Pediatric traumatic brain injury and ocular injury

Major Article Pediatric traumatic brain injury and ocular injury Ryan Gise, MD,a Timothy Truong, BA,b David M. Poulsen, MD, MPH,a Yssra Soliman, BA,b Afshin Parsikia, MD, MPH,c and Joyce N. Mbekeani, MD, FRCSa,d PURPOSE

Traumatic brain injury (TBI) is a leading cause of pediatric disability and mortality. Together with sight-threatening ocular injuries, TBIs may lead to devastating consequences in developing children and complicate rehabilitation. We sought to investigate this relationship in pediatric patients admitted with major trauma.

METHODS

The records of pediatric patients admitted with ocular injury and concomitant TBI were reviewed retrospectively using the National Trauma Data Bank (2008-2014).

RESULTS

Of 58,765 pediatric patients admitted for trauma and also had ocular injuries, 32,173 were diagnosed with TBI. Mean patient age was 12.3  7 years. Most were male (69.8%) and White (61.2%). The most frequent injuries were contusion of the eye/adnexa (39.1%) and orbital fractures (35.8%). The youngest age groups had greatest odds of falls in home locations, whereas older groups were more likely to suffer motor vehicle trauma as occupants (MVTO), struck by or against (SBA) injuries, and firearms injuries in street locations (P \ 0.001). Blacks and Hispanics were most likely to suffer assault (P \ 0.001) and Whites, unintentional (P \ 0.001) and self-inflicted (P \ 0.012) injury. Blacks were at a higher risk of firearms injury, Whites of MVTO, and Hispanics of motor vehicles as pedestrians (P \ 0.001).

CONCLUSIONS

TBI frequently is experienced by trauma patients with concomitant ocular injury and should be considered in children admitted with major trauma. Resultant demographic patterns may help identify patients that have a higher risk of TBI leading to earlier diagnosis and treatment. ( J AAPOS 2018;-:1-6)

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raumatic brain injury (TBI) increasingly is recognized as a major source of mortality and lifelong disability that can disrupt normal development.1,2 One study of TBI in children estimated an annual rate of hospitalization of 70 cases per 100,000, costing in excess of $1 billion.3 This figure, however, does not include follow-up visits, imaging, rehabilitation, or loss of potential income for the patient and caregiver. Children with all severities of TBI have exhibited attention deficit, and severe TBI has been associated with emotional instability, compromised conceptual and practical skills, and incapacity to make social adjustments.4,5 All severities of TBI

Author affiliations: aOphthalmology & Visual Sciences, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; bMontefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; cDepartment of Surgery (Trauma), Jacobi Medical Center, Bronx, New York; dDepartment of Surgery (Ophthalmology), Jacobi Medical Center, Bronx, New York Presented as a poster at the 43rd Annual Meeting of the North American NeuroOphthalmology Society in Washington, DC, April 1-6, 2017. Submitted May 8, 2018. Revision accepted July 19, 2018. Correspondence: Ryan Gise, MD, Ophthalmology Department, Montefiore Medical Center, 3332 Rochambeau, Avenue, 3rd Floor, Bronx, NY, 10467 (email: Ryan.gise@ gmail.com). Copyright Ó 2018, American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved. 1091-8531/$36.00 https://doi.org/10.1016/j.jaapos.2018.07.351

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can be associated with multiple visual disabilities,6 including vision loss, diplopia, photophobia, convergence insufficiency, saccadic dysfunction, and poor visual tracking (smooth pursuit).7,8 Previous pediatric TBI reports have focused on neurological injuries and visual system sequelae, not on associated ocular injuries.2,5-8 The eye’s location and proximity to the brain places it at high risk for both direct and indirect injury. Similarly, high-impact eye injuries also may result in an associated TBI. To our knowledge, only Weichel and colleagues9 have investigated the relationship between ocular injuries and TBIs. The presence of both injuries would compound the burden of visual rehabilitation in this developing group. We sought to characterize ocular injuries in children admitted for trauma who also had TBIs. The revealed patterns could help identify patients with ocular injury at risk of concurrent TBIs with implications for initial and long-term management and rehabilitation support. These findings also could provide a foundation for developing preventative public health measures.

