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 Table of Contents    
ORIGINAL ARTICLE
Year : 2022  |  Volume : 15  |  Issue : 3  |  Page : 309-314  

An unusual rise in cases of assault in ophthalmic practice during COVID-19 lockdown in a tertiary care hospital


1 Department of Ophthalmology, Karachi Medical and Dental College, Abbasi Shaheed Hospital, Karachi, Pakistan
2 Department of Ophthalmology, Baqai Medical University, Karachi, Pakistan
3 Department of Ophthalmology, Karachi Medical and Dental College, Spencer Eye Hospital, Karachi, Pakistan

Date of Submission05-Nov-2021
Date of Decision30-Mar-2022
Date of Acceptance09-Apr-2022
Date of Web Publication02-Nov-2022

Correspondence Address:
Erum Shahid
C 88, Block A, North Nazimabad, Karachi
Pakistan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ojo.ojo_323_21

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   Abstract 


OBJECTIVE: The objective of the study is to report an unusual rise in cases of assault with ocular injury and their medicolegal implications presenting in an eye department of a tertiary care hospital during COVID-19 lockdown.
MATERIALS AND METHODS: A retrospective, observational case series was conducted in the Department of Ophthalmology, Abbasi Shaheed Hospital, Karachi. Data were retrieved from the medicolegal records of the patients from April 1, 2019, to July 31, 2019, and similar months in 2020. We included all the patients of assault with ocular injury as alleged, registered as medicolegal cases. Patients with accidental injuries were excluded from the study.
RESULTS: There was 34.3% increase in cases of assault with ocular injury as alleged with 72.35% reduction in the outpatient department patients. The ratio of cases of assault in 2019 and 2020 is 1:4.62. The mean age of the patients in the lockdown year was 33.74 ± 11.9 standard deviation (SD) and in preCOVID year 2019 was 39.74 ± 15.9 SD. Blunt trauma was experienced by 57 (66.3%) and penetrating injury in 2 (2.3%) patients. Sixteen (18.6%) patients had no ocular involvement. Home was the place of assault in 32 (37.2%) and street in 27 (31.4%) individuals. Fist was the source of assault in 46 (53.3%) and rod or stick in 15 (17.4%) individuals.
CONCLUSION: There is a fourfold increase in patients of assault during 4 months of COVID-19 lockdown in 2020 as compared to the same time period in 2019. Most of these patients were young age, male gender, and uneducated. The most common place of incident was home, and fist was the most common source of infliction. Most of the injuries were superficial and had minimum effect on visual acuity.

Keywords: Assault, COVID-19, forensic medicine, medicolegal aspects, pandemic, trauma


How to cite this article:
Shahid E, Fasih U, Taqi U, Jafri AR. An unusual rise in cases of assault in ophthalmic practice during COVID-19 lockdown in a tertiary care hospital. Oman J Ophthalmol 2022;15:309-14

How to cite this URL:
Shahid E, Fasih U, Taqi U, Jafri AR. An unusual rise in cases of assault in ophthalmic practice during COVID-19 lockdown in a tertiary care hospital. Oman J Ophthalmol [serial online] 2022 [cited 2022 Dec 4];15:309-14. Available from: https://www.ojoonline.org/text.asp?2022/15/3/309/360415




   Introduction Top


A medicolegal case is a case of injury or illness where the attending doctor after eliciting history and examining the patient thinks that some investigations by law enforcement agencies are necessary to establish and fix accountability for the case in accordance with the law of the land.[1] Alleged cases of assault, road traffic accident, burn, poisoning, industrial accident, and alcohol intoxication are some of the categories of medicolegal cases.[2]

Physical assault is a common cause of morbidity and mortality worldwide in underdeveloped and developing countries.[3] Punching, kicking, biting, beating, and attacking with broken pieces of glass, metal, or gun are the commonly employed tools.[4] Assault causing trauma to the eyes becomes a concern of legal authorities.[5] Ocular trauma that has medicolegal implications in terms of punishment to the offender or compensation for the loss could be a fight, fall, or foreign body at work or road traffic accident.[6] Patients with medicolegal implications come to an ophthalmologist for examination at varying time intervals of trauma infliction.[7] This requires a careful history and thorough examination to ascertain the actual and realistic estimation of injuries.[8] These patients may feign injuries to deliberately mislead the doctor to make a wrong diagnosis for compensation purposes.[9]

