Pediatric Annals

Pediatric Eye Trauma

Thomas Frey, MD, FACS

Abstract

There were, in 1 977, 740,000 Americans who were blind in one eye because of trauma. Childhood is a particularly vulnerable time for eye injuries to occur. In 1978, for example, an estimated 160,000 school children suffered from eye injuries.

When an injury does occur, prompt recognition and treatment is the goal and may mean the difference between a seeing or non-seeing eye. Newer diagnostic tools such as ultrasound and the CT scan and modern treatment modalities such as microsurgical techniques and vitrectomy have made previously "lost" eyes salvageable. Speed is especially important in a child, since delay in visual rehabilitation may lead to deep amblyopia despite an excellent surgical outcome. The younger the child, the greater the urgency.

The role of the pediatrician is of prime importance since he or she is often the first physician to see the child and must make the vital decisions.

EVALUATING THE CHILD WITH AN EYE INJURY

History

A good history may be difficult to obtain but the effort, if successful, will be worthwhile. It is, of course, important to know what happened, when it happened, where it happened, and how the child is doing now.

The question of when the injury occurred should be followed with the question of when the child last ate (in the case of potential surgical need). The parents can then be instructed not to feed the child until a decision has been made. The frustration of delaying surgery for six hours because of a bag of french fries can be considerable. How the child has felt and what has been done to him following the injury are important considerations. The child whose vision is decreasing, whose pain is increasing and who is nauseous obviously raises more flags of alarm than the child who, after his initial injury, has gradually become asymptomatic.

The possibility of a battered child should always be considered. Marked facial trauma, bilateral corneal abrasions, unexplained hyphemas, particularly if bilateral, and cigarette burns in children all are warning signs. Unusual family dynamics or an unexplained history should alert the examiner. The eyes may be the first warning in an otherwise unsuspected battered child. A child can be saved by a tuned-in pediatrician.

A good history will separate most eye injuries into one of six major categories, channeling the examiner's thinking and examination and making proper disposition an easier task (Table 1).

The only true emergency, the one that needs to be dealt with immediately and where minutes may count and where treatment should precede further history and exam, is in the case of chemical injuries. In all other situations, there is time to be deliberate and to proceed with a thorough, methodical history and examination. This deliberate approach will be well-rewarded.

Examination

Approaching a frightened child with an eye injury may cause great anxiety in the non-ophthalmologist physician. The solution is a systematic, methodical exam on each patient, with special consideration to certain problems as directed by the history. This approach makes for a confident practitioner and well-cared-for patient. Special tools are helpful (Figure I, Table 2).

Table

1. Vision Problems in the U.S.. Data Analysis: Definitions. Data Sources. Detailed Data Tables. Analysis. Interpretation. New York. National Society to Prevent Blindness. I980. pp 24-33.

2. Friendly DS: Ocular manifestations of physical child abuse. Transactions of the American Academy of Ophthalmology Otolaryngology 1971; 75:318.

3. Leopold IH. Maylath FR: Chemical injuries of the cornea. Fed Pr oc 1971 ; 30:92-95.

4. Wilkins RB. Havins WE: Current treatment of blow-out fractures. Ophthalmology 1982: 89:464-466.

5. Beyer CK. Fabian RF. Smith B: Naso-orbital fractures, complication and treatment. Ophthalmology…

There were, in 1 977, 740,000 Americans who were blind in one eye because of trauma. Childhood is a particularly vulnerable time for eye injuries to occur. In 1978, for example, an estimated 160,000 school children suffered from eye injuries.

When an injury does occur, prompt recognition and treatment is the goal and may mean the difference between a seeing or non-seeing eye. Newer diagnostic tools such as ultrasound and the CT scan and modern treatment modalities such as microsurgical techniques and vitrectomy have made previously "lost" eyes salvageable. Speed is especially important in a child, since delay in visual rehabilitation may lead to deep amblyopia despite an excellent surgical outcome. The younger the child, the greater the urgency.