Methods This retrospective survey of the National Trauma Data Bank (NTDB), 2008-2014, was approved by the Institutional Review Board of Albert Einstein College of Medicine and met all requirements of the US Health Insurance Portability and Accountability

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Table 1. Description of findings in pediatric ocular trauma and traumatic brain injury, National Trauma Data Bank (2008-2014) Characteristic Year 2008 2009 2010 2011 2012 2013 2014 Sex Male Female Race Black White Other Ethnicity Hispanic Injury type Penetrating Blunt Other Unknown Mortality Age 0-3 4-6 7-11 12-18 19-21 ISS #15 16-25 .25 Unknown GCS #8 9-12 13-15 Unknown Common injuries Contusion eye/adnexa Orbital Open adnexa wound Superficial Open wound eyeball Visual pathway Related cranial nerves

No. (%)

Mean  SD Median (IQR)

4,458 (13.9) 4,727 (14.7) 4,762 (14.8) 4,443 (13.8) 4,767 (14.8) 4,385 (13.6) 4,631 (14.4) 22,148 (68.8) 10,025 (31.2) 5,175 (16.1) 19,675 (61.2) 7,323 (22.9)

grouped into categories based on the type and the location of the injury. TBI was identified based on Centers for Disease Control (CDC) criteria by ICD-9-CM codes 800.0-801.9 and 803.0-804.9 (skull fracture), 850.0-854.1 (intracranial injury), 950.1-950.3 (injury to the optic chiasm, optic pathway, or visual cortex), 959.01 (head injury not otherwise specified), and 995.55 (shaken baby syndrome).12 We tabulated data detailing patient demographics, Injury Severity Score (ISS), Glasgow Coma Score (GCS) on arrival to the emergency department, length of admission, and disposition upon discharge for each patient. ISS assigns a numerical value of 0-75 based on location and severity of injuries. High scores indicate severe injury; scores .15 are considered major trauma.13 Regional contribution (Northeast, West, Midwest, and South) based on US census regions and level of hospital trauma service (levels I-IV) also were documented.

Statistical Analysis 5,063 (15.7) 1,144 (3.6) 25,494 (79.2) 3,836 (11.9) 1,699 (5.3) 1,631 (5.1) 6,170 (19.2) 2,291 (7.1) 3,335 (10.4) 13,284 (41.3) 7,093 (22.0) 16,256 (50.5) 7,787 (24.2) 6,665 (20.7) 1,465 (4.6)

12.3  7.0

15 (6-18)

11.6  4.5

15 (8-15)

11.8  4.7

The mean, median, standard deviation, and interquartile range (IQR) were calculated for all continuous variables. These variables were then grouped into categories to facilitate regression analysis. Children were divided into developmental age groups of 0-3 years, 4-6 years, 7-11 years, 12-18 years, and 19-21 years. Association between variables was analyzed using the t test, the c2 test, and univariate logistic regression analysis. All calculations were performed using SPSS software (Statistical Package for Social Science, IBM Corp, Armonk, NY). Patients classified as “unknown” and “undetermined” were excluded from the analyses.

Results 15 (8-15)

7,321 (22.8) 1,768 (5.5) 20,150 (62.6) 2934 (9.1) 26,643 (45.9) 21,871 (37.7) 9,342 (16.1) 5,838 (10.1) 4,497 (7.7) 400 (0.7) 509 (0.9)

GCS, Glasgow Coma Score; IQR, interquartile range; ISS, Injury Severity Score; SD, standard deviation. Act of 1996. Our study methods have been described in detail in a previous publication and are summarized here.10 The NTDB is one of the largest trauma registries in the world and is maintained by the American College of Surgeons.11 It contains deidentified data of major trauma admissions collected from over 900 centers within the United States. Qualification for inclusion requires admission or death after initial evaluation with an appropriate diagnosis based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). We evaluated pediatric patients (\21 years of age) with concurrent diagnoses of ocular injury and TBI. Ocular injuries were

