Although visual loss due to ocular trauma has been reported to be widespread in Nepal [6, 7, 9–13], the burden of ocular trauma resulting from the recent earthquakes in Nepal has not been described thus far. In this series of 59 patients seen at TIO, a variety of ocular injuries were managed. The mode of trauma was direct and indirect impact with closed and open globe injury. The primary mechanism for injury was reported by patients to be trauma from collapsing structures in buildings or falls from heights as patients escaped buildings. Many patients were from the Everest base camp, where an avalanche resulted in multiple casualties. Several patients underwent immediate surgery to save the integrity of the eye as well as the vision.
The management of ocular injuries at TIO was complicated by the chaos associated with a large-scale natural disaster. Due to the numerous minor aftershocks and fear of a repeat earthquake, clinicians often felt unsafe entering the hospital building, preventing some injured patients from receiving prompt management. In the event of a future earthquake, the authors recommend preparing a separate, temporary tent shelter to provide an emergency service, in order to mitigate concerns about the safety of the building and allow more patients to benefit from early surgery. A triaging system in the casualty area would also be useful to ensure serious injuries are prioritized and will be outlined in a new policy at TIO.
Despite appropriate management, a quarter of patients were observed to have monocular blindness (visual acuity <3/60) in their affected eye at follow-up, however no patient developed bilateral blindness. In contrast, previous series in Nepal have demonstrated monocular blindness in only 5–10% of patients on follow-up , even when presentation was delayed , reflecting the greater severity of injuries in the current series. Blindness may be devastating for an individual, with loss of vision in one or both eyes being classified as a 24% or 85% whole person impairment respectively . Severe ocular trauma may further impose significant direct costs due to the need for specialist medical care, hospitalization, follow-up appointments and visual rehabilitation, as well as indirect costs due to loss of income and time away from caregiving roles [18, 19]. The social cost due to lost productivity may be substantial, particularly as most individuals affected by ocular trauma are young .
Natural disasters such as earthquakes can pose significant challenges for countries’ health systems. Mass casualties often occur and management of patients may be complicated by concurrent damage to hospitals and transport infrastructure which can prevent patients from being able to access healthcare [1–3]. These issues are exacerbated in a developing country such as Nepal, where poorly-build houses led to numerous casualties and health services prior to the earthquake were already strained in servicing the demands of the population . The mountainous terrain further complicated transport and search and rescue operations, contributing to a delay in emergency response before international teams arrived. While the primary burden of earthquake-related trauma was orthopaedic [20, 21], all medical fields were involved in managing patients in the aftermath of the earthquake [22–24]. Ophthalmology services in the acute setting following a natural disaster are particularly important, as even minor ocular injuries that are sustained may become sight threatening if not managed promptly.
The spectrum of ocular trauma resulting from the earthquake contrasted markedly with that of general ocular trauma cases seen in Nepal due to agriculture or domestic work [6, 8–13]. The equal male:female ratio contrasts with studies examining general trauma cases in Nepal, which report a predominance of eye injuries in males [6, 8–13]. This ratio has been proposed to reflect that males are often exposed to a higher risk of ocular injury, however may also reflect an apparent lower incidence in women due to gender-related barriers in accessing care . A much higher proportion of cases also presented with very low visual acuity (40% of cases <3/60) compared with comparable studies of general ocular trauma cases (2.7% of cases <3/60 in reported a series presenting to Dhulikhel hospital . This was not surprising as TIO is the major tertiary referral centre for Ophthalmology in the area and would be expected to be referred cases on the more severe end of the spectrum. Indeed, the most common injury in this study was closed globe injuries, in contrast to previous series conducted in Nepal in which less serious injuries such as corneal abrasions were predominant . The mean age and age range was comparable to previous series of ocular trauma in Nepal [6, 8–13].
A further explanation for the low initial visual acuity on presentation might be delays in healthcare presentation, as the average duration before presentation was a fortnight. In contrast, 50–70% of patients presented within 1 day of injury in comparable series of ocular trauma patients in Nepal [9, 13]. Late presentations could have occurred as patients first presented to closer institutions which could not provide specialized eye care, with other serious injuries such as orthopedic injuries which had to be managed first . Another reason could be a lack of awareness or education about the potentially sight-threatening nature of eye injuries. Such a lack of knowledge has been reflected in previous population wide studies and has been associated with worse visual outcomes [6, 9]. Further in rural areas, a lack of transport and availability of eye care facilities mean many patients consult traditional healers or medical shopkeepers before presenting at hospital [9, 11], further delaying presentation.
There have been a few other reports on the management of ocular-related conditions in other natural disasters, which are of interest for comparison. Anecdotal reports following the major earthquake in Haiti reported frequent open globe injuries, crush injuries, ptosis and head injuries associated with cranial nerve defects . However, in our study, closed globe injury was found most frequently, followed by open globe injury and corneal ulcer. Reports describing outreach Ophthalmological management in the 1 month following the Great Japan earthquake also described longer term management following natural disasters. Key issues that were addressed included replacing lost eye glasses, managing pre-existing ocular diseases that required medical therapy and providing surgical follow-up after the acute management of ocular trauma [26–28].