Injuries to the eye are a common cause of emergency department (ED) visits in the pediatric age group. There were nearly 14 million ED visits for traumatic injuries in children under age 5 in 2017 in the US, and most of these occurred at a private residence [1]. The highest number of pediatric ED visits for ocular injury were reported in children ages 1-5 [2]. The goal of this study is to characterize the epidemiology of pediatric ocular injury in children (ages <5) occurring at home in the U.S from 2000-2019.

The National Electronic Injury Surveillance System (NEISS) database was utilized to source information for this retrospective epidemiologic study. NEISS, an injury surveillance system run by the Consumer Product Safety Commission (CPSC) gathers data on consumer-product related injuries and is a representative sample of 100 US hospital EDs. The inclusion criteria for this study were: ocular injury that occurred at home between January 1, 2000 and December 31, 2019 in patients under 5 years of age. The subjects were divided into age groups: <1 (age<12 months old); 1-year-olds (yo) (1≤ age <2 years of age); 2yo; 3yo; and 4yo. Prior to analysis, data weights, from the NEISS database, were applied to make estimates representative of the national population. All incidence calculations utilized population data from the US Census Bureau Intercensal estimates [3].

An estimated 258,071 total ED visits were identified for children age <5 due to an ocular injury at home caused by a consumer product, with 151,471 (58.7%) being in boys. Of these subjects, 35,216 (13.6%) were under age 1; 62,520 (24.2%) were 1yo; 66,970 (26.0%) were 2yo; 51,367 (19.9%) were 3yo and 41,998 (16.3%) were 4yo. Boys accounted for the majority of injuries among all age groups. The incidence of ocular injury at home in preschoolers was estimated at 5.45 per 10,000 persons in 2010 and 5.97 per 10,000 in 2019 (Figure 1).

Detergents/chemicals accounted for one-third of all eye injury-related ED visits followed by toys (30,677; 12%) (Figure 2). The top 3 subcategories within detergents/chemicals were laundry soaps or detergents (23.6%), non-cosmetic bleaches (19.7%) and general-purpose household cleaners (15.4%). The most common product categories, accounting for ≥70%, leading to ocular injury for boys and girls is shown in Table 1.

The most common eye injuries were ocular contusions (101,642; 39.4%), dermal/conjunctival injury (41,321; 16.0%), chemical burn (37,018; 14.9%), and other (36,216; 14.0%). Most patients were treated and released from the ED (250,070; 96.9%). Nineteen percent of the estimated 5,147 admitted/transferred to the hospital had an open globe injury (OGI) with an estimated mean of 50 OGIs per year. The male-to-female ratio of OGIs was 3.6:1.

The greatest number of ED visits for ocular injuries occurred in April and May, and the fewest injuries presented in February. Approximately 30% of injuries were seen on the weekend.

The findings illustrate that most consumer product-related ocular injuries presenting to the ED in the preschool age population between 2010-2019 were 1 and 2yo boys. One-third of the injuries were related to detergents/chemicals. Most injuries were mild, and these young patients were triaged in the ED and sent home, with ocular contusion being the most common diagnosis. Average daily ocular injuries that presented to the ED were higher for weekend days than weekdays. During the 20-year period,1990-2009, an estimated 296,369 ocular injuries occurred at home in children less than 5 years of age [4] compared to 258,071 in our study between 2000-2019, representing a 12.9% decrease in the estimated number of injuries presenting to the ED. In children 4 years or younger, the mean annual rate of ocular injury between 1990-2009 was 11.31 per 10,000 [4] compared to our finding of 5.74 per 10,000 during 2010-2019. The frequency of ocular injuries in preschool children younger than 5yo due to detergents/chemicals shows a downward trend over the past two decades. This finding can, in part, may be attributed to efforts by regulatory bodies such as the American Academy of Pediatrics (AAP) to educate parents [5]. Though specific brands for consumer products were not consistently reported, specific brands of laundry detergents reported in the dataset involved in ocular injuries included Bravo and Church and Dwight. Similarly, manufacturers of general-purpose cleaners involved in ocular injuries include Tangelo citrus cleaner and Odoban.

