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Socioeconomic status and decreasing incidence of ocular injuries in Bosnia and Herzegovina


Zvorničanin, Jasmin; Zvorničanin, Edita (2021), Socioeconomic status and decreasing incidence of ocular injuries in Bosnia and Herzegovina, Dryad, Dataset,


Purpose: To examine the epidemiologic and clinical characteristics of ocular injuries and their association with socioeconomic status (SES).

Material and Methods: All cases of ocular injuries hospitalized in Department of Ophthalmology of University Clinical Center Tuzla, Bosnia and Herzegovina, from January 2009 to December 2012 and January 2017 and December 2019 were prospectively followed. The injuries were classified according to Ocular Trauma Classification System (OTCS) and Birmingham Eye Trauma Terminology (BETT).

Results: This study included a total of 420 eyes from 396 patients. There were 162 (38.57%; 95%CI:32.86–44.99) open globe injuries (OGI) and 258 (61.43%; 95%CI: 54.16–69.4) closed globe injuries (CGI). The decrease in incidence of ocular trauma requiring hospitalization was noted from 16.7 per 100 000 (95%CI: 13.11–20.97) in 2009 to 9.25 per 100 000 (95%CI: 6.64–12.55) in 2019 (p=0.006). Most injuries occurred in males 341 (81.19%; 95%CI: 72.8–90.28), active working patients 258 (61.43%, 95%CI:54.16–69.4), and patients with rural residence 285 (67.86%; 95%CI: 60.21–76.21). Almost all ocular injuries 418 (99.52%; 95%CI: 90.21–109.54) occurred in patients with middle and lower SES categories, and home was the most prevalent place of injury in 258 (61.43%, 95%CI: 54.16–69.4) patients. The total of 289 (70.49%; 95%CI: 62.59–79.1) patients had good final best corrected visual acuity (BCVA). Poor final BCVA was associated with lower ocular trauma score (OTS) (p=0.000), poor initial BCVA (p=0.000), penetrating injuries of cornea (p=0.004) and sclera (p=0.001), Zone III injuries (p=0.000), intraocular foreign body presence (p=0.000), cataract (p=0.002), retinal detachment (p=0.001), endophthalmitis (p=0.000) and vitreous hemorrhage (p=0.010).

Conclusion: This study provides a detailed insight into epidemiology and socio-economic characteristics of patients hospitalized for ocular injuries.


Material and methods
This prospective epidemiological study included all consecutive patients with ocular injuries hospitalized in Department of Ophthalmology, University Clinical Center Tuzla, Bosnia and Herzegovina. The study covered two time periods, the first from 1 January 2009 to 31 December 2012 and the second from 1 January 2017 to 31 December 2019. The current study was approved by the University Clinical Center Tuzla Ethics Committee on September 1, 2008 (Approval number: 32-1-2008). A written informed consent was obtained from all patients and tenets of the Helsinki Declaration were followed.

University Clinical Center Tuzla is the only tertiary referral center that serves as the main health institution in the Tuzla Canton. It offers the emergency and specialized eye care for patients with ocular or orbital conditions. Tuzla Canton is in the north eastern part of Bosnia and Herzegovina. It covers the area of 2649 square km with 445028 inhabitants. The economy includes industries, commerce, agriculture, tourism, handicraft, and services. During eleven year period from 2009 to 2020, the population of Tuzla canton was relatively stable.13

In this study, ocular injury was defined as any injury of the eye or adnexa requiring hospitalization.14 The following demographic variables were recorded: age, sex, side of the eye involved, place of residence, level of education, occupation, and employment status. According to the Labor Law of Bosnia and Herzegovina, persons aged 18-65 are considered able to work. Therefore, for the purposes of this study, age was categorized into three groups: less than 18, 18-65, more than 65 years.12 Based on the highest level of formal education and occupation Hollingshead Two-Factor Index of Social Position (ISP) was calculated.15 Education level and job position were assigned with numeric values ranging 1-7, and multiplied with weighted scores 7 and 4 for occupation and education, respectively. The obtained values were combined to obtain ISP. For patients younger than 18 years the SES was calculated based on status of both parents. Based on the ISP values, all patients were categorized into three social classes: upper (11-27), middle (28-43), and lower social class (44-77). Occupations were grouped into five main categories: manual workers, fire and explosion hazard workers, agricultural workers, not working, and other.12

Injury information included: time of the injury onset (working time 8am-3pm, afternoon 4pm-11pm and late evening time 12pm-7am), season of injury (spring, summer, fall, winter), time from the injury occurrence to hospital admission (less than 2h, 2-12h, 12-48h and more than 2 days), duration of hospitalization (1-6 days; 7-13 days and 14 days or more) and information on the use of eye protection. According to the location of ocular injury, the data were classified in six groups: work related injuries, home related injuries, recreational/sport related injuries, road accident related injuries, assaults related injuries, and other various outdoor activities related injuries.14 According to injury mechanism patients were grouped into following categories: blunt force object, sharp force object, road and explosion, biologic or organic material, and other injuries.12

Clinical eye injury variables included types of injury categorized as closed (CGI) or open globe injuries (OGI). Other clinical signs such as: eyelid laceration, hyphaema, lens injury, and vitreous haemorrhage, were also recorded. The injuries were classified by Birmingham Eye Trauma Terminology (BETT), and the Ocular Trauma Score (OTS) was calculated subsequently.16,17 For the purposes of this study the OTS categories one, two, and three were grouped as category 1 (low OTS), and categories four and five as category 2 (high OTS).12 According to the wound location all injuries were classified as: Zone I, Zone II and Zone III injuries defined by Ocular Trauma Classification System (OTCS).18 The initial best corrected visual acuity (BCVA) was measured upon the hospital admission, while the final BCVA was taken on the hospital discharge. Initial and final BCVA were classified as no light perception (NLP), light perception (LP)/hand motion (HM), 1/200–19/200, 20/200–20/50, and ≥20/40. The final BCVA ≥ 20/200 was defined as good and final BCVA of less than 20/200 as poor visual outcome.19,20

Differences between means were analysed by Student t test. The Chi-square or Fisher exact test were used to assess the differences between categorical variables, and for continuous variables the analysis of variance (ANOVA) was used. A multivariate regression model was used to assess the risk factors for final BCVA. Statistically significant P values were considered those <0.05. The data were analysed using Stata Statistical Software, version 14.0 (StataCorp LP, College Station, Texas, USA).