REVIEW ARTICLE

Ocular Trauma During COVID-19 Pandemic: A Systematic

Review and Meta-analysis
Huiyu Liang, MBBS*, Meiqin Zhang, MBBS*, Man Chen, MBBS*,
Timothy P.H. Lin, MBChB†, Mingying Lai, MD‡§, and Haoyu Chen, MD*

INTRODUCTION
Purpose: This study aimed to summarize the latest literature on the
trends and incidence of ocular trauma during the COVID-19 pandemic.
Design: Systematic review and meta-analysis.
T he coronavirus disease 2019 (COVID-19) caused by the
severe acute respiratory syndrome coronavirus 2 (SARS-
CoV-2) is one of the worst pandemics of humankind.1,2 As of
Methods: A systematic literature search was conducted to identify the
January 10, 2022, more than 300 million confirmed cases have
relevant literature. The search period was between January 1, 2020,
been reported worldwide.3 COVID-19 is a universal crisis
and September 20, 2021. The incidence of overall and various types of
globally, posing profound impacts to both public health and
ocular trauma during the COVID-19 pandemic and the control pe-
society. Governments worldwide have implemented a series of
riod was analyzed. The data from different studies were pooled. The
measures to contain COVID-19, such as suspension of
odds ratio (OR) and 95% confidence interval (CI) were calculated.
schools, restriction of public activities, and even massive
Results: A total of 32 articles were included. After pooling the data from
lockdowns. As a result, industrial, agricultural, and social
all included studies, the incidence of total and pediatric ocular trauma
activities have all been significantly altered.
during the COVID-19 pandemic was 67.7% and 54.3% of those in the
Ocular trauma is one of the major causes of preventable
control period, respectively. However, the proportion of ocular trauma in
vision loss in developed and developing countries. The
eye emergency visits increased during the pandemic (OR, 95% CI: 1.46,
causes of ocular trauma are closely related to industrial,
1.04–2.06). The proportion of domestic ocular trauma increased (OR,
agricultural, and social activities. For instance, occupational
95% CI: 3.42, 1.01–11.62), while ocular trauma related to sports and
injuries and road traffic accidents were among the leading
outdoor activities and occupational ocular trauma decreased (OR, 95%
causes of ocular trauma.4,5 Occupational injuries can cause
CI: 0.64, 0.09–4.29 and 0.18, 0.10–0.33, respectively). It was also reported
significant morbidity, especially in younger males. This age
that chemical injury caused by alcohol-based sanitizers, photokeratitis
cohort is workers’ prime productive years, a time when in-
caused by ultraviolet lamps, and mechanical eye injury caused by masks
jury can result in significant loss of wages and earning
increased during the COVID-19 pandemic.
potential.6,7 It will also be a huge burden on the society and
Conclusions: There was a reduction in overall eye injuries and
the family.
substantial differences in the spectrum of ocular trauma during the
Like all other medical specialties, ophthalmology has
COVID-19 pandemic. Proper health education and supervision
witnessed significant changes and impacts brought by COV-
should be strengthened to prevent ocular injuries related to
ID-19 to its clinical practice.8,9 Trends in ophthalmic emer-
COVID-19 preventive interventions.
gency department visits have changed during the COVID-19
pandemic due to the aberrancy in social activities.10 Never-
Key Words: COVID-19, ocular trauma, epidemiology, meta-analysis,
theless, there were discordant results from different studies
systematic review
evaluating ocular trauma during this pandemic. This study
(Asia Pac J Ophthalmol (Phila) 2022;11:481–487) aimed to analyze the epidemiological and clinical character-
istics of ocular trauma during the COVID-19 pandemic
through a systematic literature review.
Submitted February 13, 2022; accepted April 19, 2022.
From the *Joint Shantou International Eye Center, Shantou University and
The Chinese University of Hong Kong, Shantou, China; †Department of
Ophthalmology and Visual Sciences, The Chinese University of Hong
Kong, Hong Kong, China; ‡Shenzhen Eye Institute, Shenzhen Eye Hos- MATERIALS AND METHODS
pital affiliated to Jinan University, Shenzhen, China; and §School of Op-
tometry, Shenzhen University, Shenzhen, China.
A systematic search of the literature on PubMed, Web of
Source of support: Joint Shantou International Eye Center Intramural Grant Science, Scopus, China Biology Medicine, Wanfang Data,
(20-023).
The authors have no conflicts of interest to declare.
and China National Knowledge Infrastructure (CNKI) were
Address correspondence and reprint requests to: Haoyu Chen, Joint Shantou conducted without limitation of language. The search terms
International Eye Center, North Dongxia Road, Shantou, China.
E-mail: drchenhaoyu@gmail.com; Mingying Lai, Shenzhen Eye Hospital,
included (“COVID-19” OR “novel coronavirus pneumonia”)
18 Zetian Road, Shenzhen, China. E-mail: laimydoc@163.com AND (“ocular trauma” OR “eye injury” OR “eye trauma”
Copyright © 2022 Asia-Pacific Academy of Ophthalmology. Published by
Wolters Kluwer Health, Inc. on behalf of the Asia-Pacific Academy of
OR “ocular injury”). The search period was between January
Ophthalmolog. This is an open access article distributed under the terms of 1, 2020, and September 20, 2021. Duplicate records were re-
the Creative Commons Attribution-Non Commercial-No Derivatives
License 4.0 (CCBY-NC-ND), where it is permissible to download and
moved. The abstracts were screened, and the irrelevant re-
share the work provided it is properly cited. The work cannot be changed cords were excluded. The full texts of the remaining records
in any way or used commercially without permission from the journal.
ISSN: 2162-0989
were retrieved and reviewed, and the relevant articles were
DOI: 10.1097/APO.0000000000000539 included. The references of the included articles were also