Of the 58,765 admitted with trauma including ocular injuries, 32,174 (54.8%) had TBI. The mean age with standard deviation was 12.3  7 years (Table 1). The majority were 12-18 years of age (41.3%) and male (68.8%). See eFigure 1. Male patients were slightly older than females (mean ages, 12.6  6.6 vs 10.6  7 [P \ 0.001]). Whites made up 61.2% of the population; Blacks, 16.1%; and Hispanics, 15.7%. The mean GCS was 11.8  4.7 (range, 3-15; median, 15; IQR, 8-15). Most patients (62.6%) presented emergently with a GCS of 13-15 (mild TBI), although 22.8% had a GCS of \8 (severe TBI). The mean ISS was 17  11.2, with most patients (50.5%) having scores of \15. The mean length of admission was 6.7  10.8 days. Blunt injury accounted for 79.2% of injuries; penetrating injury, for 3.6%. Injuries were unintentional in 74.1% of cases, due to assault in 18.8%, and self-inflicted in 1.1%. Overall mortality was 5.1%. Patients most often presented to level 1 trauma centers (35.5%). The annual number of injuries was stable during the period 2008-2014, averaging 4,596 cases/year (range, 4,385-4,762). The South region (as defined by the US census) reported the most cases (36.4%). See Table 1. Contusion of the eye/adnexa (39.1%) and orbital injuries (35.8%) were the most common ocular injuries and contusions had the greatest odds of being associated with TBI (OR 5 2.52; 95% CI, 2.43-2.62; P \ 0.001). Ruptured globes or open wounds of the eyeball were less likely to

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FIG 1. A, Race and ethnic association with mechanism of pediatric ocular trauma and traumatic brain injury, NTDB (2008-2014). B, Race and ethnic association with intent of pediatric ocular trauma and traumatic brain injury, NTDB (2008-2014). MVTO, motor vehicle trauma as occupant; MVTmotorcycl, motor vehicle accident as motorcyclist; MVT-ped, motor vehicle trauma as pedestrian SBA, struck by or against; Self, self-inflicted; Un, unintentional.

have concomitant TBI (OR 5 0.23; 95% CI, 0.21-0.24; P \ 0.001). The most common visual pathway injury was optic neuropathy, occurring in 85.4% of the 789 cases with concomitant TBI. The remainder of injuries involved the optic chiasm (1%), the post-chiasm (1.3%), and the visual cortex (4.1%). Of the 1,258 cranial nerve injuries, the abducens nerve (25.4%) was most frequently reported, followed by the oculomotor nerve (15.7%) and the trochlear nerve (4.1%). The facial nerve was involved in 4.8% of cases; the trigeminal, in 3.7%. Common mechanisms of injury were motor vehicle trauma as occupant (MVTO), 32.6%; struck by or against (SBA), 12.6%; and falls, 10.9% (eFigure 2). The 0-3 years age group was most likely to be injured in falls (OR 5 3.52;

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95% CI, 3.27-3.8; P \ 0.001), and the 12-18 years group (OR 5 1.76, 95% CI, 1.67-1.86; P\0.001) and 19-21 years group (OR 5 1.36, 95% CI, 1.29-1.42; P \ 0.001) had greater odds of MVTO. Older groups were also more likely to be injured by SBA (eFigure 3). Whites had greater odds of MVTO (OR 5 1.31; 95% CI, 1.25-1.37; P \ 0.001), MVT-cyclist (OR 5 1.34; 95% CI, 1.141.56; P \ 0.001), and falls (OR 5 1.27; 95% CI, 1.181.37; P \ 0.001), whereas Blacks were significantly more likely to suffer injury from firearms (OR 5 4.43; 95% CI, 3.83-4.91; P \ 0.001) and SBA (OR 5 1.46; 95% CI, 1.34-1.58; P \ 0.001). Patients of Hispanic ethnicity were more likely to suffer MVT-pedestrian (OR 5 1.86; 95% CI, 1.67-2.07; P \ 0.001). See Figure 1A.