Like earlier studies [4,6], “chemicals” was identified as the most common consumer product that caused ocular injury at home in preschool-age children. Some have noted that the most common location of injury in this population was at home [7]. It has also been noted that the proportion of ocular injury due to chemicals is greatest in children <2 years of age [7,8]. In this study, an estimated 90,345 (35%) ocular injures at home were due to detergents/chemicals in children <5 years compared to 126,016 (28.2%) between 1990-2009 in the same population [4].

In this study, the 19,868 (7.7%) furniture-associated ocular injuries at home in children under 5 were much lower than the 76,816 (17.2%) noted in the previous decade,1990-2009 [4]. Safety efforts promoted by the AAP or the CPSC or the National Safety Council may have contributed to this decrease in furniture related injuries over the last decade [9,10].

Ocular injuries due to toys have been almost the same over the last 30 years. Pollard et al. noted an estimated 45,381 (10.1%) injuries in children less than 5yo due to toys from 1990-2009 and this current study estimated 30,677 (11.9%) ocular injuries due to toys in the same group between 2010-2019. We noted 8.5% of cases were caused by toys at home in toddlers 1-2 years of age and 9.2% of cases in infants (0-1yo cohort). Further safeguards against injury with children’s toys are needed at home.

Severe ocular injury causing open globes were reported in <1% cases. Boys accounted for over 75% of OGIs which is higher than previously reported. Children presenting with an OGI, on average, are younger for injuries documented at home compared to outdoors [11]. In addition, visual acuity outcomes following an OGI in the pediatric population are poor [12], and safeguards are needed to prevent these severe injuries.

General recommendations for prevention of ocular injury in this age group come from various organizations such as the American Academy of Ophthalmology. These include the use of safety latches/locks for cabinets with potentially harmful chemicals like laundry detergents, use of edge bumpers throughout the home to prevent injuries against sharp corners on furniture and choosing toys that are compliant with safety standards set by the American Society for Testing and Materials [9,13,14]. Should an injury occur, parents are recommended to not touch or rub the child’s eye even if an object can be seen stuck in the eye. They should seek out medical treatment emergently; however, if there has only been an ocular exposure to chemicals, it is recommended to immediately flush the eye with water [13].

As NEISS provides information for ocular injuries presenting to the ED, the database does not capture injuries managed at home, in urgent care settings, by community ophthalmologists and primary care physicians. Thus, the total number of injuries are likely an underrepresentation of the true frequency of consumer product-associated pediatric ocular injury. Injuries that did not present to emergency departments would not be included. Minor injuries may present to urgent care centers and doctor’s offices. Similarly, the demographic of patients may be skewed towards subjects with no insurance as they are more likely to utilize emergency departments over community-based physicians. Additionally, as visual acuity is not reported in the dataset, severity of injury is difficult to assess other than a suggestion that a patient being treated and released from the ED may have suffered a less severe injury than the patient admitted to the hospital. Finally, the database records consumer-product injuries based on narratives written in the electronic health record. Vague descriptions not meeting inclusion criteria would also not be included in the database.

Consumer product related ocular injuries occurring at home in preschool-age children (<5yo) are mostly seen in the toddler cohort (1-2-year-olds). These are predominantly ocular contusions and are most often caused by detergents/chemicals. Toys continue to cause 10% of ocular injuries in this cohort. Severe open globe injury was seen in less than 1 in 250 consumer product-related eye trauma cases in the preschool pediatric population.

There were no funding or grants for this manuscript.

1. MZ is a consultant for Genentech/Roche, Novartis Pharma AG, Frequency Therapeutics, Iveric Bio, Ophthotech, Perfuse Therapeutics, Selphagy, Iduna, and Life Biosciences. He is a stockholder for Frequency Therapeutics, Iveric Bio, and NVasc. He is Co-Founder of NVasc.
2. None of the following authors have any proprietary interests or conflicts of interest related to this submission: PP, AU, NB

Consumer Product Safety Commission. National Electronic Injury Surveillance System 2000-2019 on NEISS Online Database, released April 2020. Generated at https://www.cpsc.gov/cgibin/NEISSQuery/home.aspx