r 2022 Asia-Pacific Academy of Ophthalmology. https://journals.lww.com/apjoo | 481

Liang et al Asia-Pacific Journal of Ophthalmology
screened. We only included original articles that reported eye
injuries during the COVID-19 pandemic period. Reviews or
commentaries which did not report original data or cases were
excluded.
The enumeration data from different studies were added
up and compared between the pre–COVID-19 and COVID-19
periods. The data from different studies were merged, and the
odds ratio (OR) and its 95% confidence interval (CI) were
computed using the R software (R Foundation for Statistical
Computing).
RESULTS
Literature Search Results
A total of 691 articles were initially identified after fol-
lowing the aforementioned search strategy. After title and
abstract screening, 48 studies were selected for full-text eval-
uation. Finally, 32 studies were included for analysis
(Fig. 1).10–24 There were 31 studies in English and 1 in
Chinese.
Incidence of Ocular Trauma
Among the 32 studies included, 13 evaluated the number
of presentations to the ophthalmic emergency department and
the incidence of ocular trauma cases (Table 1).
Eleven studies compared the incidence of ocular trauma
during the COVID-19 pandemic with the control period,
ranging from 3 months to 1 year. Among these studies, almost
all (10/11) concluded that the incidence of ocular trauma de-
creased during the COVID-19 pandemic compared to the
control period.10,12,13,15–18,25,26 One study described a 5-times
increase in the number of ocular trauma cases during the
pandemic compared to the control period,19 but the sample
FIGURE 1. Results of systematic literature search strategy.
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 Volume 11, Number 5, September/October 2022
size was small. By merging the 11 articles, the total incidence
of ocular trauma during the COVID-19 pandemic decreased
to 67.7% of that in the control period (Table 1).
Six articles reported that the proportion of ocular trauma
cases in ophthalmic emergency visits increased,10,12,13,16,17,24
while 2 articles reported that the proportion decreased.15,25
The pooled data showed that the proportion of ocular trauma
cases in ophthalmologic emergency visits increased from
16.8% to 23.9% during the COVID-19 pandemic (OR, 95%
CI: 1.46, 1.04–2.06) (Fig. 2).
Pediatric Ocular Trauma
Table 2 summarized the studies which compared the
incidence of pediatric ocular trauma cases prior to and during
the COVID-19 pandemic. Six studies reported that the
incidence of pediatric ocular injury cases declined during the
pandemic period,12–16,28 accounting for only 54.3% of that in
the control period.
Four studies reported the proportion of pediatric eye in-
juries among total eye injuries, in which 3 studies (75%) re-
ported a decline in the proportion of pediatric eye injuries
during the COVID-19 pandemic.12,15,16 The pooled data
showed that the proportion decreased from 17.7% to 12.3%
during the COVID-19 pandemic, compared to the control
period (OR, 95% CI: 0.72, 0.36–1.44) (Fig. 3).
Category of Ocular Trauma
Five studies compared the incidence of domestic ocular
trauma during the pandemic and the control
period.12,16,18,19,25 The pooled results showed that the in-
cidence of domestic ocular trauma remained at a similar level
during the pandemic compared to the control period. Four
studies reported that the proportion of domestic ocular trau-
ma increased during the COVID-19 pandemic,12,16,18,25 while
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Asia-Pacific Journal of Ophthalmology  Volume 11, Number 5, September/October 2022 Ocular Trauma During COVID-19 Pandemic

