Published online June 1, 2006
PEDIATRICS Vol. 117 No. 6 June 2006, pp. e1263-e1271 (doi:10.1542/peds.2005-1950)
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Pediatric Eye Injury–Related Hospitalizations in the United States

Megan Brophy, Sara A. Sinclair, MPH, Sarah Grim Hostetler, BA and Huiyun Xiang, MD, MPH, PhD

Center for Injury Research and Policy, Columbus Children's Research Institute, Columbus Children's Hospital, The Ohio State University College of Medicine and School of Public Health, Columbus, Ohio


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 APPENDIX.
 REFERENCES
 
OBJECTIVE. An estimated 2.4 million eye injuries occur in the United States each year, with nearly 35% of injuries among persons aged 17 years or less. Although previous research has identified some of the characteristics of pediatric eye injuries, many studies focused only on a specific patient population or type of eye injury or relied on self-reported data. In addition, little information has been reported on the total charges associated with treating pediatric eye injuries. Using a large national database, our aim was to examine hospitalizations for the treatment of pediatric eye injuries in the United States, including the demographic, medical care, and financial characteristics associated with major categories of eye injury.

METHODS. Cross-sectional data were derived from the 2000 Kids' Inpatient Database of the Healthcare Cost and Utilization Project. Eye injury–related hospitalizations were identified by using International Classification of Disease, Ninth Revision, Clinical Modification codes. Discharges were selected if the eye injury was the principal or secondary diagnosis. Guidelines from the Centers for Disease Control and Prevention were used to group external-cause-of-injury codes into broader categories to allow meaningful comparison with previous studies. The reported charges for the treatment of eye injuries and the expected primary payer were determined. Cases were statistically weighted to produce national estimates of hospitalizations for pediatric eye injuries and to determine the characteristics of these injuries.

RESULTS. Data were collected by the Kids' Inpatient Database for 3834 actual eye injury–related hospitalizations. These records represent an estimated 7527 eye injury–related hospitalizations among children aged 20 years or less in the United States during 2000. Inpatient charges for the treatment of these injuries were more than $88 million. The rate of hospitalization for pediatric eye injuries in the United States in 2000 was 8.9 per 100000 persons aged 20 years or less. Young adults aged 18 to 20 years accounted for the highest percentage of hospitalizations (23.7%). Males accounted for 69.7% of hospitalizations. A majority of hospitalizations were for open wounds of the ocular adnexa. Motor vehicle crash was the most common cause of injury, followed by being struck by or against an object and being cut or pierced.

CONCLUSIONS. These findings illustrate the considerable morbidity, financial burden, and proximal causes for pediatric eye injury–related hospitalizations. Our data support the need for eye injury prevention efforts that consider the age, gender, and developmental stage of children. Educating parents and children about the potential for eye injuries at home and during hazardous activities is an important public health goal. In addition, promoting the use of appropriate protective eyewear by children during activities with a high risk of ocular trauma will help prevent future eye injuries.

Key Words: hospitalization • eye injuries • pediatrics • prevention and control

Abbreviations: KID—Kids' Inpatient Database • HCUP—Healthcare Cost and Utilization Project • ICD-9-CM—International Classification of Diseases, Ninth Revision, Clinical Modification • CDC—Centers for Disease Control and Prevention • CI—confidence interval

Eye injuries are a significant public health problem in the United States. An estimated 2.4 million eye injuries occur in the United States each year,1 with nearly 35% of those injuries among persons aged 17 years or less.2 Overall, eye injuries are the leading cause of monocular visual disability and noncongenital unilateral blindness in children.3 In recent years, the home has replaced the workplace as the most common setting for serious eye injuries, thereby increasing risk for ocular trauma to the general population, particularly children.1,2,4–8

Limited research has been conducted to determine the characteristics of pediatric eye injuries. Researchers have found that among children, contusions and foreign bodies in the eye are the most common types of eye injuries and that males account for the majority of these injuries, with a male-to-female ratio ranging from 2.0 to 7.3:1.2–6,9–14 By cause of injury, researchers found that up to 59% of pediatric eye injuries occur during sport and recreational events.3 Among all ages, sport and recreational activities cause 27% of all eye injuries,15 with 72% of sports- and recreation-related eye injuries occurring in individuals aged less than 25 years and 43% to individuals aged less than 15 years.16 In addition to sport and recreation activities, a study on children admitted to a hospital with ocular trauma in Scotland revealed that blunt trauma accounted for 65% of the injuries.6