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Blacks (OR 5 2.59; 95% CI, 2.43-2.78; P \ 0.001) and Hispanics (OR 5 1.52; 95% CI, 1.42-1.64; P \ 0.001) had greater odds of assault than other intentions, and Whites had greater odds of unintentional (OR 5 2.23; 95% CI, 2.11-2.36; P \ 0.001) and self-inflicted trauma (OR 5 1.34; 95% CI, 1.07-1.69; P \ 0.012) (Figure 1B). Injury severity score (ISS) was mostly \8 (minor injury) for SBA (OR 5 2.97; 95% CI, 2.76-3.19) and falls (OR 5 1.76; 95% CI, 1.63-1.90) and .24 (very severe injury) for MVTO (OR 5 1.55; 95% CI, 1.47-1.64), MVT-pedestrian (OR 5 1.55; 95% CI, 1.39-1.72), and firearms (OR 5 3.3; 95% CI, 2.92-3.75; P \ 0.001). The findings for GCS mirrored the ISS analysis with minor TBI (GCS 5 13-15) for falls (OR 5 2.22; 95% CI, 2.022.45) and SBA (OR 5 3.99; 95% CI, 3.59-4.44) and severe TBI (GCS \8) for MVT-occupant (OR 5 1.42; 95% CI, 1.34-1.49), MVT-pedestrian (OR 5 1.54; 95% CI, 1.391.70), and firearms injuries (OR 5 3.30; 95% CI, 2.913.75; P \ 0.001). See eTables 1 and 2. Frequent locations of trauma were the street (49.8%) and home (22.7%). The likelihood of injury occurring in the street increased with age, with those 19-21 years of age having the greatest odds (OR 5 2.2; 95% CI, 2.082.32; P \ 0.001). The 0- to 3-year-olds had the greatest odds of injury at home (OR 5 15.78; CI, 14.78-16.85; P \ 0.001). Falls were most likely to occur at home (OR 5 4.46; 95% CI, 4.14-4.8; P \ 0.001), SBA in public buildings (OR 5 6.58; 95% CI, 5.8-7.54; P \ 0.001) and residential institutions (OR 5 5.52; 95% CI, 3.93-7.75; P \ 0.001). Analysis of the location of injury also exhibited demographic tendencies, with Blacks having greatest odds of sustaining injury in residential institutions (OR 5 2.18; 95% CI, 1.54-3.09; P \ 0.001) and public buildings (OR 5 1.18; 95% CI, 1.02-1.38; P 5 0.03); Whites, on a farm (OR 5 3.48; 95% CI, 2.41-5.02; P \ 0.001); and Hispanics, at home (OR 5 1.14; 95% CI, 1.06-1.22; P \ 0.001). See eTable 3.

Discussion Traumatic brain injury has been described as a “silent epidemic,” and more frequently, it is being recognized in patients with minor head injuries.14 Its signs and symptoms, not always initially apparent, can have devastating effects. The timing and degree of injury can affect a child’s development and have lifelong deleterious consequences. Chen and colleagues14 reported an increase in pediatric TBI hospital visits of 34.1% between 2006 and 2013. Additionally, Thornhill and colleagues2 found that 47% of adolescents and adults with mild head injury developed “moderate or severe” disability. This rate was similar to those with moderate or severe head injuries.2 Our study disclosed significant concurrence of TBI and ocular injury in children admitted for trauma, an association that previously has been noted in adult trauma studies.9,15 Most TBIs in our study were considered mild (Table 1). Kulkarni and colleagues15 examined 200 adults

Volume - Number - / - 2018 with closed head injury and found similarly that most patients had mild TBI. In their study of concurrent TBI and ocular injury, Weichel and colleagues9 noted also that combat-related TBI frequently was associated with ocular injury, occurring in two-thirds of patients. However, TBI severity was evenly distributed from mild to severe. The increased incidence of moderate-to-severe TBI was likely secondary to war-related injuries that do not compare well with our study population. The preponderance of injuries in adolescent males that we observed is a common finding in other pediatric and adult ocular injury or TBI studies.13,16-20 The bimodal age distribution we observed also is consistent with the Garcia and colleagues13 study and one meta-analysis of international epidemiology of pediatric TBI.21 Young children were more likely to be injured at home and secondary to falls, whereas adolescents were more likely to be injured in the street as passengers in motor vehicle accidents. Increased frequency of adolescent MVTO comports with previous studies of both head trauma and ocular injury.15,22,23 Blacks and Hispanics were significantly more likely to be victims of assault, whereas Whites were more likely to suffer unintentional and self-inflicted injuries. Blacks also were significantly more likely to suffer injuries from firearms than Whites or Hispanics (Figure 1). Barmparas and colleagues17 recently published a study looking specifically at assault-related traumatic injury in children and found similar racial patterns. Using NTDB data (20072011), they found Black children were at higher risk of assault-related trauma as they approached adolescence.17 These findings also are supported by Haider and colleagues,18 who examined the National Pediatric Trauma Registry and found that Blacks were at higher risk of assault, had greater inpatient rehabilitation requirements and inferior outcomes on discharge. Our study identified both racial and ethnic disparities in mechanisms of injury (Figure 1A), with Whites more frequently suffering MVTO, MVT-cyclist, and falls; Blacks more frequently suffering firearms, MVT-pedestrian, and SBA; and Hispanics more frequently suffering MVT-pedestrian, pedal cyclist, and SBA. Along with differences in intent (Figure 1B) and locations of injuries, these differences must be studied further before suggesting preventative intervention strategies. The most common ocular injuries associated with TBI were contusions to the ocular adnexa and orbital fractures—a finding that comports with two other studies.15,22 Orbital fractures were much less common in both studies. Garcia and colleagues,13 however, observed similar proportions of both injuries. Differences with adult studies likely result from variable exposure to injury mechanisms. In one of the few studies that have reported ocular injury in children with head trauma, Shokunbi20 also found that periorbital ecchymosis was the most common ocular finding. We noticed globe ruptures were not significantly associated with TBI, occurring in only 5.1% of cases.