Proportion of Ocular Trauma in Ophthalmic Emergency

1 study reported a reduction in such proportion.19 The merged

Pre-COVID-19
COVID-19 / data showed that the proportion of domestic ocular trauma

105.7%

127.5%
120.3%

134.5%

260.6%
291.1%

142.4%
96.7%

92.4%

—
—

—
—
—
cases increased from 16.8% to 43.1% during the COVID-19
pandemic, compared to the control period (OR, 95% CI: 3.42,
1.01–11.62) (Fig. 4A). Various case reports documented
Pre-COVID-19

different domestic ocular trauma which occurred during the

Cases

19.1%

73.1%
15.6%
12.1%

29.2%

16.8%
COVID-19 pandemic. There were 2 reported cases of metallic
6.3%

2.5%
7.8%

—
—

—
—
—
nail embedded in the left upper eyelid and corneal injury
caused by gardening,29,30 respectively. Two studies reported
2 and 11 cases with ocular trauma due to resistance band–
COVID-19

related exercises carried out at home,31,32 respectively. Bapaye

20.2%

70.7%
19.9%
14.6%

39.2%
22.8%

23.9%
5.9%

6.6%
—
—

—
—
— et al33 described 2 cases of pediatric ocular trauma caused by
bow and arrow at home due to imitation of TV dramas, and
Alqudah et al21 reported 4 cases of open globe injury that
Pre-COVID-19 COVID-19 COVID-19 Pre-COVID-19
COVID-19 /
Ophthalmic Emergency or Outpatient

occurred at home.
46.8%

62.6%
24.8%
46.9%
77.1%
45.9%

12.1%
15.6%

11.8%
35.0%
36.4%
—
—

Four studies compared the incidence of ocular trauma

caused by sports and outdoor activities during the COVID-
TABLE 1. Comparative Study of the Total Number of Ophthalmic Patients and Ocular Trauma Cases in Pre- and During COVID-19 Pandemic Periods

19 pandemic and the control period. Among them, 3 (75%)

Cases

12776

1855
2269
1818
1372
1854

7242
3106

33417
288
837
Pre-

—
—

reported a decrease in ocular trauma caused by sports and

outdoor activities during the pandemic,12,16,25 but 1 re-
ported that the incidence of sports-related eye injuries in-
5978

1161
563
852
1058
851

876

12149
483

34
293
—
—

creased from 3 to 10 cases during the COVID-19 pandemic

as compared to the control period.18 The pooled results of
COVID-19 /

these 4 articles showed that the overall incidence of ocular

49.5%

60.5%
31.6%
56.4%
71.3%
61.7%
85.4%
41.5%
31.5%
45.3%

67.7%
500%

injuries caused by sports and outdoor activities fell to 25.3%

—
—

of the prepandemic period. The merged data also showed

that the proportion of ocular trauma related to sports and
Ocular Trauma Cases

outdoor activities decreased from 10.4% to 6.9% during the

Pre-COVID-19

COVID-19 pandemic (OR, 95% CI: 0.64, 0.09–4.29)

