. In patients referred due to non-traumatic reason (1200 patients), eye infection occurred in 482 patients (40.2%) and 299 patients (24.9%) were referred for non-urgent reasons. There was little difference between the frequency of non-trauma-related problems among genders (672 male patients; 56% versus 528 female patients; 44%). Conclusions: This study identified multiple risk factors whose presence significantly increases severity of an eye injury. Male gender, youth and unprotected eyes during high-risk activities such as sports and certain jobs are risk factors for eye injuries. In patients referred due to non-traumatic reasons, males and females are similar. Considerable proportion of non-trauma-related problems was due to eye infection, that one of the most important reasons may be connected to the increasing use of contact lenses in our target population. Thereupon, we need for further educative and preventive interventions at the level of general population.

Keywords: Eye, emergency, globe injury, trauma

How to cite this article:
Jafari AK, Bozorgui S, Shahverdi N, Ameri A, Akbari MR, Salmasian H. Different causes of referral to ophthalmology emergency room. J Emerg Trauma Shock 2012;5:16-22

How to cite this URL:
Jafari AK, Bozorgui S, Shahverdi N, Ameri A, Akbari MR, Salmasian H. Different causes of referral to ophthalmology emergency room. J Emerg Trauma Shock [serial online] 2012 [cited 2022 Jun 30];5:16-22. Available from:

   Introduction Top

Eye-related complaints compose approximately 1-6% of complaints of patients referring to general emergency ward around the world. [1],[2],[3],[4] More than 65,000 work-related eye injuries and illnesses are reported in the United States annually. [5] One study showed that 85% of these patients are less than 30 years-old, i.e., in the most productive years of their life. [6] This study also indicated that simple eye protection strategies such as using safety goggles have a significant role in declining the chances of severe eye injuries. Visual conditions can have substantial long-term effects on the quality of life of the subject, and can introduce a burden on public health resources, especially when occurring in children. [7]

People are at different risks for eye injuries, depending on factors such as their activities, jobs and protection methods they use. Apart from traumatic injuries, conditions such as using contact lenses can lead to eye infections, which may potentially result in complete blindness. [8] Other eye emergencies like glaucoma are also of high importance, and outcome of the disease severely differs if treated in a timely manner. [9] All in all, eye emergencies cause a noteworthy share of medical expenses and studying them is a cornerstone for developing local preventive and therapeutic programs. Regard the scarcity of such information in Iran, [10] this study was conducted to identify the major causes of patient referrals to eye emergency ward.

   Materials and Methods Top

In a cross-sectional study, detailed information about patients referred to Farabi Hospital, one of the oldest ophthalmology centers in Iran, from January to December 2007 were recorded. During these 52 weeks, 52 days were defined (with equal distribution within week days) as where an ophthalmology resident attended the emergency ward and recorded all required information in the given forms.

Informed consent was obtained from the patients. The study protocol was approved by the review board/ethics committee of Tehran University of Medical Sciences.

Demographic information including age and sex and details about the eye-related complaints and other variables such as involved eye, reasons for patient referral, their activity at the time of injury (if any), previous history of ophthalmic disorders or eye injuries, history of ophthalmic surgery, the use of eye protection, and need for hospitalization was filled in a questionnaire by interview. The types of eye injuries were defined according to the recommendations of the Birmingham Eye Trauma Terminology System (BETTS) [Figure 1]. [11] For non-traumatic causes of patient referral, a single diagnostic term was assigned that could explain the condition the best. This also applied for patients who were referred with a non-urgent condition such as refractive errors or cataracts.
Figure 1 - Birmingham eye trauma terminology system (BETTS) *The double-framed boxes show the diagnoses that are commonly used in clinical practice

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Patients with incomplete information in the questionnaire and those that refused to participate in the study were excluded. Data was acquired by interview before and during examination and patients were ensured about the privacy of the data in the beginning of the interview. They were also ensured that refusing to participate in the study would have no effect in the medical care provided to them.

Data was analyzed using SPSS version 13.0 for windows (SPSS Inc., Chicago, IL, USA).