The role of the pediatrician is of prime importance since he or she is often the first physician to see the child and must make the vital decisions.

EVALUATING THE CHILD WITH AN EYE INJURY

History

A good history may be difficult to obtain but the effort, if successful, will be worthwhile. It is, of course, important to know what happened, when it happened, where it happened, and how the child is doing now.

The question of when the injury occurred should be followed with the question of when the child last ate (in the case of potential surgical need). The parents can then be instructed not to feed the child until a decision has been made. The frustration of delaying surgery for six hours because of a bag of french fries can be considerable. How the child has felt and what has been done to him following the injury are important considerations. The child whose vision is decreasing, whose pain is increasing and who is nauseous obviously raises more flags of alarm than the child who, after his initial injury, has gradually become asymptomatic.

The possibility of a battered child should always be considered. Marked facial trauma, bilateral corneal abrasions, unexplained hyphemas, particularly if bilateral, and cigarette burns in children all are warning signs. Unusual family dynamics or an unexplained history should alert the examiner. The eyes may be the first warning in an otherwise unsuspected battered child. A child can be saved by a tuned-in pediatrician.

A good history will separate most eye injuries into one of six major categories, channeling the examiner's thinking and examination and making proper disposition an easier task (Table 1).

The only true emergency, the one that needs to be dealt with immediately and where minutes may count and where treatment should precede further history and exam, is in the case of chemical injuries. In all other situations, there is time to be deliberate and to proceed with a thorough, methodical history and examination. This deliberate approach will be well-rewarded.

Examination

Approaching a frightened child with an eye injury may cause great anxiety in the non-ophthalmologist physician. The solution is a systematic, methodical exam on each patient, with special consideration to certain problems as directed by the history. This approach makes for a confident practitioner and well-cared-for patient. Special tools are helpful (Figure I, Table 2).

Table

TABLE 1MAJOR EYE INJURY CATEGORIES

TABLE 1

MAJOR EYE INJURY CATEGORIES

Table

TABLE 2EYE CARE "PACKAGE"

TABLE 2

EYE CARE "PACKAGE"

Vision in the office is best evaluated with a Snellen letter chart, or with an isolated "E" or picture chart, depending on the child's age. In the homes or at the bedside, the readily available "Rosenbaum Pocket Screener" near vision card is an excellent screening device.

The entire exam can be greatly enhanced in a child with a painful eye by using a topical anaesthetic. Proparacaine is preferable as the drop works quickly and the child will often relate the comfort he feels to the physician. The rest of the examination becomes much less traumatic to patient and doctor and may mean the difference between making a diagnosis or even being able to come close to the child. The patient should never be sent home with a bottle of anaesthetic since rapid tolerance develops and causes the patient to ask for more and more drops. The anaesthetic in repeated dosage may also impede corneal healing and in so doing make the patient become "hooked" on harmful medication. Anaesthetic drops should be regarded only as a diagnostic tool.

Adequate light makes the difference between diagnosis and confusion. The disposable pocket flashlight is an excellent source, as is the bright light of the halogen ophthalmoscope.

Magnification combined with proper light will greatly facilitate diagnosis and treatment. The barely perceptible spot under the lid is readily seen as a treatable foreign body. Purchase of a pair of loupes, for example the readily available Telesight loupes, is recommended.

Fluorescein dye which comes impregnated on paper strips will stain the underlying corneal stroma green if there is a defect in the corneal epithelium. The examiner merely wets the paper with a drop of water or saline and lightly. touches the inner surface of the lid or globe. A corneal defect then glows bright green when examined with good light and magnification.

Figure 1. "Eye Care Kit: Rosenbaum Pocket Screener on the left and clockwise; Telesight loupes, halogen ophthalmoscope, Tropicamide 1% drops, light, proparacaine drops.

Figure 1. "Eye Care Kit: Rosenbaum Pocket Screener on the left and clockwise; Telesight loupes, halogen ophthalmoscope, Tropicamide 1% drops, light, proparacaine drops.