2444

1356
354
220

541
4959
171
184

10561
243

87

2
—
—

(Fig. 4B).
Two articles revealed that the incidence of occupational
ocular trauma decreased during the COVD-19 pandemic,
compared to the control period.18,25 The pooled results
COVID-19

1209

821
112
124
110

62
334
4236
71
58
10
10

7147

showed that the proportion of occupational ocular injuries

—

decreased from 44.2% to 12.0% during the pandemic (OR,

95% CI: 0.10, 0.18–0.33) (Fig. 4C).
2019/1/23-2019/3/31

2019/3/10-2019/4/10

2019/3/18-2019/4/15

2011/1/1-2019/12/31
2019/3/25-2019/7/31
2019/3/24-20194/23

2019/3/10-2019/5/3

2019/3/23-2019/7/4
2019/3/1-2019/5/31

2019/4/1-2019/6/30
Pre-COVID-19

An article showed that only 3 cases of ocular trauma

caused by road traffic accidents were documented during the
—

—
2019/3/17-

COVID-19 pandemic, compared with 16 in the control

period.18 Among all ocular trauma cases, the proportion of
ocular trauma caused by traffic accidents decreased from 9.3%
Date

in the control period to 4.2% during the pandemic (OR, 95%

2020/1/23-2020/3/31

2020/3/10-2020/4/10
2020/3/24-2020/4/23
2020/3/23-2020/4/20

2020/1/1-2020/12/31
2020/3/25-2020/7/31
2020/3/1-2020/5/31

2020/3/10-2020/5/3

2020/4/1-2020/6/30
2020/3/23-2020/7/4

2020/4/9-2020/4/15

CI: 0.43, 0.12–1.52).

COVID-19

2020/3/17-

Ocular Trauma Related to COVID-19 Preventive

Measures
Five studies compared the incidence of chemical eye
Study period

injury during the pandemic and the control period. Among

3 months

3 months

2 months
128 days

103 days
1 month
1 month
1 month

1 weeks
68 days

54 days
1 year
—

them, 3 reported that the incidence of chemical eye injury

decreased during the pandemic compared with the control
period.12,17,18 The pooled results showed that the incidence
of chemical eye injury during the pandemic decreased to
Country

56.1% of that in the control period. However, the proportion

Turkey

Britain

Britain
Jordan

of chemical eye injury increased during the pandemic com-

Britan
China
India

India
India
USA

USA
Italy

Italy

pared to the control period when all ocular trauma were

analyzed (OR, 95% CI: 1.33, 0.78–2.27, Fig. 5). Martin
et al20 reported that although no significant differences in the
Hamroush27

incidence and proportion of chemical injuries in children

Pellegrini16

Salvetat 24

Stedman19
Alqudah21
Agrawal18
Halawa26

Kauser12
Akova15

Poyser17
Author

were documented during the pandemic compared to the

Shah13

Total
Wu25
Ma10

control period (from 98 cases to 80 cases, accounting for 4%

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Liang et al Asia-Pacific Journal of Ophthalmology  Volume 11, Number 5, September/October 2022

FIGURE 2. Forest plot of the proportion of ocular trauma in ophthalmic emergency visits during COVID-19 and pre–COVID-19 periods. Events: ocular
trauma; Total: ophthalmic emergency visits; OR: odds ratio; CI: confidence interval.