T-test, χ2 test and Pearson's test for correlation were used and a P-value of less than 0.05 was assumed as statistically significant. Descriptive measures are shown as frequencies or as means±standard deviations.

   Results Top

We included 3150 patients in our study. They were aged between 0 and 85 years (33.2±16.8 years) and mostly in their third decade of life, [Table 1]. Seven-hundred and seventy patients (24.4%) were females and 2380 (75.6%) were males. Males were significantly younger than females (32.52±15.7 vs. 35.38±19.5 years, mean difference = 2.85 years, P<0.001); nevertheless, third decade of life was the most common age group in both genders (35.8% in males and 25.8% in females).
Table 1: Frequency of eye injury based on sex in different age groups

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While 299 patients (9.5%) were referred for non-urgent reasons, work-related injuries were the most common cause of referral (955 patients; 30.3%), followed by accidental (by chance) injuries (819 patients; 26.0%), and infections (482 patients; 15.3%), [Table 2].
Table 2: Different causes of referral to eye emergency ward

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In total, 1950 patients (61.9%) were diagnosed as eye trauma cases. Among these cases injury occurred during work in 955 patients (49%) and was accidental in 819 patients (42%), [Table 3]. In the 1200 patients (38.1%) with non-trauma problems; eye infections was the leading cause of referral (482 patients; 40.2%) followed by non-urgent reasons (299 patients; 24.9%) and eye inflammations (197 patients; 16.4%), [Table 4]. In both groups, most of the patients were in their 20s, [Table 5].
Table 3: Different causes of referral to eye emergency ward in trauma cases

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Table 4: Different causes of referral to eye emergency ward in non-trauma cases

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Table 5: Frequency of eye injury based on admission reason in different age groups

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While the majority of patients referred with traumatic injuries were males (1708 patients; 87.6% versus 242 patients; 12.4%), there was little difference between the frequency of non-trauma-related problems among genders (672 male patients; 56% versus 528 female patients; 44%). This yields an odds ratio (OR) of 5.54 of being male for traumatic injuries against non-trauma-related conditions. Also, unlike males in whom work-related problems and accidental injuries were the most common reasons for referral (949 patients; 39.9% and 602 patients; 25.3%, respectively), in female patients, accidental injuries and eye infections were the main causes of emergency care request, followed by non-urgent reasons and eye inflammations (217 patients; 28.2%, 192 patients; 24.9%, 134 patients; 17.4% and 107 patients; 13.9%, respectively), [Table 2].

Twenty-five percent of the patients (783 patients) referred to the emergency ward within 24 hours from the time of occurrence of eye problem. In patients with eye trauma, this figure was higher (714 patients of 1950; 36.6%), while it was much lower in patients with non-trauma-related problems (69 patients of 1200; 5.8%), (OR=9.46, P<0.001). Frequency of involvement of eyes was as follows: right eye in 1294 patients (41.1%), left eye in 1391 patients (44.1%) and both eyes in 465 patients (14.8%). Single eye involvement was seen in 93% (1814 patients) of eye trauma cases, but only in 72.6% (871 patients) of those with non-trauma-related problems, [Table 6].
Table 6: Frequency of eye involved side in trauma and non-trauma group

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In 11.1% (349 patients), history of previous eye diseases (excluding refractive error) was present and 20.9% (659 patients) mentioned a history of previous eye trauma. These figures were 2.2% (43 patients) and 27.0% (527 patients) for those referred with trauma, respectively. In the non-trauma group, 25.5% (306 patients) had a history of previous eye diseases and 11.0% (132 patients) had a history of previous eye trauma (P<0.001 for both comparisons), [Table 7] and [Table 8]. Also, 272 (8.6%) of patients had undergone eye surgeries previously, of which 239 patients (87.9%) belonged to the non-trauma group (P<0.001), [Table 9].
Table 7: History of previous eye disease in trauma and non-trauma group

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Table 8: History of previous eye trauma in trauma and non-trauma group

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Table 9: History of previous eye surgery in trauma and non-trauma group

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The most common etiologies of eye trauma were metal filings (814 patients; 41.8%), blunt trauma (338 patients; 17.3%), fireworks (236 patients; 12.1%) and sharp objects (222 patients; 11.4%). Exposure to chemical substances was the fifth common etiology (149 patients; 7.6%), [Table 10]. The most frequent chemicals were paste (38 patients; 25.5%), melted alloys (29 patients; 19.5%), acids (23 patients; 15.4%), battery contents (16 patients; 10.7%) and detergents (16 patients; 10.7%).
Table 10: Different etiologies of eye trauma

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Only 18.6% of patients who referred with trauma caused at work or during sport activity (186 out of 1002 patients) employed eye protection equipments. These included face shields, safety goggles and regular spectacles.