Although previous research has identified some of the characteristics of pediatric eye injuries, many studies focused only on a specific patient population or type of eye injury or relied on self-reported data.9,17,18 A small number of studies used national data to investigate eye injuries,5,7,19–21 but researchers grouped children into age categories as broad as 0 to 15 years, thus preventing meaningful comparison by developmental stage.5,7,19–21 In addition, little information has been reported on the total charges associated with treating pediatric eye injuries.

The purpose of this study was to describe the characteristics of and total charges for pediatric eye injury–related hospitalizations. We analyzed the 2000 Kids' Inpatient Database (KID) to estimate the national prevalence of pediatric eye injury–related hospitalizations and to describe the demographic, medical care, and financial characteristics associated with major categories of eye injury. Research has consistently documented that ~90% of eye injuries could have been prevented or decreased in severity with better education, appropriate use of safety eyewear, and removal of common and dangerous risk factors.1,22–27 The results of this study can be used to develop eye injury prevention initiatives for children, including measures specifically addressing the most serious and most costly pediatric eye injuries.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 APPENDIX.
 REFERENCES
 
Data Source
Researchers obtained hospital discharge records for children aged 20 years or less from the KID from January 1, 2000, to December 31, 2000, the most recent dates available. The KID is a component of the Healthcare Cost and Utilization Project (HCUP) maintained by the Agency for Healthcare Research and Quality (AHRQ).28 The 2000 KID collected hospital discharge information on pediatric treatments and resource utilization from 2784 hospitals in 27 states. In total, the 2000 KID included information on 2516833 hospital discharges.28 The 2000 KID included nonfederal hospitals, short-term hospitals, academic medical centers, and specialty hospitals such as obstetrics-gynecology, ear-nose-throat, orthopedic, and pediatric hospitals.28 The 2000 KID excluded federal hospitals, short-term rehabilitation hospitals, long-term hospitals, psychiatric hospitals, and alcoholism/chemical dependency treatment centers.28 Hospitals were assigned to 6 strata for random selection on the basis of ownership/control, bed size, teaching status, rural/urban location, US region, and hospital type (pediatric versus other).28 All data are discharge level; therefore, individuals that were hospitalized multiple times will have multiple records in the KID.

Variables
Eye Injury–Related Hospitalizations
A series of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes were used to identify hospitalizations for the treatment of eye injuries (see Appendix), a procedure consistent with coding used in previous research.29 Discharges were selected if the eye injury was the principal or secondary diagnosis. Diagnosis categories that represented <1% of eye injury–related hospitalizations were grouped into the "other" category and are detailed in the table footnotes.


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  		APPENDIX ICD-9-CM Codes for Eye Injury–Related Hospitalizations

 
Cause of Injury
Researchers used ICD-9-CM external-cause-of-injury codes (E codes) to determine the cause of injury. In 2000, 20 of the 27 involved states reported E codes to the KID. Researchers used guidelines from the Centers for Disease Control and Prevention (CDC) to group E codes into broader categories to allow meaningful comparison with previous studies.30

Total Charges
The KID is the only national, all payer database of hospital discharges for children.31,32 Total charges reported to the AHRQ by each state are edited by professional KID coders to round values to the nearest dollar, to set zero charges to "missing," and to set excessively high (greater than $1 million) or excessively low (less than $25) charges to "inconsistent."32 Total charges reflect the amount of the hospital bills for the entire hospital stay, excluding most physician fees.32,33 Reported charges are those that were expected to be paid by the primary payer, not necessarily the actual payment that was made.