to 5% of all ophthalmic emergencies), chemical eye injuries DISCUSSION

related to alcohol-based sanitizers increased from 1 case to
16 cases. Wasser et al23 reported that the incidence of
pediatric chemical injuries in 2019 was 36, which increased to
72 cases during the pandemic. More importantly, a
significant increase in chemical injuries related to alcohol-
based sanitizers was observed. During the pandemic, 9 cases
of children aged below 10 were documented, compared to
0 in 2019. In addition, 3 studies reported ocular trauma
caused by the improper use of alcohol-based sanitizers
during the pandemic. Sonam et al22 mentioned 2 cases of
toxic keratopathy in children aged under 5 years. One article
reported alcohol-based-sanitizers–related ocular trauma in
two 3-year-old girls.34 The cause of the injury was that the
children stepped on the pedal to obtain the disinfectant, and
the alcohol sprayed into their eyes. Sunny et al35 described a
32-year-old woman who accidentally made the portable
disinfectant spray on her right eye.
Ma et al10 reported that the number of cases of photo-
keratitis during the lockdown period was higher than that in
the control period (141 cases vs 53 cases), and the proportion
of photokeratitis cases in nonmechanical injuries sig-
nificantly increased from 46.9% to 81.0% in comparison with
the control pandemic (χ2 = 36.437, P < 0.001). In
addition, 2 studies reported 7 cases and 3 cases of electric
ophthalmia caused by improper use of ultraviolet
disinfection, respectively.36,37
A study also documented ocular trauma secondary to
the inappropriate use of masks.38 Seven patients were injured
by metal nasal wires or other hard and sharp parts of masks,
and 2 patients were injured by elastic masks.
By summarizing the current literature, we found that the
overall incidence of ocular trauma during the pandemic de-
creased to 67.7% of that in the control period. Various po-
tential reasons could account for such observation. Firstly,
COVID-19 changed many human activities, including in-
dustrial, agricultural, and social activities, which are all risk
factors of ocular trauma.10 In addition, large-scale lockdowns
imposed by many governments may limit some patients with
mild ocular trauma from medical contact, hence resulting in
an apparent reduction in the incidence of ocular injuries. This
is further aggravated by the negative financial impact brought
by COVID-19 to the general population, which may deter
patients from seeking medical care unless the nature of the
ocular injuries was urgent or severe.12 However, there were
inconsistencies in the literature. Stedman et al19 reported 10
cases of serious ocular trauma (4 globe ruptures, 4 full-
thickness lid lacerations, and 2 intraocular foreign bodies).
There was a 5-times increase in the incidence of ocular trauma
in Royal Hallamshire Hospital Sheffield in the UK during the
pandemic compared with the control period, in which the
incidence of ocular trauma related to falls and house deco-
ration increased significantly. This inconsistency was ac-
counted for by the authors due to the increased time people
spent at home in compliance with extended lockdown periods,
during which they engaged in home improvement–related
projects and the elderly individuals were limited at home. Such
alteration in daily activities, therefore, led to increased ocular
trauma related to domestic renovation. Elderly individuals
were regarded as high-risk population of eye injuries due to
falling at home and their risk of fall increased as their time at

TABLE 2. Comparative Study of Ocular Trauma Cases and Pediatric Ocular Trauma Cases Between COVID-19 Pandemic and Pre-COVID-19 Period Period
(Number in brackets indicates percentage of total ocular trauma cases)
Pediatric Ocular Trauma Cases
Author Country Study Period COVID-19 Pandemic Pre-COVID-19 Period COVID-19 Pandemic/Pre-COVID-19 Period
Kauser6 India 3 mo 5 29 17.2%
Shah7 India 1y 40 57 70.2%
Akova9 Turkey 3 mo 81 241 33.6%
Pellegrini10 Italy 1 mo 9 52 17.3%
Cavuoto8 America 6 mo 156 237 65.8%
Maria30 Austria 3 mo 110 123 89.4%
Total 401 739 54.3%

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Asia-Pacific Journal of Ophthalmology  Volume 11, Number 5, September/October 2022 Ocular Trauma During COVID-19 Pandemic

FIGURE 3. Forest plot of the proportion of pediatric ocular trauma among all ocular trauma during COVID-19 and pre–COVID-19 periods. Events:
pediatric ocular trauma; Total: total number of ocular trauma; OR: odds ratio; CI: confidence interval.