In the group of 299 patients who referred for non-urgent reasons, 162 patients (54.2%) believed that their condition requires emergency workup. Most of the others referred at a time when other eye clinics were closed (e.g., late night).

In trauma cases (1950 patients); in 1865 patients (95.7%), globe injury was diagnosed. Of whom 1739 patients (89.2%) had an injury to the globe exclusively, while 126 patients (6.5%) had an injury to the globe accompanied by an extra-global injury, [Table 11].
Table 11: Different diagnosis in trauma group

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In globe injuries (1865 patients), Mechanism of injury was mechanical in 1630 patients (87.4%) and non-mechanical in 235 patients (12.6%). Only 7.1% (116 patients) of mechanical injuries were open injuries. Chemical injuries were the most common etiology of non-mechanical injuries (149 patients of 235; 63.4%) followed by photic injuries (44 patients of 235; 18.7%) and thermal injuries (42 patients of 235; 17.9%). Comparison of these etiologies in males and females showed that mechanical closed injuries were by far more common from open injuries in males than female (OR=6.51, P<0.001) and among non-mechanical etiologies, thermal injuries were significantly more frequent in men than females (P=0.012), [Table 12]. Also, chemical injuries and open injuries were not seen in participants who used eye protection but interestingly, thermal injuries were seen in them.
Table 12: Different diagnosis in globe injuries

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In extra-global injuries (211 patients), eyelid and lacrimal system injuries were the most common type of injuries (190 patients; 90.1%) and comprised all of extra-global injuries in women. They were followed by orbital injuries (10 patients; 4.7%), injuries to eye muscles (6 patients; 2.8%) and extra-ocular injuries (5 patients; 2.4%), [Table 13].
Table 13: Different diagnosis in extra-global injuries

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In non-trauma cases, among 482 patients presented with eye infection, the most frequent diagnosis was conjunctivitis (189 patients; 39.2%), hordeolum (61 patients; 12.7%) and keratitis (60 patients; 12.5%), [Table 14]. Among 197 patients presented with eye inflammation, uveitis was the most frequent cause (41 patients; 20.8%). Allergic conjunctivitis and keratitis (contact lens-related) were the next most frequent cause of eye inflammation (38 patients; 19.3% both).
Table 14: Different causes of eye infection

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Among 299 patients who referred with non-urgent reasons the most common diagnosis was  Meibomian gland More Details dysfunction (62 patients; 20.7%). cataract and surgery follow-up (47 patients; 15.7% both) were the next in the order.

Fifty-three patients presented with glaucoma, of whom 26 patients (49.1%) had closed-angle glaucoma. Malignant glaucoma was seen in 6 patients (11.3%) and phacomorphic glaucoma was diagnosed in 5 patients (9.4%). The rest of them (16 patients; 30.2%) had uncomplicated open-angle form of the disease.

A total of 42 patients were diagnosed with vascular problems including sub-conjunctival hemorrhage in 20 patients (47.6%), branch retinal vein occlusion (BRVO) in 13 patients (31.0%), choroidal neovascularization (CNV) in 6 patients (14.3%) and central retinal artery occlusion (CRAO) in 3 patients (7.1%).

Ophthalmic complications of systemic diseases were noted in 37 patients. Diabetic retinopathy was seen in 21 patients (56.8%). Less frequent complications included hypertension-induced retinopathy in 7 patients (18.9%), uveitis caused by Behçet's syndrome in 6 (16.2%) and exophthalmos due to Graves' disease in 3 patients (8.1%).

