[version 2; peer review: 1 approved, 2 approved with reservations]
No competing interests were disclosed.
Motorcycle accidents can be particularly hazardous, as riders are exposed to various risk factors, such as high speeds, lack of protective enclosures, and limited safety features.
To describe the ocular injuries associated with motorcycled accidents presented to tertiary hospitals and forensic centers in Iraq.
The study was conducted in three Teaching hospitals and forensic centers in Baghdad and Al-Qadisiyah in Iraq. Information regarding ocular injuries, recorded and classified according to the International Ocular Trauma Classification, was gathered from motorcycle crash injuries that were presented to the emergency departments of these facilities from June 1, 2019, to June 1, 2023
The study involved 335 ophthalmological accidents; the mean age of the patients was 27.84± 9.6 years, most of them were males (96.7%), and there were only 11 females as passengers, 39 (11.6%) had injuries in both eyes. Lesions involving the periorbita, lids, and conjunctiva comprised most of the findings. There were 60.9% of patients with lid lacerations with or without sub-conjunctival bleeding, 22.1% with corneoscleral injury, and 17.9% with commotio retinae. It was the leading cause of decreased visual acuity, with 9% having lens capsule damage with or without iris prolapse and 8.1% having a ruptured capsule, 55.82% of patients had a mild injury, 27.16% had a moderate injury, and 17.01% had a severe injury.
Eye injury associated with motorcycle accidents mainly affects males in their youth age and has serious outcomes, sometimes ending with blindness.
Based on the reviewers recommendation, we added the total prevalence of ocular injuries from all monocycle injuries reported, we improved the introduction, methods, results and discussion. and the article now is more comprehensive.
Millions of injuries occur worldwide as a result of road traffic accidents, making them the primary cause of death in adolescents and adults across the world.
The lack of strict enforcement of licensing regulations has created opportunities for individuals to obtain licenses without undergoing required eye tests or demonstrating riding proficiency.
Although ocular trauma imposes a substantial burden on ophthalmic services, constituting 38-52% of all new patients seeking emergency care at hospitals due to accidents.
Enock
This study presented motorcycle accident injuries patients to the Emergency Department from June 1, 2019, to June 1, 2023. After admission, patients were screened to identify the motorcycle injuries that presented ocular trauma; for those identified to have ocular trauma, written consent was sought and obtained from the patients to participate in the study. Information was obtained from the injured patients, whether they were stable enough or from those who accompanied them for care. Written consent was obtained from the patients if they were over 18 years old or from their caregivers after providing an adequate explanation of the aims and methods of the study. Further information was gathered on the age, sex, laterality, type of ocular injury, ocular findings, lesion severity, and visual acuity. The information regarding ocular injuries was classified and recorded according to the International Ocular Trauma Classification.
According to the World Health Organization (WHO), Iraq’s healthcare system has 2,652 facilities, of which 61 are teaching hospitals. This study was conducted in two governorates (Baghdad, the Iraqi capital, and Al-Qadisiyah), a total of three teaching hospitals: Ibn Al-Haitham Teaching Hospital (in Baghdad), Al-Nauman Teaching Hospital (in Baghdad), and Al-Diwaniyah Teaching Hospital (in Al-Diwaniyah), and the three forensic centers associated with these hospitals. Patients were interviewed initially in the emergency department; if the ocular trauma related to motorcycle injuries were confirmed, the patient would be transferred to the ophthalmology department when the patient was managed and interviewed for the study.
Ibn Al-Haitham Teaching Hospital is Iraq’s primary and largest ophthalmology hospital. This hospital only receives patients with ophthalmological conditions. It has a large inpatient capacity (200 beds) and many operating rooms (16 Operating Rooms) for various ophthalmic procedures. Al-Nauman Teaching Hospital is one of the largest teaching hospitals in Baghdad, and it contains various departments, including emergency and ophthalmology departments. Finally, Al-Diwaniyah Teaching Hospital is the largest teaching hospital in the Al-Diwaniyah governorate, with large emergency and ophthalmology departments.