Statistical Analysis
Data analyses were conducted by using SAS 9.1 (SAS Institute, Inc, Cary, NC)34 and SUDAAN 9.0.1 (Research Triangle Institute, Research Triangle Park, NC)35 statistical software to account for the weighting structure of the KID. The SAS program was used to calculate frequencies, percentages, means, medians, and sums. The SUDAAN program was used to calculate frequencies, percentages, and confidence intervals (CIs) for national estimates. Statisticians at the KID provided discharge-level and hospital-level statistical weights to account for the complex survey design and sampling procedures. The KID was specifically designed to provide national estimates of hospitalizations using discharge-level statistical weights.28

The actual sample size is a statistically unweighted number and is specified when presented in the results. All other frequencies, percentages, rates, means, medians, and sums are national estimates calculated by using the statistical weights. National estimates of eye injury–related hospitalizations were calculated with 95% CIs by age, gender, median household income, and expected primary payer. Percentages and 95% CIs for these variables were further calculated for each major type of eye injury. Injury rates per 100000 persons were calculated by age and gender by using the publicly available 2000 population estimates from the US Census Bureau.36 Total charges per discharge were reported by mean, median, and overall sum for each type of eye injury. Percentages and 95% CIs were calculated for length of stay and discharge status for each type of eye injury. For each type of eye injury, the top 3 causes of injury were determined by the percentage of hospitalizations that cause represented.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 APPENDIX.
 REFERENCES
 
Characteristics of Patients Hospitalized for the Treatment of Eye Injuries
The KID collected data on 2516833 hospital discharges between January 1, 2000, and December 31, 2000. Of these discharges, 3834 actual hospitalizations were for the treatment of a pediatric eye injury. On the basis of these data, there were an estimated 7527 (95% CI: 7519–7535) eye injury–related hospitalizations among children aged 20 years or less in the United States during 2000. National estimates and weighted percentages of selected demographic characteristics of patients hospitalized for treatment of an eye injury are presented in Table 1. Young adults aged 18 to 20 years had the highest percentage of hospitalizations for the treatment of an eye injury (23.7%). Males had 69.7% of hospitalizations, but this proportion varied by age (data not shown). Private payers, including health maintenance organizations, were the most common expected primary payer of all eye injury–related hospitalizations (57.7%), followed by Medicaid (24.8%).


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  		TABLE 1 Actual Sample and National Estimates of Selected Characteristics of Patients Hospitalized for Treatment of Pediatric Eye Injuries: 2000

 
Eye Injury–Related Hospitalizations by Age and Gender
Figure 1 presents the rates of hospitalization for the treatment of pediatric eye injuries by age and gender. The overall rate of hospitalization for pediatric eye injuries in the United States in 2000 was 8.9 per 100000 persons aged 20 years or less. The rates of hospitalization for eye injuries were higher for males than for females in all age groups, but the difference in rates increased considerably after the 9- to 11-year age group. Males aged 18 to 20 years had the highest rate of hospitalization for treatment of an eye injury (22.6 per 100000 persons). Adolescents aged 15 to 17 years had the highest rate of hospitalization for an eye injury for females (7.8 per 100000 persons).


Figure 1
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  		FIGURE 1 Rates of eye injury–related hospitalizations by age and gender: 2000. Source: Kids' Inpatient Database, 2000.

 
Table 2 presents information on hospitalizations for specific types of eye injuries by age and gender. For all persons, a majority of hospitalizations were for open wounds of the ocular adnexa (25.9% [95% CI: 24.2–27.6]), followed by orbital floor fractures (22.5% [95% CI: 20.9–24.1]) and open wounds of the eyeball (20.9% [95% CI: 19.4–22.4]). The distribution of hospitalizations for specific types of eye injuries varied by age. Open wounds of the adnexa and orbital floor fractures accounted for almost two thirds of the hospitalizations for both adolescents aged 15 to 17 years (61.6%) and young adults aged 18 to 20 years (62.9%). For children aged 9 to 11 years, 29.7% (95% CI: 24.4–35.5) of hospitalizations were for open wounds of the eyeball. Children aged 0 to 2 years had higher percentages of hospitalizations for superficial wounds to the eye and adnexa and for burns confined to the eye and adnexa than the overall sample (18.5% and 4.3%, respectively, for children aged 0 to 2 years; 7.1% and 1.5%, respectively, for the overall sample).