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Volume - Number - / - 2018 This finding also is consistent with studies that reported rates of 2% and 4.3%.15,22 Degrees of injury severity and TBI were both associated with mechanism of injury. MVT-occupant, MVT-pedestrian, and firearm injuries more likely to result in “very severe” injury severity and “severe” TBI designations (eTable 1 and 2). However, over half of the patients did not meet the criterion of major trauma (ISS .15) and GCS was commonly 13-15, an indicator of mild TBI. Thus, children at risk of immediate or remote effects of TBI may present initially with minor findings in terms of trauma scoring, leading some to recommend intensive care unit admission in all children with mild TBI.24 In addition to the loss of vision associated with damage to the visual pathway—optic nerve, optic chiasm, visual pathways, and visual cortex—there also can be secondary loss of vision from cranial nerve injury and the development of amblyopia. Amblyopia and cortical loss of vision can occur in young children from visual stimulus deprivation or disparate visual input. Trauma is a common cause of all ocular motor nerve palsies in children, representing major amblyogenic factors from ptosis or ocular misalignment.25,26 In this study, the abducens nerve was the most commonly injured ocular motor nerve followed by the oculomotor and trochlear nerves. These findings are unusual; typically, the abducens nerve is the least commonly injured cranial nerve. Van Stavern and colleagues27 examined 326 pediatric and adult patients after head trauma and found injury of the trochlear nerve in 13.2%, of the oculomotor nerve in 11.2%, and of the abducens nerve in 6.4% of patients. In both pediatric and adult studies, the oculomotor and trochlear nerves are the most frequently injured ocular motor nerves.7,23,27 Our findings were likely due to observer bias. In contrast to previous studies, where examinations were probably conducted by ophthalmologists or pediatric neurologists, our findings represent initial evaluations by emergency/ trauma team providers.7,23,27 In the context of major trauma, diagnosis of trochlear nerve injury would require a cooperative patient and skilled examiner. The adducted eye with an abducens nerve palsy or the abducted, infraducted, and variably mydriatic or ptotic eye with oculomotor nerve palsy are easier to identify. Limitations of this study include inherent errors introduced by retrospective database sourcing. The data used also did not represent a fixed and defined population, and contributions from centers and regions varied with time. Second, neither ophthalmologists nor pediatric neurologists contributed to the submissions, possibly underestimating ocular or visual pathway injuries. Lastly, our study was skewed toward admitted patients, lacking outpatient cases common in ophthalmology. These limitations notwithstanding, our study used a large, inclusive database that allowed for statistical analyses, providing a foundation for further research. To our knowledge, this is the first study of this scope dealing with this subject matter.

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Literature Search The authors searched PubMed on April 4, 2018 for English-language results from 1970 through 2018. The following search terms were used alone or in combination: pediatric ocular trauma, traumatic brain injury, ocular trauma, eye injury, pediatric ocular injuries, and pediatric head injuries.

