Injury, 5, 4 1 - 4 6 41

Eye injuries in road traffic accidents* K. G. S o n i West Norfolk and King's Lynn General Hospital, King's Lynn, Norfolk

Summary Sixty-four cases of road traffic accidents with eye injury were seen between January, 1966 and April, 1971.

Fifty-one of these cases were studied in detail. Most of the accidents involved frontal collision with

another vehicle and produced eye injuries to the un- belted driver or the front seat passenger.

Ninety per cent of the eye injuries in this series were caused by tempered glass windscreen. Perforating injuries that are bilateral or involve the expulsion of the lens at the time of accidents have the worse visual prognosis.

The mechanism of eye injuries is discussed. Most of the injuries can be prevented by wearing

safety belts and installing high penetration resistant laminated glass windscreens.

EACH year a quarter of a million people all over the world are killed on the roads. This is equivalent to one fatal accident every 2 minutes all the year round. Many more are seriously injured and often the injuries include serious ocular trauma. In Britain, road traffic statistics show that 90,719 people were seriously injured and 7365 people killed on the roads in 1969. No reliable statistics are available for the incidence of eye injuries, but different authors (Kenney, 1964; MacKay, Siegal, and Hight, 1970) put this figure at 4.5-9 per cent of the injured. The injuries sustained are fre- quently multiple. The incidence of accidents is reported to be greatest between the ages of 10 and 40 years.

Reports f rom Germany (Holland, 1965, 1970; Junghannss, 1967; Meyerratken, 1967) and France (Pouliquen and Defoug, 1969; Renard Bregeat, and Offret, 1970) indicate an increasing incidence of eye injuries caused by the tempered or toughened glass windscreens. British Standard

*Paper presented at The Royal Society of Medicine, 21-22 May, 1971.

857 of 1967 permits the car manufacturers to fit either zone tempered or high penetrat ion resistant laminated glass windscreens to cars in this country. In practice, 95 per cent of British cars are fitted with zone tempered windscreens. These windscreens tend to fracture into small fragments on impact. In contrast, high penetration resistant laminated windscreens are more

20

15

¢- a3

IO ,.~

0 Z

5 4 3 2 I

"O ~O ",O,,O -O O~ O~ O.~O~ ",4 O~ ",,I ~ ,,O O

Year Fig. l .--Yearly incidence of injuries resulting from road traffic accidents 1966-70.

resistant to penetration and usually show only localized starring at the area of impact.

This study concerns the cases of road traffic accidents seen at the Birmingham and Midland

42 Injury : the British Journal of Accident Surgery Vol. 5/No. 1

Eye Hospital from January, 1966 to April, 1971 and deals with the various aspects of these cases.

P R O C E D U R E

Sixty-four cases were recalled to answer a questionnaire and for examination, and 51 of these attended.

Patients whose visual or oculomotor distur- bances were due to intracranial injury were excluded from this study.

RESULTS Incidence Age and sex There were 47 males and 17 females. Forty-one of these patients (64 per cent) were between the ages of I 1 and 30 years (Table I).

Year Fig. 1 shows the incidence of road traffic accidents from 1966 to 1970. The lowest incidence was in 1967, the year when legislation against 'drink and dr ive ' was introduced. Twelve cases had occurred between January and April, 1971.

M o n t h of the year There were more cases in March (Fig. 2).

Day of the w e e k Sixty-four per cent of the accidents occurred over the weekend (Fig. 3).

20

20

15

8. "6 IO

I CASES DURING 1966-70

5 4 3 2 1

~ N

Month of the yeor

Fig. 2.--Frequency of injury related to the month of the year.

. 15

"8-- B. "6

O - 4 Z Z

0Oy Of the week Fig. 3.--Frequency of injury related to the day of the week.

Table/.--Age and sex distribution of the injured patients seen at the Birmingham and Midland Eye Hospital from January, 1 966-April, 1971

Age in years Sex 0-10 11-20 21-30 31-40 41-50 51-60 61 and Total

o ver

Male 3 15 17 6 2 2 2 47 Female 2 3 6 3 1 1 1 17

Total 5 18 23 9 3 3 3 64

Soni : Eye Injuries in Road Traffic Accidents 43

T ime of day As the t ime o f day when the accident occurred was not always recorded, only 51 patients were considered. Table I I shows that 13 accidents occurred dur ing the day, 34 at night, and 4 at dawn or dusk. Thus accidents producing injuries are more common at night and this is confirmed by the Minist ry of Transport Road Accident Statistics for 1969.