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  		TABLE 2 Weighted Percentages and 95% CIs of Hospitalizations for Specific Pediatric Eye Injuries by Age and Gender: 2000

 
The distribution of hospitalizations for certain types of eye injuries also was influenced by gender. Although males experienced a larger number of hospitalizations for each type of eye injury (data not shown), females had a significantly higher percentage of hospitalizations for open wounds of the adnexa (females: 31.8% [95% CI: 28.5–35.2]; males: 23.3% [95% CI: 21.5–25.3]) and for superficial wounds of the eye and adnexa (females: 12.6% [95% CI: 10.4–15.3]; males: 4.7% [95% CI: 3.8–5.7]). For orbital floor fractures and open wounds of the eyeball, males had a significantly higher percentage of hospitalizations than females.

Medical Care Characteristics of Hospitalizations for Pediatric Eye Injuries
The estimated total charges for pediatric eye injury–related hospitalizations in the United States in 2000 were $88065800 (Table 3). Orbital floor fractures accounted for the largest percentage of total hospital charges (29.2%), the largest mean charge per hospitalization ($15559), and the largest median charge per hospitalization ($10100). Orbital floor fractures and open wounds of the eyeball accounted for greater percentages of total hospital charges (29.2% and 23.2%, respectively) than their overall percentage of pediatric eye injury–related hospitalizations (22.5% and 20.9%, respectively).


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  		TABLE 3 Medical Care Characteristics of Hospitalizations for Pediatric Eye Injuries by Diagnosis: 2000

 
For all pediatric eye injury–related hospitalizations, the majority of patients' length of stay in the hospital was ≤3 days (0–1 day: 38.7% [95% CI: 36.9–40.5]; 2–3 days: 39.1% [95% CI: 37.3–41.0]). A majority of hospitalizations for all eye injuries were routinely discharged (94.3% [95% CI: 93.3–95.2]).

Causes of Pediatric Eye Injury–Related Hospitalizations
Of the hospitalizations for pediatric eye injuries with a recorded cause of injury (90.2%), the most common cause of hospitalization was for a motor vehicle crash (28.8%), followed by being struck by or against an object (26.5%) and being cut or pierced (7.6%) (Table 4). Motor vehicle crashes were the most common cause of injury for hospitalization of open wounds of the adnexa (48.6%) and superficial wounds of the eye and adnexa (29.4%). Struck by or against an object was the most common cause of injury for hospitalization of orbital floor fractures (37.1%) and contusions of the eye and adnexa (44.3%).


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  		TABLE 4 Most Common Causes of Hospitalized Pediatric Eye Injuries by Diagnosis: 2000

 

   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
APPENDIX.
 REFERENCES
 
Major Findings
In 2000, there were >7500 hospitalizations for the treatment of pediatric eye injuries resulting in more than $88 million in inpatient charges. These hospitalizations followed age- and gender-specific characteristics and rates. In addition, the specific type of eye injury influenced total charges, length of stay, and discharge status. Finally, we determined the major causes of injury for these hospitalizations, the first step in developing targeted eye injury prevention initiatives.

The distribution of hospitalizations for pediatric eye injuries showed significant trends by age and gender. The oldest children (aged 15–20 years) had the highest percentages of hospitalizations for pediatric eye injuries. This distribution is very similar to the CDC's findings for all unintentional nonfatal injuries in 2000 for children aged 20 years or less.37 By gender, males had more than double the number of hospitalizations for eye injuries than females. This finding is consistent with previous research indicating that males have a significantly higher frequency of pediatric eye injuries.6,7,13,21,22

We found that the rate of hospitalization for pediatric eye injuries in the United States was 8.9 per 100000 persons aged 20 years or less in 2000. Previous researchers have estimated the rate of eye injury–related hospitalizations at 13.2, 18.0, 27.3, and 29.1 per 100000 persons.11,19–21 However, these rates are for persons of all ages, not just children. When considering only children, McGwin et al19 reported that the rates of eye injury–related hospitalizations among children aged less than 20 years were ~5 to 10 per 100000 for males and ~50 to 60 per 100000 for females. Although the age groups in each study are not identical, our rates of eye injury–related hospitalizations were higher for males and lower for females. This difference may have occurred because different years of data were used. Eye injury–related hospitalizations are relatively uncommon, and therefore discharges may have been affected by a significant increase in 1 year versus another. In addition, we included only principal or secondary diagnosis codes for an eye injury, and McGwin et al included up to 7 diagnosis codes.