Acknowledgments For their contributions and support, the authors thank Melvin Stone Jr, MD, Associate Director, Trauma Services & Surgical Critical Care, Department of Surgery, and James Meltzer, MD, Department of Pediatrics, Jacobi Medical Center, Bronx, New York. References 1. Neurological Disorders: Public Health Challenges. Available at: http://www.who.int/mental_health/neurology/en/. Accessed February 20, 2018. 2. Thornhill S, Teasdale GM, Murray GD, McEwen J, Roy CW, Penny KI. Disability in young people and adults one year after head injury: prospective cohort study. BMJ 2000;320:1631-5. 3. Schneier AJ, Shields BJ, Hostetler SG, Xiang H, Smith GA. Incidence of pediatric traumatic brain injury and associated hospital resource utilization in the United States. Pediatrics 2006;118:483-92. 4. Vasa RA, Suskauer SJ, Thorn JM, et al. Prevalence and predictors of affective lability after paediatric traumatic brain injury. Brain Inj 2015; 29:921-8. 5. Shultz EL, Hoskinson KR, Keim MC, et al. Adaptive functioning following pediatric traumatic brain injury: Relationship to executive function and processing speed. Neuropsychology 2016;30:830-40. 6. Ventura RE, Balcer LJ, Galetta SL. The neuro-ophthalmology of head trauma. Lancet Neurol 2014;13:1006-16. 7. Zahavi A, Luckman J, Yassur I, Michowiz S, Goldenberg-Cohen N. Severe cranial neuropathies caused by falls from heights in children. Graefes Arch Clin Exp Ophthalmol 2016;254:765-72. 8. Phillipou A, Douglas J, Krieser D, Ayton L, Abel L. Changes in saccadic eye movement and memory function after mild closed head injury in children. Dev Med Child Neurol 2014;56:337-45. 9. Weichel ED, Colyer MH, Bautista C, Bower KS, French LM. Traumatic brain injury associated with combat ocular trauma. J Head Trauma Rehabil 2009;24:41-50. 10. Gise R, Truong T, Parsikia A, Mbekeani JN. Visual Pathway Injuries in Pediatric Ocular Trauma-A Survey of the National Trauma Data Bank From 2008 to 2014. Pediatr Neurol 2018;85:43-50. 11. National Trauma Data Bank. 2018. Available at: https://www.facs. org/quality-programs/trauma/ntdb. Accessed April 18, 2018. 12. Report to Congress: The Management of Traumatic Brain Injury in Children. Atlanta, Ga: National Center for Injury Prevention and Control; Divion of Unintentional Injury Prevention; 2018. Available at: https://www.cdc.gov/traumaticbraininjury/pdf/reportstocongress/ managementoftbiinchildren/TBI-ReporttoCongress-508.pdf. Accessed April 18, 2018. 13. Garcia TA, McGetrick BA, Janik JS. Spectrum of ocular injuries in children with major trauma. J Trauma 2005;59:169-74. 14. Chen C, Shi J, Stanley RM, Sribnick EA, Groner JI, Xiang H. U.S. trends of ED visits for pediatric traumatic brain injuries: implications for clinical trials. Int J Environ Res Public Health 2017;14. pii: E414. 15. Kulkarni AR, Aggarwal SP, Kulkarni RR, Deshpande MD, Walimbe PB, Labhsetwar AS. Ocular manifestations of head injury: a clinical study. Eye (Lond) 2005;19:1257-63. 16. Strahlman E, Elman M, Daub E, Baker S. Causes of pediatric eye injuries. A population-based study. Arch Ophthalmol 1990;108:603-6. 17. Barmparas G, Dhillon NK, Smith EJT, et al. Assault in children admitted to trauma centers: Injury patterns and outcomes from a

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19. 20. 21.

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Gise et al 5-year review of the national trauma data bank. Int J Surg 2017;43: 137-44. Haider AH, Efron DT, Haut ER, DiRusso SM, Sullivan T, Cornwell EE 3rd. Black children experience worse clinical and functional outcomes after traumatic brain injury: an analysis of the National Pediatric Trauma Registry. J Trauma 2007;62:1259-62. discussion 62-63. Garcia TA, McGetrick BA, Janik JS. Ocular injuries in children after major trauma. J Pediatr Ophthalmol Strabismus 2005;42:349-54. Shokunbi T, Agbeja A. Ocular complications of head injury in children. Childs Nerv Syst 1991;7:147-9. Dewan MC, Mummareddy N, Wellons JC 3rd, Bonfield CM. Epidemiology of global pediatric traumatic brain injury: qualitative review. World Neurosurg 2016;91:497-509.e1. Odebode TO, Ademola-Popoola DS, Ojo TA, Ayanniyi AA. Ocular and visual complications of head injury. Eye (Lond) 2005;19:561-6.