The pediatrician should have available a means of dilating the pupil when a better view of the lens, vitreous, or retina is desirable. Tropicamide (l%). a rapidly acting cycloplegic, is a good choice.

There are more sophisticated instruments available which help guarantee more definitive diagnoses. Virtually every ophthalmologist and most emergency rooms are equipped with a slit lamp biomicroscope that, with its high resolution, magnification and light source enables the observer to examine in great detail the anterior segment of the eye. If the pediatrician has access to this instrument, the time spent learning to develop expertise will be well-rewarded. Most ophthalmologists use an indirect ophthalmoscope which has an intense light source, gives a three-dimensional view and a wide field and enables the observer to see virtually the entire retina. X-rays, of course, may be helpful when one suspects fractured facial bones or a foreign body. The CT scan has made localization of intraorbital or extraorbital foreign bodies easier. Ultrasonography is another new technique that has proved beneficial (Figure 2). Since sound waves travel where light waves sometimes may not, the clinician now can "see" into an eye with an opaque cornea, or with an anterior chamber filled with blood or with a cataract. He can determine whether there is a retinal detachment or retained foreign body and plan his treatment accordingly. This examination is safe, painless, rapid and requires little cooperation by the child.

THE EXAMINATION ROUTINE

The examination should always begin by evaluating the vision. The object of the examination is to determine the child's vision and the goal is preserving sight. A baseline determination is essential. The child presenting with blurred vision or whose vision is decreasing should cause concern for it means that the visual pathway is obstructed or there is optic nerve or retinal pathology (Table 3).

Figure 2. Normal ultrasonogram: a) lens echo, b) vitreous cavity appears black, c) orbital fat appears white, d) optic nerve appears as a black wedge-shaped area.

Figure 2. Normal ultrasonogram: a) lens echo, b) vitreous cavity appears black, c) orbital fat appears white, d) optic nerve appears as a black wedge-shaped area.

The examination should proceed in a stepwise fashion. The patient's motility status can be quickly screened by checking tor double vision and by having the child rotate his eyes up. down and to either side. Double vision or limited eye movements may mean fractured orbital bones with muscle entrapment, injury to the orbit or eye muscles or paresis of the third, fourth, or sixth cranial nerve.

The face and periorbital area are checked. Orbital asymmetry and or ecchymosis raise suspicion of blunt trauma while a lacerated eyelid should alert the examiner to the possibility of a lacerated globe. A child with a suspected eye laceration should be approached very cautiously and gently, lest too vigorous an examination cause extrusion of intraocular contents.

The conjunctiva in the fornices is examined. If a foreign bodv is suspected, the upper lid should be everted. The key here is to use the upper edge of the semi-rigid tarsal plate as a fulcrum. If a cotton tip applicator stick is placed at that border, and the lashes are grasped with the other hand, the lid will easily fold back over the stick and the upper tarsal surface, a common place for foreign bodies to lodge, can be examined.

The cornea is examined most easily with the use of fluorescein stain and with a good light and magnification, looking for abrasions, lacerations, or foreign bodies.

The anterior chamber, the space between the cornea and the iris, should be compared to the other eve. A shallow anterior chamber with a dome-like appearance of the iris may mean a lacerated eye with loss of the anterior chamber (hyphema), which is a serious problem and needs to be promptly recogni/ed and cared for.

Pupil size should be noted as should its shape and position. The presence of a dilated pupil is a worrisome sign when the patient has suffered head trauma. Increased intracranial pressure can cause stretching of the oculomotor nerve as it crosses from the mid-brain to the eye. particularly in the presence of a herniated temporal lobe. It may result from direct trauma to the oculomotor nerve or its nucleus. The clinician, however, should be aware that direct trauma to the eve may damage the iris sphincter or dilating muscles and cause a dilated pupil that can persist indefinitely. This does not have dire implications and is a rather common sequela of a direct blow to the eve. Direct trauma to the eye may cause ciliary spasm and iritis resulting in a small pupil (fable 4).