Class of road user O f the 51 injured, 50 were car occupants and I was a pedestrian. Only 2 o f the car occupants, a driver and a front-seat passenger, were wearing

Table/L--Time of accident

Time of accident No. of patients

During the day 13 During the night 34 Dawn or dusk 4

Total 51

Table IIl.--Sex distribution

Category of road user Sex Front-seat

Driver Pedestrian Total passenger

Male 22 14 1 37 Female 3 11 0 14

Total 25 25 1 51

safety belts. There were 50 drivers, 34 front-seat passengers, and 7 back-seat passengers. Twenty- five drivers and 25 front-seat passengers received eye injuries. Eighty-eight per cent of the drivers and 56 per cent of the front-seat passengers were males (Table III).

Type of acc iden t In 94 per cent the type of accident was frontal (Table IV).

Objec t s t ruck Table V gives, in order to frequency, the object struck by the crashing vehicle.

I n j u r i e s These are discussed under two major headings:

1. Eye injuries. 2. General injuries.

Eye in jur ies Forty-five cases were injured by glass from the shattered windscreen.

Eyelids The eyelids were usually injured in multiple fashion with lacerations and many tiny abrasions containing small glass foreign bodies. Frequently the lacerations were horizontal involving both upper lids and the bridge of the nose. Other lacerations were oblique involving an eyebrow, the bridge of the nose, and the contralateral eye- lids. Vertical lacerations also occurred. In 3 cases both upper and lower canaliculi were divided and in 1 case the lower canaliculus alone was involved.

Table/V.--Type of accident

Type of accident No.

Front 32 Front right corner 6 Front left corner 10 Left side 1 Roll over 1

Table V.--Object struck by the car

Object No.

Another car 24 Commercial vehicle 10 Lamp post 5 Tree 4 Telegraph post 2 Metal barrier 1 Road bank 1 Motor-cycle 1 Pedestrian 1

Tota I 49

In only 5 cases in this series were there no injuries to the globe and of these 1 had involvement of the superior oblique tendon.

Orbit There was 1 case of ' b low-out ' fracture and 2 cases of optic atrophy due to retrobulbar haemor- rhage.

Ocular injuries Fifteen patients had bilateral involvement and 2 patients had bilateral perforating injuries. These 2 patients did badly; the first patient had one eye enucleated and the remaining one is aphakic with 6/18 vision. The second case has one aphakic eye with 3/60 vision and one aphakic eye with 6/12 vision.

Non-per forat ing injuries (26 eyes) Twenty-four of these were corneal, 1 was scleral, and there was 1 traumatic macuiopathy with

44 Injury : the British Journal of Accident Surgery Vol. 5/No. 1

subsequent development of a macular hole. Corneal injuries were of 3 types:

I. Corneal abrasions with or without foreign body in the fornix: 8 cases.

2. Non-perforating corneal laceration : 7 cases. 3. Corneal lacerations with multiple glass

foreign bodies embedded in the corneal stroma: 9 cases.

Table V/.--Incidence of general injuries

Incidence No.

Multiple facial lacerations 36 Fractured parietal bone 1 Fractured maxilla 4 Fractured nose 2 Fractured ribs 1 Hand or wrist injury 7 Knee injury 13 Fractured tibia 1 Ankle injury 1

Perforat ing injur ies These consist of 10 corneal, I scleral, and 24 corneoscleral perforations. The incidence of associated features was:

1. Uveal prolapse in 29 eyes. 2. Full hyphaema in 2 eyes. 3. Glass foreign body in the anterior chamber

in 3 eyes. 4. Lens damage in 8 eyes. 5. Lens expulsion at the time of injury in 12

eyes. 6. Vitreous prolapse in 19 eyes. 7. Retina in the wound in l eye. There was no predominant direction for the

lacerations.