Volume - Number - / - 2018 23. Sharma B, Gupta R, Anand R, Ingle R. Ocular manifestations of head injury and incidence of post-traumatic ocular motor nerve involvement in cases of head injury: a clinical review. Int Ophthalmol 2014;34:893-900. 24. Ament JD, Greenan KN, Tertulien P, Galante JM, Nishijima DK, Zwienenberg M. Medical necessity of routine admission of children with mild traumatic brain injury to the intensive care unit. J Neurosurg Pediatr 2017;19:668-74. 25. Holmes JM, Clarke MP. Amblyopia. Lancet 2006;367:1343-51. 26. Holmes JM, Mutyala S, Maus TL, Grill R, Hodge DO, Gray DT. Pediatric third, fourth, and sixth nerve palsies: a population-based study. Am J Ophthalmol 1999;127:388-92. 27. Van Stavern GP, Biousse V, Lynn MJ, Simon DJ, Newman NJ. Neuroophthalmic manifestations of head trauma. J Neuroophthalmol 2001; 21:112-17.

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eFIG 1. Age distribution by sex of pediatric ocular injury and TBI, National Trauma Data Bank (2008-2014).

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eFIG 2. Frequency of mechanism of ocular injury associated with pediatric TBI, National Trauma Data Bank (2008-2014).

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eFIG 3. Age association with mechanism of pediatric ocular trauma and traumatic brain injury, NTDB (2008-2014).

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eTable 1. Simple logistic regression analysis of injury severity scores vs mechanism of concomitant pediatric ocular injury and traumatic brain injury, National Trauma Data Bank, 2008-2014 Confidence interval Mechanism Falls

SBA

MVTO

MVT-pedestrian

Firearms

ISS (total frequency)

Frequency (%)

P value

OR

Low

High

1-8 [minor] (n 5 6367) 9-15 [moderate] (n 5 8953) 16-24 [severe] (n 5 7041) .24 [very severe] (n 5 6753) 1-8 [minor] (n 5 6367) 9-15 [moderate] (n 5 8953) 16-24 [severe] (n 5 7041) .24 [very severe] (n 5 6753) 1-8 [minor] (n 5 6367) 9-15 [moderate] (n 5 8953) 16-24 [severe] (n 5 7041) .24 [very severe] (n 5 6753) 1-8 [minor] (n 5 6367) 9-15 [moderate] (n 5 8953) 16-24 [severe] (n 5 7041) .24 [very severe] (n 5 6753) 1-8 [minor] (n 5 6367) 9-15 [moderate] (n 5 8953) 16-24 [severe] (n 5 7041) .24 [very severe] (n 5 6753)

1047 (16.4) 1227 (13.7) 693 (9.8) 367 (5.4) 1579 (24.8) 1563 (17.5) 522 (7.4) 190 (2.8) 1982 (31.1) 2642 (29.5) 2590 (36.8) 2867 (42.5) 241 (3.8) 477 (5.3) 432 (6.1) 522 (7.7) 35 (0.5) 204 (2.3) 292 (4.1) 503 (7.4)

\0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 0.042 0.104 \0.001 \0.001 \0.001 0.002 \0.001

1.761 1.361 0.803 0.376 2.968 1.65 0.45 0.148 0.817 0.716 1.133 1.549 0.586 0.893 1.098 1.545 0.12 0.543 1.244 3.309

1.627 1.262 0.735 0.336 2.763 1.539 0.409 0.127 0.77 0.679 1.071 1.465 0.51 0.801 0.981 1.388 0.086 0.465 1.083 2.919

1.906 1.467 0.877 0.42 3.188 1.769 0.496 0.171 0.868 0.755 1.198 1.638 0.674 0.996 1.229 1.72 0.169 0.634 1.428 3.75

GCS, Glasgow Coma Score; ISS, Injury Severity Score; MVTO, motor vehicle trauma as occupant; MVT-Pedestrian, motor vehicle trauma as pedestrian; OR, odds ratio; SBA, struck by or against. eTable 2. Simple logistic regression analysis of Glasgow coma scores versus mechanism of concomitant pediatric ocular injury and traumatic brain injury, National Trauma Data Bank, 2008-2014 Confidence interval Mechanism Falls SBA MVTO MVT-pedestrian Firearms

GCS (total frequency)

Frequency (%)