Table

TABLE 3DECREASED VISION FOLLOWING TRAUMA

TABLE 3

DECREASED VISION FOLLOWING TRAUMA

Table

TABLE 4DILATED PUPILS FOLLOWING TRAUMA

TABLE 4

DILATED PUPILS FOLLOWING TRAUMA

An attempt should be made to look at the retina. This may be bypassed in a child with a suspected lacerated globe since extra manipulation may be dangerous and the child will shortly be seeing an ophthalmologist. Inability to see the retina implies a visual pathway that is not clear.

CHEMICAL BURNS

Treatment and evaluation of the child with a chemical burn begins with the telephone call. The mother needs to pay immediate attention to her child rather than make a frantic race to the doctor's office. She should be instructed to immediately begin irrigating the eyes, holding the lids apart, and using plain, cool tap water. Using a milk carton or enema bag or a pitcher, etc., she should irrigate for at least 20 minutes by the clock. The office staff should be alerted to give the child immediate attention, and if the causative agent is toxic enough to warrant it, begin irrigation with saline or plain water almost immediately after the patient arrives. Twenty minutes of irrigation, using about two liters of fluid, is recommended. The eye should then be examined for particulate matter. In lime burns, which may occur when laying down foul lines or football yard markers, persistent particles can stick to the conjunctiva and cause ongoing insult. They should, of course, be removed.

Figure 3. Corneal abrasion: fluorescein dye causes the epithelial defect in the inferior temporal cornea to appear green.

Figure 3. Corneal abrasion: fluorescein dye causes the epithelial defect in the inferior temporal cornea to appear green.

The type of chemical is, of course, important in planning management. Fortunately, other than the alkali cleaners, most of the household products that children splash in their eyes - perfumes, cosmetics, shampoos - cause nothing but a superficial keratitis and will, after initial irrigation, cause no problems other than some small burning discomfort. Mace burns fall into this category. Although the loss of eyes has been reported.' rarely does mace cause more than superficial skin and corneal burns. These are. by and large, short-lived problems that have minimal sequelae. An ocular lubricant (artificial tears) or an antibiotic ointment may help to relieve the discomfort. A short course of topical steroids may be helpful if excess inflammation and discomfort are present.

Of much greater concern are the injuries caused by one particular type of common household product - strong alkali oven cleaners, drain uncloggers. and ammonia products, and by strong acids found in industrial settings, chemical labs and car batteries.

These acids cause immediate damage. They bind very quickly to the tissue protein, "fixing" tie tissue. They do not continue to penetrate the eye after the original insult, although the force generated by an exploding car battery may indeed force potent sulfuric acid into the tissues. By and large, what you see is what you have got, as far as acids are concerned.

Alkali burns are a different matter. They rapidly penetrate the cornea, saponifying fat and destroying cells. The acute phase may last three days, while a subacute phase with an active inflammation may last up to seven days. Collagenase is released which further breaks down the corneal tissue. Continued thinning of the cornea followed by perforation or opacification may be the end result. Scarring of the fornices. leaving a dry, uncomfortable eye may occur.

These children need to be examined very carefully. Blanching of limbal blood vessels or evidence of necrosis is an ominous sign and should suggest hospitalization. The ophthalmologist will usually treat these children in the hospital with continued lavage. He may use antiglaucoma medication since a rise in intraocular tension is not uncommon, cycloplegics for the accompanying iritis, steroid drops, and anti-collagenase drugs such as Mucomyst.

Ultraviolet burns are caused by over-exposure to a sun lamp and, on occasion, the sun itself. The patient has a red Photophobie eye. decreased vision and marked discomfort. Examination is facilitated by the use of a topical anaesthetic. The child should be managed as a corneal abrasion.

Thermal burns of the lids and periorbital tissue are no different than any other burn of the face and need to be treated no differently. The eye reacts remarkably quickly and efficiently to danger and rapid lid closure and elevation of the eye (Bell's phenomenon) rarely allow thermal injury to the globe itself.