home raised. Moreover, eye injuries constitute a huge cost to
the individual, health care system, and society. Therefore,
family members should strengthen their care for the elderly to
avoid falls during the COVID-19 pandemic.7
Children are a special population, and the occurrence of
pediatric ocular trauma warrants special attention. The
pooled number of pediatric ocular trauma cases decreased
during the pandemic. The merged proportion of pediatric
ocular trauma cases among the total ocular trauma cases
decreased. This may be related to the suspension of classes,
which prohibited children from sports and recreational
activities.14 Their exposure to risk factors was subsequently
reduced. Parents also had more time to supervise their
children due to lockdowns, thereby potentially reducing the
risk of misadventure.
We further analyzed the category of ocular trauma
reported in the literature. The results showed that the
proportion of occupational, sports-related, and traffic-related ocular
trauma decreased, while the proportion of domestic ocular injuries
increased during the pandemic. The change in the category of oc-
ular trauma may be attributed to the alterations of social activities
caused by pandemic-control policies such as massive lockdowns
and the implementation of work-from-home strategies worldwide.
During the COVID-19 pandemic, many measures were
implemented to prevent and curb the transmission of the coro-
navirus, such as the use of alcohol-based sanitizers, ultraviolet

FIGURE 4. Forest plots of the proportion of domestic (A), sports-related (B) , and occupational (C) ocular trauma among all ocular trauma during COVID-
19 and pre–COVID-19 periods. Events: domestic (A), sports-related (B), and occupational (C) ocular trauma; Total: total number of ocular trauma; OR:
odds ratio; CI: confidence interval.

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Liang et al Asia-Pacific Journal of Ophthalmology
FIGURE 5. Forest plot of the proportion of chemical eye injury among all ocular trauma during COVID-19 and pre–COVID-19 periods. Events: chemical
eye injury; Total: total number of ocular trauma; OR: odds ratio; CI: confidence interval.
lamps, and masks.39 These measures may cause ocular injuries by
accident. Keeping hands clean is a simple, effective, and eco-
nomical measure of infection control. Alcohol-based sanitizers
were placed in many public places for hand disinfection. There
was a significant increase in alcohol-based-sanitizer–related eye
chemical injuries, many of which involved children.22,23,34,35 It is
likely that most alcohol-based sanitizers were installed at the
waist height of an adult in public, which approximated a child’s
eye level and rendered children prone to ocular chemical injuries
when these alcohol-based sanitizers were activated in close
proximity to them. To prevent ocular chemical injuries, guard-
ians ought to maintain a high level of vigilance to prevent in-
advertent ocular exposure of children to such devices.
Meanwhile, manufacturers of alcohol-based sanitizers should
consider design modifications for such devices to minimize the
said risk. In addition, we observed an increase in photokeratitis
caused by ultraviolet disinfection. The public ought to be better
informed and educated on the proper use of UV germicidal
lamps in order to prevent such accidents.10
During the pandemic, masks, as a preventive measure, are
widely used to combat the spread of coronavirus.40 The correct
use of masks can effectively prevent us from infection. How-
ever, with the increase in the use of masks, ocular trauma
secondary to improper use of masks has been documented.38,41
Therefore, public education on the proper donning of masks
should be emphasized, in particular to empower vulnerable
groups such as the elderly and children.
In conclusion, during the COVID-19 pandemic,the total
incidence of ocular trauma decreased. People were more likely
to suffer from ocular trauma while at home. The incidence of
pediatric ocular trauma and sports and outdoor activities–
related ocular trauma decreased. Significant variations in the
spectrum of ocular trauma during the pandemic should
nonetheless be noted by frontline ophthalmologists, in par-
ticular ocular trauma related to pandemic-control strategies.
Epidemic prevention and control measures such as alcohol-
based sanitizers, ultraviolet disinfection, and masks may also
cause eye damage. Adequate education should be offered to
the general public to prevent them from ocular trauma sec-
ondary to improper implementation of pandemic preventive
measures.
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