General in jur ies Table VI sets out the frequency of these injuries. Multiple facial lacerations were most frequent.

In only I case was there an intracranial injury. Knee or wrist injuries occurred in 20 cases.

Late c o m p l i c a t i o n s These were frequent and often multiple. It is noteworthy that the 6 excised eyes and the I phthisical eye had all expelled the lens at the time of injury. There was no case of intraocular infection or sympathetic ophthalmitis.

Visual results These are shown in Table VII. It can be seen that perforated eyes had a worse prognosis.

D I S C U S S I O N Recent research in Europe (Holland, 1965, 1970; Junghannss, 1967; Meyerratken, 1967; Pouli- quen and Defoug, 1969; Renard and others, 1970) has shown an increasing incidence of ocular injuries due to tempered glass windscreens. There, as in this country, the majority of cars are fitted with tempered windscreens. Canada, Norway, Sweden, and the United States, however, have regulations making the use of high penetration resistant laminated glass windscreens compulsory. In this series, 45 victims (90 per cent) mentioned the head or face striking the windscreen and breaking it, and in 12 cases glass foreign bodies were retained in the globe.

Patrick, Trosien, and Dupont (1970), working with anthropomorphic dummies, and in some cases with cadavers, as occupants under simu- lated accident conditions, found high penetration resistant laminated glass windscreens superior to differentially tempered windscreens, the type currently in use in this country.

MacKay, Siegel, and Hight (1970) compared a large series of cases drawn from Birmingham (United Kingdom) and Los Angeles (California), and confirmed Patrick's experimental results in a clinical situation. Further, they found no eye

Table V//.--Final visual results in 61 eyes with injury into the globe

Final visual result Type of injury Eye Blind Light perception Total

excised eye 6/60 6/60 6/36 6/24 6/18 6/12 6/9 6/6 or better

Number of eyes with non-perforating injury 0 0 3 0 0 1 0 1 1 20 26

Number of eyes with perforating injury 6 1 6 0 1 3 3 4 3 8 35

Total 6 1 9 0 1 4 3 5 4 28 61

Soni: Eye Injuries in Road Traffic Accidents 45

injuries in the Los Angeles sample, while the Birmingham sample included 4 cases of eye injuries with one enucleation.

M E C H A N I S M OF I N J U R Y The probable mechanism of eye injuries is very similar to that described by Huelke, Grabb, and Dingmann (1966) for facial lacerations. At the time of frontal collision the car hits a relatively immovable object and comes to a halt almost immediately. The unbelted car occupant is thrown forward and the knee or hand strikes the instrument panel or glove compartment. This stops the forward movement of the lower half of the body, and carries the upper half of the body in an arc around the pivot formed by the area of contact. The head or face hits the windscreen and in the case of a tempered glass windscreen usually breaks it. The action of the head after going through the windscreen is called ' plough-in ' and most injuries are produced during it by the head hitting the lower edge of the broken windscreen. In addition small fragments of glass from the shattered windscreen pepper the face. Patrick and others 0970) have shown the same sequence of events using anthropomorphic dummies and high speed cinematography.

I N C I D E N C E This series shows a steady increase in the number of eye injuries over the past few years. As in the series from Europe most of the injured are young males between the ages of l0 and 30 years. There are relatively more accidents over the weekends (64 per cent), and in March (17 per cent). Sixty-six per cent of the accidents occurred at night. This series and road statistics (H. M.S.O., 1969), indicate that a higher proportion of injury-producing acci- dents occur at night. Headlamps, by reducing the effective field of vision may be a rather important cause of accidents. Alcohol, fatigue, and high speed are contributory factors. The front-seat car occupant (98 per cent) is practically always injured and the accident is usually a frontal collision (94 per cent).

I N J U R I E S Eyelid and eye injuries are frequently extensive, multiple and bilateral (30 per cent in this series). In no other form of trauma is the simultaneous involvement of the face, the eyelids, and the globe so frequent. There was a very low incidence of associated head injury (2 per cent) in this series. Holland (1970), has also remarked on the low incidence of head injury.

The visual prognosis is poor due to extensive initial injuries and frequent later complications. In this series, 1 out of every 6 eyes with perforating injury was enucleated. Similar results were reported for all types of perforating injuries by Roper-Hall (1967).