Patients of all ages and both sexes are presented with ocular injuries during motorcycle accidents.
Patients who refused to participate in the study.
This study was approved by the Research Ethics Committee at Al-Qadisiyah University, College of Medicine. (Approval no.: 25/285, on 22 nd of May 2019).
Sample size estimation was based on the following equation:
Where n is the minimum sample size, p is the prevalence of ocular trauma was 13.5% based on a previous study
Descriptive statistics were used that included frequency and percentage; GraphPad Prism version 10 was used for the analysis.
During the four years of the study, 6,243 patients presented with motorcycle injuries in the three Teaching hospitals and their forensic centers. Of those (5.37%), 335 patients were identified to have ocular trauma from the road crash.
| Characteristic | N (%) |
|---|---|
| Number of cases | 335 |
| Age | |
| <18 year | 121 (36.1%) |
| 18-50 years | 142 (42.4%) |
| >50 years | 72 (21.5%) |
| Sex | |
| Male | 324 (96.7%) |
| Female
|
11 (3.3%) |
| Eye involved | |
| One eye | 296 (88.4%) |
| Both eyes | 39 (11.6%) |
The involvement of females was as passengers.
Regarding the type of eye lesions during their presentation, there were 60.9% of patients with lid laceration ± sub-conjunctival hemorrhage, 22.1% with corneoscleral injury, 17.9% with commotio retinae and it was the leading cause of decreased visual acuity, 9% with lens capsule damage ± iris prolapse, and 8.1% with ruptured capsule, as shown in
| Presenting lesion
|
N (%) |
|---|---|
| Lid laceration ± subconjunctival hemorrhage | 204 (60.9%) |
| Hyphema | 90 (26.9%) |
| Cornea ± scleral wound | 74 (22.1%) |
| Commotio retinae | 60 (17.9%) |
| Lens capsule damage ± iris prolapse | 30 (9.0%) |
| Rupture globe | 27 (8.1%) |
| Diplopia (blunt trauma) | 17 (5.1%) |
| Blowout fracture | 13 (3.9%) |
This grouping concentrates on the presenting and most severe injury.
After applying the International Ocular Trauma Classification system, 55.82% of patients had a mild injury, 27.16% had a moderate injury and 17.01% had a severe injury, as shown in
| Severity | No (%) |
|---|---|
| Mild | 187 (55.82%) |
| Moderate | 91 (27.16%) |
| Severe | 57 (17.01%) |
The visual acuity of the participants ranged from 6/6 to no light perception, 59.1% of patients had visual acuity better than 6/18, 29.0% from 6/18 to 6/60, 8.1% from 6/60 to counting fingers, and 3.9% with no light perception, as shown in
| Snellen visual acuity | N (%) |
|---|---|
| Better than 6/18 | 198 (59.1%) |
| Between 6/18-6/60 | 97 (29.0%) |
| 6/60-CF | 27 (8.1%) |
| Non-seeing eye | 13 (3.9%) |
Ocular injuries resulting from motorcycle accidents can range from mild to severe and can have lasting effects on vision; motorcycle accidents often expose riders to various types of impact debris and forces that can directly or indirectly lead to ocular injuries.
In the current study, patient injuries included lid lacerations and sub-conjunctival hemorrhage, corneoscleral injury, commotio retinae, lens capsule damage ± iris prolapse, ruptured capsule, and orbital blowout fractures. Soft tissue injuries were the most prevalent probably because of the very limited use of helmets in our country. None of the current studies reported using helmets regularly, Arif
Direct contact between the eye and a chemical (
Since only two governates out of 18 limit the conclusion, at the same time, it gives us an initial assessment of the seriousness of the ocular injuries, a national study that involves most of the country is necessary.