The distribution of the rates of hospitalizations for eye injuries was higher for males than for females at all age groups, but the difference in rates increased considerably after the 9- to 11-year age group. This finding may have resulted from an overall trend of all unintentional nonfatal injuries among children. Our finding is consistent with information from the CDC on rates of unintentional nonfatal injury, which shows that among persons aged less than 21 years, males typically have a higher rate of injury than females, with this difference increasing considerably at 9 years of age.37

The financial and medical care characteristics associated with major categories of pediatric eye injury–related hospitalizations also were investigated. To our knowledge, this study was the first to estimate the total charges associated with hospitalizations for pediatric eye injuries in the United States. We found that total charges for pediatric eye injury–related hospitalizations were more than $88 million in 2000, a small percentage of the reported $650 billion in total charges for all hospitalizations among patients of all ages recorded in the HCUP.33 The average charge per hospitalization in our study was $12132, lower than the reported $17300 average charge per hospitalization among all persons in the HCUP.33

The most common expected primary payers for pediatric eye injury–related hospitalizations were private insurance (57.7%) and Medicaid (24.8%). This finding differs slightly from overall HCUP trends indicating that private insurance was the expected primary payer for 36% of hospitalizations and Medicaid was the expected primary payer for 22% of hospitalizations. This difference is likely because of the role that Medicare has as the expected primary payer in the HCUP sample of all-aged patients, compared with our pediatric population. Descriptions of the total charges for pediatric eye injury–related hospitalizations by type of eye injury and by payer will help researchers, clinicians, and payers develop eye injury prevention initiatives directed at the most expensive types of injuries.

Overall, the most common types of pediatric eye injury–related hospitalizations in this inpatient population were for open wounds of the adnexa, orbital floor fractures, and open wounds of the eyeball. This finding differs from previous research indicating that the most common types of eye injury were contusions and foreign bodies.2,5,13 This discrepancy is interesting, because one of the previous studies also used an inpatient data source. However, this study was conducted in Hong Kong; thus, the differences in injury type may be a reflection of differences in culture and geographic region. In addition, our study differs from the McGwin et al19 study because we analyzed eye injuries treated inpatient at a hospital, and their analysis included injuries treated in an ED.

Motor vehicle crashes caused the largest percentage of injuries and were the most common cause of injury for 2 major types of eye injuries. Our results differ from previous research at a large urban hospital, which reported that motor vehicle crashes accounted for only 12% of eye injuries among all ages.38 In addition, McGwin et al19 found that only 2.3% of eye injuries were caused by motor vehicle crashes.5 Our results for causes of pediatric eye injury–related hospitalizations also differ from previous reports from the CDC on overall unintentional nonfatal injuries among persons of the same age, which found that the most common causes of injury were falls and being struck by or against an object.39 These discrepancies are likely because of the fact that all of our injuries were treated inpatient at a hospital and the injuries in the other reports included those treated in other health care settings.

Limitations
Several limitations of this study should be considered when interpreting the results. The KID data only include information related to injuries that require hospitalization. Our findings may not be representative of eye injuries treated in other health care settings or injuries that did not receive medical attention. We recognize that ~95% of eye injuries are minor,7 most of which would not require hospitalization, and therefore would not be represented in this study.7 Our results are not intended to represent the overall burden of all pediatric eye injuries on the population. We reported on the most serious and most costly pediatric eye injuries that usually result in long-term sequelae.40,41

We developed broad categories of cause of injury recommended by the CDC to provide meaningful comparison with previous research, but these categories did not provide enough information to implement detailed cause-specific injury prevention methods. For example, previous researchers have found that sport and recreation activities are a major cause of pediatric eye injuries. We could not determine if sport or recreation activities were the cause of the injuries in our study on the basis of the categories we used. However, with this broad sense of the causes of pediatric eye injury–related hospitalizations, future research can focus on more specific causes of injury. In addition, location of injury can be determined if more E code location coding is included in the KID (eg, in our sample, only approximately one third of the cases had a reported location E code).