P value

OR

Low

High

13-15 [minor] (n 5 19098) 9-12 [moderate] (n 5 1618) \8 [severe] (n 5 6979) 13-15 [minor] (n 5 19098) 9-12 [moderate] (n 5 1618) \8 [severe] (n 5 6979) 13-15 [minor] (n 5 19098) 9-12 [moderate] (n 5 1618) \8 [severe] (n 5 6979) 13-15 [minor] (n 5 19098) 9-12 [moderate] (n 5 1618) \8 [severe] (n 5 6979) 13-15 [minor] (n 5 19098) 9-12 [moderate] (n 5 1618) \8 [severe] (n 5 6979)

2513 (13.2) 167 (10.3) 382 (5.5) 3227 (16.9) 148 (9.1) 268 (3.8) 6304 (33.0) 599 (37.0) 2894 (41.5) 1037 (5.4) 132 (8.2) 587 (8.4) 424 (2.2) 74 (4.6) 525 (7.5)

\0.001 0.331 \0.001 \0.001 \0.001 \0.001 \0.001 0.153 \0.001 \0.001 0.002 \0.001 \0.001 0.053 \0.001

2.221 0.922 0.39 3.999 0.651 0.205 0.72 1.079 1.418 0.629 1.338 1.536 0.303 1.269 3.302

2.018 0.782 0.349 3.598 0.547 0.181 0.683 0.972 1.341 0.57 1.112 1.385 0.267 0.996 2.912

2.445 1.087 0.435 4.444 0.773 0.233 0.759 1.197 1.499 0.694 1.609 1.702 0.344 1.617 3.745

GCS, Glasgow coma score; MVTO, motor vehicle trauma as occupant; MVT-pedestrian, motor vehicle trauma as pedestrian; OR, odds ratio.

Journal of AAPOS

Volume - Number - / - 2018

Gise et al

6.e3

eTable 3. Simple logistic regression analysis of race and ethnicity versus location of concomitant pediatric ocular injury and traumatic brain injury, National Trauma Data Bank, 2008-2014 Confidence interval Race/ethnicity White

Black

Hispanic

Location (total frequency)

Frequency (%)

P value

OR

Low

High

Home (n 5 7298) Farm (n 5 219) Industry (n 5 109) Mine (n 5 6) Public building (n 5 1154) Recreation (n 5 2692) Residential institution (n 5 153) Street (n 5 16010) Home (n 5 7298) Farm (n 5 219) Industry (n 5 109) Mine (n 5 6) Public building (n 5 1154) Recreation (n 5 2692) Residential institution (n 5 153) Street (n 5 16010) Home (n 5 7298) Farm (n 5 219) Industry (n 5 109) Mine (n 5 6) Public building (n 5 1154) Recreation (n 5 2692) Residential institution (n 5 153) Street (n 5 16010)

4283 (58.7) 185 (84.5) 71 (65.1) 4 (66.7) 665 (57.6) 2044 (75.9) 70 (45.8) 9842 (61.5) 1275 (17.5) 8 (3.7) 5 (4.6) 1 (16.7) 212 (18.4) 187 (6.9) 45 (29.4) 2613 (16.3) 1246 (17.1) 11 (5) 24 (22) 1 (16.7) 181 (15.7) 258 (9.6) 26 (17) 2555 (16.0)

\0.001 \0.001 0.393 0.782 0.012 \0.001 \0.001 0.241 \0.001 \0.001 0.001 1 0.031 \0.001 \0.001 0.251 \0.001 \0.001 0.071 0.95 0.96 \0.001 0.669 0.277

0.875 3.48 1.188 1.27 0.859 2.12 0.534 1.027 1.139 0.197 0.25 1.043 1.182 0.367 2.184 1.035 1.136 0.282 1.514 1.071 0.996 0.544 1.097 1.034

0.83 2.412 0.8 0.233 0.763 1.935 0.388 0.982 1.062 0.097 0.102 0.122 1.015 0.315 1.541 0.976 1.059 0.153 0.962 0.125 0.847 0.477 0.718 0.974

0.923 5.02 1.762 6.937 0.968 2.323 0.735 1.074 1.22 0.398 0.614 8.933 1.376 0.427 3.096 1.099 1.218 0.517 2.385 9.168 1.171 0.621 1.674 1.098

OR, odds ratio.

Journal of AAPOS