In summary, the analysis of eye injuries associated with motorcycle accidents highlights a significant concern primarily affecting young males. The outcomes of these incidents can be particularly severe, at times resulting in permanent blindness. Policymakers, traffic safety authorities, and healthcare professionals must address this issue with targeted interventions and awareness campaigns. By emphasizing the importance of proper protective gear, safe riding practices, and education, we can work towards reducing the occurrence of such injuries and minimizing their life-altering consequences. Furthermore, fostering a culture of responsible riding and enhancing road infrastructure can contribute to safer roads for all, ultimately preventing these devastating eye injuries and their far-reaching impacts on individuals and society as a whole.
Zenodo: Ocular Injuries Caused by Motorcycle Accidents [Data set].
The project contains the following underlying data:
Data sets of Ocular Injuries Caused by Motorcycle Accidents.
Zenodo: Ocular Injuries Caused by Motorcycle Accidents.
The project contains the following underlying data:
STROBE Checklist.
Data are available under the terms of the
This article deals with the important subject of ocular injury by motorcycles; no previous study estimates the impact of these accidents in Iraq. Additionally, this study reports initial estimates regarding the type of injuries. Since it was carried out in multiple centers, this will provide a broader picture of the current problem in multiple centers.
I have several minor questions:
1/ Please calculate the 95% confidence interval of the overall prevalence of ocular injuries.
2/ Why did you choose this particle type of equation to calculate the sample size, and what is the power of detection?
3/ To better present your data, I recommend adding Figures, not just tables, as part of your results.
4/ Please emphasize the study recommendations (Future perspective).
Best regards
Is the work clearly and accurately presented and does it cite the current literature?
Yes
If applicable, is the statistical analysis and its interpretation appropriate?
Not applicable
Are all the source data underlying the results available to ensure full reproducibility?
Yes
Is the study design appropriate and is the work technically sound?
Yes
Are the conclusions drawn adequately supported by the results?
Yes
Are sufficient details of methods and analysis provided to allow replication by others?
Yes
Reviewer Expertise:
Ophthalmology
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
The study is now a good read, Informative & comprehensive.
Is the work clearly and accurately presented and does it cite the current literature?
Yes
If applicable, is the statistical analysis and its interpretation appropriate?
Partly
Are all the source data underlying the results available to ensure full reproducibility?
Yes
Is the study design appropriate and is the work technically sound?
Yes
Are the conclusions drawn adequately supported by the results?
Yes
Are sufficient details of methods and analysis provided to allow replication by others?
Yes
Reviewer Expertise:
Public Health, Healthcare Strategy, Healthcare Administration, Community Eye Health, Diabetes, Medical imaging, Ophthalmology, Optometry, Medical Investigations & research, Cell biology research
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
What went well?
The comprehensive study conducted across multiple centres in Iraq provides valuable insights into the ocular injuries resulting from motorcycle accidents. The meticulous classification of injuries according to the International Ocular Trauma Classification has allowed for a detailed understanding of the types and severities of ocular trauma. The findings highlight the importance of protective gear and safety measures for motorcyclists, as the majority of injuries were to young males, indicating a demographic at high risk. The study's extensive data collection over four years offers a solid foundation for developing strategies to prevent such injuries and improve outcomes for those affected. It's a significant step towards enhancing road safety and healthcare protocols for ocular injuries in Iraq and potentially other regions with similar contexts.
The study gap
The study presents a significant contribution to understanding the ocular trauma associated with motorcycle accidents in Iraq, highlighting the prevalence of such injuries among young male riders. However, the research reveals gaps that warrant further investigation. The disproportionate representation of male patients could be indicative of cultural or behavioral patterns that influence motorcycle usage and risk exposure, suggesting a need for gender-specific safety interventions. Additionally, the study's focus on tertiary centers in urban areas may not capture the full spectrum of ocular injuries, particularly those treated in rural or non-hospital settings. The classification of injuries, while standardized, does not account for long-term outcomes or the socioeconomic impact on the patients. Future studies could benefit from a longitudinal approach, assessing the recovery trajectory and quality of life post-injury, as well as exploring preventive measures tailored to the local context. Moreover, integrating multidisciplinary perspectives, including ophthalmology, trauma surgery, and public health, could provide a more comprehensive understanding of the factors contributing to these injuries and the strategies needed to mitigate them.