The emergence of COVID-19 in Wuhan city, Hubei Province of China, in December 2019 has changed the perspective of the world. This pandemic has resulted in lockdown not only in China but also worldwide.[10] Most of the countries globally have adopted several health measures to prevent the rapid spread of COVID-19. Lockdown has been implemented in many countries with closing down of educational institutes, shopping malls, markets, restaurants and community centers, prohibition of public gatherings, and banning of national and international travel. The aim of social distancing through lockdown is to flatten the curve of the diseases by halting exponential growth of the disease.[11]

Pakistan had reported its first case of coronavirus in February 2020. Educational institutes were the first to close down, followed by banning of intracity and intercity transports, mosques, shrines, gyms, and other public places from March 24, 2020, and onward.[12]

Lockdown due to COVID-19 pandemic has a massive impact on social, economic, and public health of the individuals not only in Pakistan but also worldwide. People are working from home, children are getting online education, and females are burdened with extra household work. Low-paid and unskilled workers have become unemployed as industries and services have closed down. Financial distress, job loss, isolation, loneliness, and death from COVID-19 have led to anxiety, depression, trauma-related symptoms, abuse, and suicidal tendencies among the masses. During lockdown, we have observed an escalation in cases of assault presenting in ophthalmic practice in a tertiary care hospital.

The objective of the study is to report an unusual rise in cases of assault with ocular injury and their medicolegal implications presenting in an eye department of a tertiary care hospital during COVID-19 lockdown. Secondary objective of the study was to document the etiology and outcome of the cases of assault reporting in ophthalmic practice in COVID19 lockdown in 2020.


   Materials and Methods Top


This was a retrospective, observational case series, conducted in the Department of Ophthalmology, Abbasi Shaheed Hospital, Karachi. This is a tertiary care, government-funded, multidisciplinary hospital that caters to a large number of medicolegal patients belonging to different areas of the city. Cases of assault report to a medicolegal officer, who then refers them to the respective departments for expert opinion. The study adheres to the tenants of Declaration of Helsinki and was approved by the ethical committee. The data were retrieved from the medicolegal records of the patients visiting an eye outpatient department (OPD) from April 1, 2019, to July 31, 2019, and similar months in 2020. In Pakistan, lockdown was implemented from March 23, 2020, which was extended till June with a few weeks of relaxation in lockdown in between. From the mid of June 2020 and onward, smart lockdown strategy was launched by the government with closure of all business activities in specific areas. We had included all the patients of assault, registered as medicolegal cases, and referred for ophthalmic examination by a medicolegal officer. Patients with accidental injuries were excluded from the study.

A detailed history of the patients was recorded, including age, gender, education, employment, occupation, time of injury, and reporting time in an eye OPD. Object of assault and place of assault were also noted down. Object of assault was classified into fist or hand, wooden stick, stone, pipe, vitriolage, and nonspecific objects. Place of assault was classified into home, work place, street, and neighborhood. Tailor, driver, factory worker, electrician, beautician, painter, and cook were classified into skilled workers. The ocular injury was classified into blunt and penetrating ocular injury.

Visual acuity was measured by Snellen's chart at the time of reporting in eye OPD and after management. Ocular examination, including torch examination of the skin and adnexa, was conducted for ecchymosis, skin laceration, subconjunctival hemorrhage, and penetrating injury. Slit-lamp biomicroscopy was carried out for anterior segment examination to rule out corneal edema, abrasion, hyphema, uveitis, iridodialysis, sphincter tear, traumatic cataract, lens subluxation, or dislocation. Direct and indirect ophthalmoscopy was carried out for vitreous hemorrhage, retinal hemorrhages, retinal detachment, tears, choroidal tear, traumatic optic neuropathy, and optic nerve avulsion. Intraocular pressure was checked with applanation tonometry for any change in intraocular pressure. Any abnormalities in pupillary light reflexes and extraocular motility restriction were documented. Reports of imaging including X-ray orbits, CAT scan, and B scan were also noted where advised.

The data were collected and analyzed on IBM SPSS Statistics ver. 21 (IBM Corp., Armonk, NY, USA). version 21. The ratio of the number of assault patients during lockdown in 2020 and 2019 was calculated. The percentage of reduction in patients visiting OPD during 2019 and 2020 was calculated. Means were calculated for numerical variables such as age and reporting time after assault. Frequencies were calculated for categorical variables, including gender, education, occupation, employment, skilled worker, type of injury, visual acuity, anterior and posterior segment findings, and cause of decrease in vision.