Other causes of referral in non-trauma cases were diagnosed in 32 patients of whom 16 (50%) was central serous retinopathy, 10 (31.3%) retinal detachment, 4 (12.5%) acute hydrops due to keratoconus (KCN) and 2 (6.2%) was acute diplopia.

From the total of 3150 patients in the study, 2932 patients (93.1%) did not require hospitalization.

   Discussion Top

Our sample consisted of a wide variety of patients (aged from 0 to 85 years), referring with a broad spectrum of ophthalmological diseases and problems. Although eye-related complaints contribute to a significant proportion of emergency referrals around the world, epidemiological data about this group of patients is still scarce. The results of current study provide useful answers for that limitation.

Previous studies have reported the most common ophthalmic diagnoses in patients referred to emergency rooms. [12],[13],[14],[15] However, it should be noted that similar studies have been conducted in the setting of general emergencies but our study was conducted in Farabi Hospital which is specialized only for eye disease and its findings may be of more value when planning for similar hospitals in other countries.

Our findings suggest that males are at higher risk for traumatic injuries. In our study, 75.6% of patients were male but in a study in Singapore that investigated the epidemiology of work-related ocular accidents, 99.3% were male. [16] This was the same of our study.

In the present study, only 18.6% of patients with eye injury used eye protection devices. In Singapore study near to our finding only 21.4% of cases used some form of protective eyewear and 78.6% of patients did not use any protection. [16]

Since the leading etiology of referral in male patients was trauma happening at work, application of protective strategies for individuals working at high risk jobs can reduce the expenses and work load in emergencies significantly. Eye protection can also reduce the chance of getting blind. [4]

Eye trauma was among the most frequent chief complaints of our participants. It is also an important preventable etiology for blindness around the world, [17],[18] although little information is available about its epidemiology in most of the world including Asian countries. [17] Estimates of frequency and epidemiology of eye trauma vary based on the definition of trauma, and the source of information. From a public health point of view, vision threatening traumas are of superior importance; consequently, studies are often focused on open eye injuries and hospital discharge records. However, eye trauma cases can be mild enough to be handled as outpatient and be treated without any harm to visual acuity. In fact, open globe injuries comprise only a small proportion of eye injuries (5.9%) in our sample and 5% in another study. [19] In a study in Pakistan, open globe injuries comprised a significant number of the presentations. [18] Therefore, attention should be paid to other types of eye injuries, which are missed in the above mentioned studies, although they comprise a significant portion of work load of emergencies. Also, these injuries should gain more attention from public health authorities as they can be prevented with simple interventions like promoting the use of appropriate eye protection equipments at high risk jobs and during sports.

Our findings show that non-urgent problems cover a noticeable share of work load in emergencies centers. This indicates that emergency centers should employ appropriate triage systems to save their resources. Furthermore, the high prevalence of eye infections in our sample, which may be connected to the increasing use of contact lenses in our target population, signifies a need for further educative and preventive interventions at the level of general population. [20]

Thermal injuries were surprisingly common in participants who used eye protection at work. This implies that safety goggles used by these patients (who mostly worked with welding instruments) were not effective against thermal injuries. This group should use protective strategies beyond a simple "eyeglass type" personal protective device, and make sure that the device absorbs harmful wavelengths sufficiently. [4] A previous study on open globe injuries in northern Sardinia, Italy, showed that only 1.1% of their study population was wearing the correct protective equipment. [21]

During the analysis of the data, we noted that the rate of eye injuries caused by fireworks was increased in the last week of the year. The last Thursday of the solar year is named "Charshanbe-Soori" and is celebrated in Iran by fireworks. [10] Young adults (particularly males) set up firecrackers and use homemade grenades in this event, and despite nation-wide actions by the police and other authorities, this is usually accompanied with an increase in burns and eye injuries, mainly due to the use of non-standard toys or not observing safety measures. This study can shed some light for a advocating more strict controlling methods to prevent and reduce the morbidities and mortalities associated with this special situation ("Charshanbe-Soori" events). Such methods include education of youths in public media and highlighting the risk of non-standardized firework.