The KID lacks information on the visual outcomes of the injury, including severity and complications. Although visual impairment is infrequent, it is more common among the most serious injuries and would be a good addition to this study and to the KID. In addition, the data only represent a single year of recorded injuries. Although the number of hospitalizations for eye injuries included in this study is greater than the number of pediatric eye injuries requiring hospitalization estimated in past studies, injuries to the eye are still relatively uncommon. Thus, random variation from year to year may produce spurious characteristics that, when viewed longitudinally, appear less dramatic.19 The anticipated release of KID data for 2003 will enhance our ability to describe hospitalization trends.31

The KID provides information on hospital discharges, not patients. Therefore, it is possible that a single patient seeking care on multiple occasions would be counted more than once, thereby inflating the rate reported in this study.19 In addition, our definition of eye injury–related hospitalization was limited to a principal or secondary ICD-9-CM code diagnosis of an eye injury. It is possible that this definition led to an underestimation of true hospitalizations for eye injuries that were secondary to another major diagnosis. Even with these 2 concerns, we are confident that our results provide an accurate representation of pediatric eye injury–related hospitalizations in the United States.

Implications and Future Research
Despite some limitations, the results of this study address some of the gaps in the field of pediatric eye injury research. Future studies should be nationally representative and should include financial information from other health care settings, including emergency departments, primary care physicians, ophthalmologist offices, and other eye care practitioner offices. In addition, additional details should be captured about the proximal cause of injury including presence of adult supervision, safety eyewear, product(s) involved in the injury, specific mechanism of injury, and detailed location of injury. Finally, future studies should assess the visual outcomes after eye injury.

Although pediatric eye injuries can be very serious, ~90% of these injuries can be prevented through the use of protective measures.1,28 Education of parents about the potential risk factors for eye injury by developmental stage is necessary. Clinicians can provide parents of children aged 0 to 2 years with information on the risk of eye injuries from fires or burns. For example, eye injury prevention materials exist from organizations such as Prevent Blindness America that include information on protecting children from burns to the eye from common household cleaners.42 In addition, parents of older children and the adolescents themselves can be educated on the risk of eye injury from motor vehicle crashes.

To protect children from having their eye struck by or against an object, clinicians can promote the use of appropriate protective eyewear during sport and recreation activities, while working, and during other hazardous situations for the eye. In addition, increased adult supervision and age-appropriate, safe toys are important for preventing injuries in children. Our data support the need for eye injury prevention efforts that are age and gender appropriate, taking into consideration the developmental stages of children. In addition, educating parents and children about the potential for eye injuries from common and dangerous risk factors is an important public health goal.


   APPENDIX.
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 APPENDIX.
REFERENCES
 


   ACKNOWLEDGMENTS
 
At the time of the study, Ms Brophy and Ms Hostetler were conducting summer internship research projects at the Center for Injury Research and Policy (Columbus Children's Research Institute). Ms Brophy was supported by the Miami University's honors program's Urban Leadership Internship Program, and Ms Hostetler was supported by the Alpha Omega Alpha Student Research Fellowship. In addition, the study was funded in part by a grant from the Centers for Disease Control and Prevention (principal investigator: Dr Xiang, grant R49/CE000241-01).


   FOOTNOTES
 
Accepted Feb 7, 2006.

Address correspondence to Huiyun Xiang, MD, MPH, PhD, Center for Injury Research and Policy, Columbus Children's Hospital, The Ohio State University, 700 Children's Dr, Columbus, OH 43205. E-mail: xiangh{at}pediatrics.ohio-state.edu

The contents of this study are solely the responsibility of the authors and do not necessarily reflect the official views of the Centers for Disease Control and Prevention, Miami University, or Alpha Omega Alpha.

The authors have indicated they have no financial relationships relevant to this article to disclose.


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 DISCUSSION
 APPENDIX.
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PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics




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