   Results Top


The total number of the patients visiting eye OPD in the pre-COVID era, from April 1, 2019, to July 31, 2019, was 10,209, and in COVID era, i.e., from April 1, to July 31, 2020, it was 2974. Among these patients, the number of cases of assault in the pre-COVID year 2019 was 64 and in the COVID year 2020 was 86. There was 34.3% increase in cases of assault with 72.35% reduction in OPD patients. The increase in cases of assault was from 0.6% to 2.89% in the pre-COVID to COVID era. The ratio of cases of assault in 2019 and 2020 is 1:4.62. In 2019, 57 (89.06%) males and 7 (10.93%) females reported as cases of assault. In 2020, amid cases of assault males were 72 (83.7%) and females were 14 (16.3%). The number of the patients presenting as assault in different months of the pre-COVID and COVID year is given in [Figure 1].
Figure 1: Monthly distribution of patients of assault in 2019 and 2020

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The mean age of the patients of assault in the lockdown year was 33.74 ± 11.9 standard deviation (SD) and in the pre-COVID year 2019 was 35.74 ± 10.9 SD.

In the COVID year 2020, the minimum reporting time of the patients was 1 h and the maximum reporting time was 60 days (2 months) after the infliction of assault. Jobless patients were 42 (48.8%). Uneducated patients were 27 (31.4%). Patients who had received primary education were 23 (26.7%) and with secondary education were 20 (23.3%). Home was the most common place of assault in 32 (37.2%) individuals, followed by street in 27 (31.4%). Fist was used as a source of assault in 46 (53.3%) patients and wooden rod or stick in 15 (17.4%) individuals. All other demographic details are given in [Table 1].
Table 1: Frequency distribution of demographic features of cases of assault in the year 2020

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Labors and homemakers were 13 (15.1%), shopkeepers were 11 (12.8%), and office workers were 10 (11.6%) among different occupations of the assault cases. Occupation of the patients is enlisted in [Table 2].
Table 2: Frequency distribution of occupation of the patients of assault in year 2020

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The right eye of the patients was injured in 32 (37.2%) and the left eye in 24 (27.9%) of patients. Sixteen (18.6%) patients had no ocular involvement at the time of reporting. Blunt trauma was experienced by 57 (66.3%) patients and penetrating injury in 2 (2.3%) patients. Lid edema was seen in 42 (48.8%) patients, ecchymosis in 34 (39.5%), and subconjunctival hemorrhage in 34 (39.5%). Two (2.32%) patients had lost their vision to no light perception due to assault. Ocular features of the patients secondary to assault are given in [Table 3].
Table 3: Percentage distribution of ocular involvement due to assault in 2020

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[Table 4] shows the frequencies and percentages of visual acuity of the patients reporting at the time of trauma and after management.
Table 4: Percentage distribution of visual acuity of patients of assault reporting at the time of trauma and after management

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   Discussion Top


Implementation of nationwide lock down to restrain the spread of COVID-19 pandemic has brought the whole country to a stand-still.[13] The results of our study have established a fourfold increase in cases of assault as alleged during 4 months of COVID-19 lockdown in 2020. There was 72.35% reduction in OPD patients in COVID lockdown than the pre-COVID era in our study. Other studies have also reported 96.6% and 97.14% reduction in OPD volume during COVID lockdown.[13],[14] A study conducted by Agarwal et al. has reported 22.22% increase in medicolegal cases during the lockdown era.[14] We reported 34.3% increase in cases of assault during lockdown as compared to 2019. There are only three hospitals in the city, Karachi, that are authorized to issue medicolegal report to medicolegal cases. Our hospital is one of them that caters to the medicolegal cases in this area. No other public or private sector institute manages medicolegal cases in the same vicinity. Agarwal et al. had included all medicolegal cases, including road traffic, assault, and workplace accidents.[14] The study from the same center has reported 9% assault cases in 2015.[15] It is obligatory for cases of assault to report to the hospital for detailed examination and expert opinion. Residing in confined space of home is not everyone's cup of tea. In Pakistan, there is culture of joint family system where several families with offspring are living together in the same dwelling. People are frustrated with the current situation of lockdown. These frustrations come out in the form of anger and quarrels over minute issues. Agarwal et al. had suggested the cause to be an amplified homestay in lockdown. General public needs to be urgently educated about the importance of patience, peace, and harmony.[14]