Statistical significance is missing in the results.
Is the work clearly and accurately presented and does it cite the current literature?
Yes
If applicable, is the statistical analysis and its interpretation appropriate?
Partly
Are all the source data underlying the results available to ensure full reproducibility?
Yes
Is the study design appropriate and is the work technically sound?
Yes
Are the conclusions drawn adequately supported by the results?
Yes
Are sufficient details of methods and analysis provided to allow replication by others?
Yes
Reviewer Expertise:
Public Health, Healthcare Strategy, Healthcare Administration, Community Eye Health, Diabetes, Medical imaging, Ophthalmology, Optometry, Medical Investigations & research, Cell biology research
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
Dear Reviewer,
What went well?
The comprehensive study conducted across multiple centres in Iraq provides valuable insights into the ocular injuries resulting from motorcycle accidents. The meticulous classification of injuries according to the International Ocular Trauma Classification has allowed for a detailed understanding of the types and severities of ocular trauma. The findings highlight the importance of protective gear and safety measures for motorcyclists, as the majority of injuries were to young males, indicating a demographic at high risk. The study's extensive data collection over four years offers a solid foundation for developing strategies to prevent such injuries and improve outcomes for those affected. It's a significant step towards enhancing road safety and healthcare protocols for ocular injuries in Iraq and potentially other regions with similar contexts.
The study gap
1/ The study presents a significant contribution to understanding the ocular trauma associated with motorcycle accidents in Iraq, highlighting the prevalence of such injuries among young male riders. However, the research reveals gaps that warrant further investigation. The disproportionate representation of male patients could be indicative of cultural or behavioral patterns that influence motorcycle usage and risk exposure, suggesting a need for gender-specific safety interventions.
We agree with the reviewer the high prevalence of ocular injuries in males is attributed to couturier factors, such as males representing the majority of the drivers in our country, and which will lead to a higher proportion of males inflicted with ocular injuries.
2/ Additionally, the study's focus on tertiary centers in urban areas may not capture the full spectrum of ocular injuries, particularly those treated in rural or non-hospital settings.
We chose the largest hospitals in the country since other locations have low presentation of such access. We agree with the reviewer that there is a strong need to examine ocular injury in non-tertiary hospitals and other health care facilities. However, this is beyond the scope of the current study.
3/ The classification of injuries, while standardized, does not account for long-term outcomes or the socioeconomic impact on the patients. Future studies could benefit from a longitudinal approach, assessing the recovery trajectory and quality of life post-injury, as well as exploring preventive measures tailored to the local context. Moreover, integrating multidisciplinary perspectives, including ophthalmology, trauma surgery, and public health, could provide a more comprehensive understanding of the factors contributing to these injuries and the strategies needed to mitigate them.
We agree with the reviewer that this work should be the basis of further studies in this direction.
4/ Statistical significance is missing in the results.
This is a descriptive study; there is no comparison between the different groups, so no statistical analysis applies to the current work.
Best regards
I have gone through the work. This is an important study that touches on a major public health concern, ocular injuries. However, the study needs to be revised and additional information added to it to make it complete. For example, the background of the study needs to be revised to improve on its readability. I have provided details in track changes which can be viewed in the file linked
The Section on Methods needs to be reexamined. For example, the authors should make it clear to readers, who may not be familiar with the study settings, sufficient geographical to introduce the study sites. Many readers may not be familiar with Iraq or the teaching hospitals and forensic centers. Equally important is to add the reasons why the teaching hospitals and forensic centers were chosen. (I have included an example of a study that has shown how to do this in a reference indicated in track changes). It should also be made clear where exactly the study participants were gotten, were they Emergency Departments? The authors should consider revising the findings and present them according to conventions of reporting scientific findings. The findings reported in this study started presenting ages and sex. It would be important for the readers to know the denominator, the total number of participants then proceed to present the distribution different categories .