P R E V E N T I O N The number of eye injuries could be reduced substantially by the use of safety belts. The serious nature of these injuries could be further reduced by the use of high penetration resistant laminated glass instead of toughened glass windscreens.

A survey carried out (H.M.S.O., 1969) showed that only about 28 per cent of the drivers and front-seat passengers wear safety belts on the motorways, and in built-up areas the figure falls to as low as 8 per cent. It is imperative to increase safety belt acceptance by the public.

C O N C L U S I O N S 1. There was a steady increase in the number of

eye injuries over the five years 1966-71. There was a higher incidence during spring, and the week- ends accounted for 64 per cent of the accidents.

2. Two-thirds of the accidents occurred at night.

3. Most of the injured were males between the ages of 10 and 30 years. Unbelted front-seat car occupants were practically the only category of road user injured.

4. The injuries were usually multiple and bi- lateral and involved the eye, the eyelids, and the face.

Eye injuries should be regarded as serious and should the eye sustain a perforating injury, there is a 1 in 5 chance of losing the vision completely, and only a l in 3 chance of retaining good vision. In addition, facial and lid injuries can produce disfiguring scars.

5. Head injury, other than the eye and facial lacerations, occurred only in one case (2 per cent).

6. Only 4 per cent of the injured were wearing safety belts and 90 per cent of the injuries were caused by shattered zone tempered glass wind- screens.

7. Most of the ocular injuries can be prevented or minimized by wearing safety belts and using high penetration resistant laminated glass wind- screens.

A c k n o w l e d g e m e n t s [ wish to thank the consultants of the Birmingham and Midland Eye Hospital for allowing me to study their patients. In particular, I would like

46 Injury : the British Journal of Accident Surgery Vol. 5 /No. 1

to thank Mr. W. Martin Walker and Dr. G. M. MacKay for their assistance and valuable suggestions, Mr. J. D. Drury for preparing the figures, and Mrs. P. G. Brooks for secretarial help.

REFERENCES H.M.S.O. (1969), Road Accidents. London: H.M.S.O. HOLLAND, G. (1965), 'Augen- und Lidverletzungen

bei Verkehrsunfallen ', Zentbl. Verk-Med, 1,208. - - - - (1970), International Automobile Safety Confer-

enee Compendium, Paper 700431, New York: Society of Automotive Engineers, Inc.

HUELKE, D. F., GRABB, W. C., and DINGMANN, R. O. (1966), ' Facial injuries due to windshield impacts in automobile accidents ', Plastic reconstr. Surg., 37, 324.

JUNGHANNSS, K. (1967), ' Augenverletzungen dutch Windschutzscheiben ', Medsche Mschv., Stuttg., 21, 325.

KEENLY, A. H. (1964), in Industrial and Traumatic Ophthahnology, p. 58. St. Louis: Mosby.

MACKAY, G. M., SIEGEL, A. W., and HIGHT, P. V. 0970), 14th Stapp Car Crash Conference, Paper 700911, 369. New York: Society of Automotive Engineers, Inc.

MEYERRATKEN, E. (1967), ' Augenverletzungen durch Platzen der Frontscheibe bei Kraftfahrzeugen ', Fortschr. Med., 85, 979.

PATRICK, L. M., TROSIEN, K. R., and DUPONT, F. T. (1970), International Automobile Safety Conference Compendium, Paper 700427, New York: Society of Automotive Engineers, Inc.

POULIQUEN, Y., and DEFOUG, D. (1969), 'R61e du bris de pare-brise dans les plaies perforantes de la corn6e ', Archs Ophthal., Paris, 29, I 1.

RENARD, G., BREGEAT, P., and OFFRET, G. (1970), Academie Nationale De Medicine, 27th October, Session (Paris).

ROPER-HALL, M. J. (1967), 'Perforating ocular injuries: prognosis ', Proc. R. Soc. Med., 60, 597.

Requests for reprints should be addressed to:--K. G. Soni, Esq., M.B., F.R.C.S., D.O., King's Lynn General Hospital, King's Lynn, Norfolk.