Home was the most common place of assault (37.2%) and fist was the most frequent source of infliction (53.3%) of assault in this study. The incidence of ocular trauma has been shown to decline during COVID lockdown in other studies.[16],[17] However, the most common place of ocular trauma reported by them was home during lockdown.[16] A study conducted in the pre-COVID era has reported farm (workplace) to be the most common place of assault.[18] Assault at workplace was seen in 20.9% of cases in our study. Businesses were closed, mass transit was prohibited and people were restricted to their homes in the lock down. An increase frequency of ocular trauma at home has been reported due to additional recreational activities at home in the lock down.[19] Other studies have also reported fist to be the most common source of assault in medicolegal cases.[1],[18]

Only 18.6% of individuals of assault in this study were graduates, and the highest number of them were uneducated (31.4%). Most of the patients in our study had blue collar jobs with daily wages. Male gender was predominant in the pre-Covid and Covid era among cases of assault. Other studies have also reported male gender to be a high risk for ocular trauma and assault.[1],[16],[17],[18]

Blunt ocular trauma due to assault was seen in 66.3% of individuals, with lid edema, ecchymosis, and subconjunctival hemorrhages being the most frequent. Agrawal has also reported 68.3% closed globe injury after trauma during lockdown.[16] Blunt ocular trauma with fist causing closed globe injury was the most commonly reported by other studies conducted in the pre-COVID era.[1],[15],[18] Ocular trauma can lead to a group of complications, including corneal lacerations, hyphema, traumatic cataract, lens subluxation, retinal detachment, optic nerve avulsions, and many more.[20],[21] In our patients, no ocular injury was seen in 18.6% of patients after assault. Either they presented late or they want to falsely claim the alleged. Most of the injuries in our study were minor and managed conservatively similar to the medicolegal cases reported by Agarwal et al.[14]

Two (2.3%) patients in this study had developed no light perception after assault. These patients had suffered vitriolage causing endophthalmitis, and finally, they end up with phthisis bulbi. Wasfy et al. have reported 25.5% of cases of assault who had lost an eye over the span of 8 years.[18] Other patients in our study with low vision claimed old corneal scar, anterior chamber intraocular lens, amblyopia, and glaucomatous optic atrophy to be the result of recent trauma. These patients were carefully examined before considered as false claims. Malingers may come with visual loss, exaggeration of visual field defect, or an old disease caused by fresh assault.[18]

Reporting time of the patients after the incident of assault in our study varied from 1 h to 60 days. More than half of the medicolegal cases reported between 3 and 6 months after assault in a study by Wasfy et al.[18] Medicolegal cases present at different time intervals of assault from weeks to months. It becomes the liability of the reporting doctor to make realistic and accurate assessment of injuries by careful history and thorough examination.[7] In circumstance of COVID era, restriction of public transport and fear of getting infected with serious illness are possible factors of presenting late for medicolegal implication. Accurate description, interpretation, and documentation of injuries are most important function of attending doctor to ensure patient gets every opportunity to maximize legal and health-care outcome.[22]

It is highly oppressive and claustrophobic for most of the low-income families confined to a single-room house for weeks and months. Unemployment and shortage of basic supplies adversely affect mental health of the population. Women, children, and elderly are exposed to abusive family members for a longer period of time making them more vulnerable against violence. All of these factors have a profound effect on aggressive and hostile behavior of individuals. The victim wants to claim litigation against the alleged on minor issues and negligible injuries. Alleged is frustrated and enraged on minor concerns. An increase in cases of assault in COVID lockdown can be the result of anxiety and depression among the masses. It can be used as a measure of deteriorating psychological and emotional health of population. Avenues of mental health counseling should be offered to individuals in the pandemic.

The limitation of the study is being retrospective design. It is a single-center study and detail of the data of assault in the pre-COVID year 2019 could not be retrieved. The strength of the study is being the only study from Pakistan representing cases of assault as alleged with ocular injuries and demographic details during COVID -19 lockdown. In addition to this, our hospital is one of the three authorized public sector hospitals to issue a medicolegal report to medicolegal cases of the city. It is the only one in the vicinity which caters to large number of medicolegal cases.


   Conclusion Top


There is a fourfold increase in patients of assault during the first 4 months of COVID-19 lockdown in 2020 as compared to the same time in 2019. Most of these patients were young age, male gender, and uneducated. The most common place of incident was home, and fist was the most common source of infliction. The most of the injuries were superficial and had minimum effect on visual acuity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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