The authors should strive to improve the discussion section by focusing the discussion on how the major findings of the study relates with other findings in previous studies. This has not been adequately achieved. The public health implication of the study findings and the implication of the findings to practice and policy should be addressed where possible. Consider also revising the study limitations and draw three or four from study design, settings or data collection instruments.
The work is a good effort but it can still be improved.
I have also taken an effort to be more clear by adding proposed suggestions in track changes. If this is required Ill provide it. I think it has captured lots of details as well.
Is the work clearly and accurately presented and does it cite the current literature?
Yes
If applicable, is the statistical analysis and its interpretation appropriate?
Partly
Are all the source data underlying the results available to ensure full reproducibility?
Yes
Is the study design appropriate and is the work technically sound?
Partly
Are the conclusions drawn adequately supported by the results?
Yes
Are sufficient details of methods and analysis provided to allow replication by others?
Partly
Reviewer Expertise:
My areas of research are in Epidemiology with emphasis on Epidemiology of NCDs and road traffic injuries.
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
Dear Reviewer,
I have gone through the work. This is an important study that touches on a major public health concern, ocular injuries. However, the study needs to be revised and additional information added to it to make it complete. For example, the background of the study needs to be revised to improve on its readability. I have provided details in track changes which can be viewed in the file linked
1/ The reference needs to be counterchecked. The authors talk of the American Academy of Ophthalmology that has an annual occurrence of 2.5 million eye injuries. However, the references appear to be from other sources, not the academy. Kindly countercheck and update appropriately.
Reference 3 was counterchecked, and it was inappropriately placed; below is the correct reference:
American Academy of Ophthalmology and American Society of Ocular Trauma, United States Eye Injury Registry summary report, 1998–2002. Available at:
2/ Also consider revising the sentence. Do the authors mean , for example, or could consider this kind of wordings: “ According to the America Academy of Ophthalmology, a total of 2.5 million eye injuries are reported/occur in USA annually, with 50,000 individuals experiencing either partial or complete loss of vision” (American Academy of Ophthalmology Report, 20..)
We agree with the reviewer; the entire sentence lacks clarity; as such, we rephrase it to the following:
According to the American Academy of Ophthalmology, 2.5 million eye injuries are reported/occur in the USA annually, with 50,000 individuals experiencing either partial or complete loss of vision.
3/Regarding the number of previous studies on motorcycle accidents in Iraq,
This is the first study to examine motorcycle ocular injury in Iraq; as such, no previous study can be reported. We used estimated facts from developing countries to reflect the numbers.
4/ The Section on Methods needs to be reexamined. For example, the authors should make it clear to readers, who may not be familiar with the study settings, sufficient geographical to introduce the study sites. Many readers may not be familiar with Iraq or the teaching hospitals and forensic centers. Equally important is to add the reasons why the teaching hospitals and forensic centers were chosen. (I have included an example of a study that has shown how to do this in a reference indicated in track changes).
We agree with the review suggestion; we included more details regarding the requested information as mentioned below:
2.1 Study design
This study presented motorcycle accident injuries patients to the Emergency Department from June 1, 2019, to June 1, 2023. After admission, patients were screened to identify the motorcycle injuries that presented ocular trauma; for those identified to have ocular trauma, written consent was sought and obtained from the patients to participate in the study. Information was obtained from the injured patients, whether they were stable enough or from those who accompanied them for care. Written consent was obtained from the patients if they were over 18 years old or from their caregivers after providing an adequate explanation of the aims and methods of the study. Further information was gathered on the age, sex, laterality, type of ocular injury, ocular findings, lesion severity, and visual acuity. The information regarding ocular injuries was classified and recorded according to the International Ocular Trauma Classification 20. Previous studies have used this classification and scoring method to classify ocular traumas according to visual acuity, pupillary light response, zone, and type of injury.