Our results reconfirm that male gender, youth and unprotected eyes during high risk activities such as sports and certain jobs such as Welding are risk factors for eye injuries. Also, workers in the factories exposed to different procedure and chemicals such as melted alloy are at such risk.

Development and implementation of prevention measures based on risk analysis should reduce the incidence of eye trauma. In the meantime, this information should be used for planning health programs both by public health decision makers and emergency centers.

   Conclusions Top

In this study according to the results mentioned above we came to some precious conclusions that could be very useful for health services to arrange special programs using preventive methods and reduce the burden of eye complaints.

Our findings demonstrated that work related injuries is the most reason of referring to eye emergency ward and could be prevented with simple measures such as protective eyewear. On the other hand, some cases had been referred to hospital because of eye injury despite they had been used some form of protective eyewear; it reveals that their eye wears did not effective. So it is very important to educate people about standard protective eye wear and encourage workers especially their employers to use these standard safety goggles or eye wears. Thereupon, if we consider simple preventive methods we can reduce work load considerably in emergencies. In this way we could have substantial reduction in treatment costs and morbidities especially blindness as well as significant increase in efficiency of emergency services.

In addition, we should educate people chiefly in schools to prevent many of eye morbidities. Education should be included some serious issues such as fireworks and using contact lenses.

Health care planners should consider proper training of general physicians to improve proper refer of eye injuries and reduce its burden.

In conclusion, this study reveals the significant role of preventive medicine and could be beneficial for public health authorities.

   Acknowledgments Top

The authors would like to thank Farzan Institute for Research and Technology for technical assistance.

   References Top

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2.Tsai CC, Kau HC, Kao SC, Liu JH. A review of ocular emergencies in a Taiwanese medical center. Zhonghua Yi Xue Za Zhi (Taipei) 1998;61:414-20.  Back to cited text no. 2
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4.Ramos MF. Prevention of work related injuries: A look at eye protection use and suggested prevention strategies. J Ophthalmic Nurs Technol 1999;18:117-9.  Back to cited text no. 4
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7.Visual impairment and use of eye-care services and protective eyewear among children-United States, 2002. Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep 2005;54:425-9.  Back to cited text no. 7
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9.Janz NK, Wren PA, Guire KE, Musch DC, Gillespie BW, Lichter PR, et al. Fear of blindness in the collaborative initial glaucoma treatment study: Patterns and correlates over time. Ophthalmology 2007;114:2213-20.  Back to cited text no. 9
10.Mansouri MR, Mohammadi SF, Hatef E, Rahbari H, Khazanehdari MS, Zandi P, et al. The persian wednesday eve festival "Charshanbe-Soori" fireworks eye injuries: A case series. Ophthalmic Epidemiol 2007;14:17-24.  Back to cited text no. 10
11.Kuhn F, Morris R, Witherspoon CD, Mester V. The birmingham eye trauma terminology system (BETTS). J Fr Ophtalmol 2004;27:206-10.  Back to cited text no. 11
12.Khare GD, Symons RC, Do DV. Common ophthalmic emergencies. Int J Clin Pract 2008;62:1776-84.  Back to cited text no. 12
13.Kumar NL, Black D, McClellan K. Daytime presentations to a metropolitan ophthalmic emergency department. Clin Experiment Ophthalmol 2005;33:586-92.  Back to cited text no. 13
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16.Ngo CS, Leo SW. Industrial accident-related ocular emergencies in a tertiary hospital in Singapore. Singapore Med J 2008;49:280-5.  Back to cited text no. 16
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18.De Juan E Jr, Sternberg P Jr, Michels RG. Penetrating ocular injuries: Types of injuries and visual results. Ophthalmology 1983;90:1318-22.  Back to cited text no. 18
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21.Pinna A, Atzeni G, Patteri P, Salvo M, Zanetti F, Carta F. Epidemiology, visual outcome, and hospitalization costs of open globe injury in northern Sardinia, Italy. Ophthalmic Epidemiol 2007;14:299-305.  Back to cited text no. 21

Correspondence Address:
Shima Bozorgui
Department of Ophthalmology, School of Medicine, Tehran University of Medical Sciences, Eye Research Center, Farabi Hospital, Tehran
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-2700.93104

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14]

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