2.2 Study settings
According to the World Health Organization (WHO), Iraq's healthcare system has 2,652 facilities, of which 61 are teaching hospitals. This study was conducted in two governorates (Baghdad, the Iraqi capital, and Al-Qadisiyah), a total of three teaching hospitals: Ibn Al-Haitham Teaching Hospital (in Baghdad), Al-Nauman Teaching Hospital (in Baghdad), and Al-Diwaniyah Teaching Hospital (in Al-Diwaniyah), and the three forensic centers associated with these hospitals. Patients were interviewed initially in the emergency department; if the ocular trauma related to motorcycle injuries were confirmed, the patient would be transferred to the ophthalmology department when the patient was managed and interviewed for the study.
Ibn Al-Haitham Teaching Hospital is Iraq's primary and largest ophthalmology hospital. This hospital only receives patients with ophthalmological conditions. It has a large inpatient capacity (200 beds) and many operating rooms (16 Operating Rooms) for various ophthalmic procedures. Al-Nauman Teaching Hospital is one of the largest teaching hospitals in Baghdad, and it contains various departments, including emergency and ophthalmology departments. Finally, Al-Diwaniyah Teaching Hospital is the largest teaching hospital in the Al-Diwaniyah governorate, with large emergency and ophthalmology departments.
5/ It should also be made clear where exactly the study participants were gotten, were they Emergency Departments? The authors should consider revising the findings and present them according to conventions of reporting scientific findings. The findings reported in this study started presenting ages and sex. It would be important for the readers to know the denominator, the total number of participants then proceed to present the distribution different categories .
The answer to this question is provided in the previous question.
6/ The authors should strive to improve the discussion section by focusing the discussion on how the major findings of the study relates with other findings in previous studies. This has not been adequately achieved. The public health implication of the study findings and the implication of the findings to practice and policy should be addressed where possible. Consider also revising the study limitations and draw three or four from study design, settings or data collection instruments.
The work is a good effort but it can still be improved.
We improved both the results and the discussion accordingly.
Abstract
The study was conducted in three Teaching hospitals and forensic centers in Baghdad and Al-Qadisiyah in Iraq. Information regarding ocular injuries, recorded and classified according to the International Ocular Trauma Classification, was gathered from motorcycle crash injuries that were presented to the emergency departments of these facilities from June 1, 2019, to June 1, 2023.
Results
During the four years of the study, 6,243 patients presented with motorcycle injuries in the three Teaching hospitals and their forensic centers. Of those (5.37%), 335 patients were identified to have ocular trauma from the road crash. Table 1 presents the characteristics of motorcycle crash cases with ocular trauma. The ages of those with ocular trauma ranged from 10 to 67 years old, with a mean age of 27.84± 9.6 years. Most of them were 324 (96.7%) males, with a male-to-female ratio of 29 to 1, and there were only 11 females as passengers; 39 (11.6%) had injuries in both eyes, as shown in Table 1.
Regarding the type of eye lesions during their presentation, there were 60.9% of patients with lid laceration with or without sub-conjunctival hemorrhage, 22.1% with corneoscleral injury, 17.9% with commotio retinae, and it was the leading cause of decreased visual acuity, 9% with lens capsule damage with or without iris prolapse, and 8.1% with ruptured capsule, as shown in Table 2.
7/ I have also taken an effort to be more clear by adding proposed suggestions in track changes. If this is required Ill provide it. I think it has captured lots of details as well.
I appreciate your help; your notes and corrections improved the work, and we changed the article accordingly.
Best regards