ABRASION-TYPE INJURIES

Perhaps the most common eye trauma problem the pediatrician faces in his office practice is the situation in which the corneal epithelium has been abraded by a scraping type of injury. This cornea belongs to a very uncomfortable young person with a blurry red, tearing Photophobie eye. The history makes the diagnosis. Common causes are fingernails, tree branches, or mascara brushes.

A common cause of corneal abrasions in teenagers is overwear or erratic wear of contact lenses. Corneal swelling results and the lens rubs directly against the cornea causing damage to the corneal epithelium. This should be treated as any other abrasion.

Examination of the child will be greatly facilitated by using a drop of topical anesthetic followed by the application of a fluorescein strip to the lower lid. The exam will reveal a green staining defect in the corneal epithelium (Figure 3). If the injury is severe enough, there may be accompanying inflammation (iritis).

Treatment consists of putting the eye at rest. Since blinking lid retards healing by mechanically wiping away the new epithelial cells that are being formed from the edge of the epithelial defect, a firm pressure dressing preventing lid movement should be applied. Acycloplegic drop (homatropine 5% or scopolamine 0.25%) to relieve ciliary spasm (the cause of brow ache) and an antibiotic drop or ointment should be instilled prior to putting on the patch. The patient should be instructed to refrain from activities that require many small eye movements, such as close-up reading. An abrasion may be quite painful and use of an oral analgesic is often necessary. Aspirin or Tylenol, or even codeine, can be used.

The child should leave the patch undisturbed for 24 hours and then be re-evaluated again to see if healing has taken place and if infection has not. It may be necessary to re-apply the patch but if good progress is noted and just minimal staining is present, an antibiotic ointment can be applied about every four hours for a few days. The ointment acts as a lubricant and will usually complete the job.

Patching in an infant should be kept to an absolute minimum. Amblyopia may develop within only a few days and the sooner the child is using his or her eyes together the better.

It is important to always consider the worst case and if the history is in any way suggestive, suspect that something more severe may be going on. That tree branch may have perforated the cornea or caused bleeding in the eye. Consider the worst diagnosis the working diagnosis and if there is any question, prompt referral to an ophthalmologist is indicated.

Recurrent Erosion

A red, tearing, painful eye with fluorescein evidence of a corneal abrasion, no history of immediate past trauma, but of a previous abrasion days, weeks, or months ago, signals a patient with a recurrent erosion. This may occur in up to 40% of abrasions. It has been, in my experience, less common in children than in adults, and when repeated episodes occur in a child, the diagnosis of a corneal dystrophy such as Reis-Bucklers' Dystrophy and lattice dystrophy should be entertained. Recurrent erosion is caused by damage to the basement membrane underlying the corneal epithelium so that the healing epithelium does not bind down tightly to the underlying layers. Just rubbing the eye may precipitate an acute problem. Firm patching after antibiotic ointment and an antibiotic drop have been applied will usually be adequate treatment. The patient should then be instructed to apply ointment to his eye every night for at least a month. Hypertonic saline drops and ointment may be used if this regime is unsuccessful and in resistant patients the fitting of a soft bandage contact lens may be necessary.

Thermal Corneal Burns

Superficial corneal burns such as those from a cigarette out of the front window of a moving car, from molten metal or hot liquid, usually causes a superficial corneal burn that behaves like an abrasion. Debridement of the edematous epithelium, application of a cycloplegic drop (homatropine 5% or scopolamine 0.25%), an antibiotic ointment, patching and an oral analgesic are indicated. It is important, of course, to examine the cornea carefully to be sure that no deep damage was done.

FOREIGN BODY

The symptoms of the child with a corneal or conjunctival foreign body are similar to that of the child with an abrasion in that he has a red, painful, irritated, Photophobie, tearing eye. He often, however, can pinpoint the exact time when his problems began, tell you when he "got something in my eye, "and will often tell you just where the foreign body is located.

The visual acuity is usually normal. If no corneal foreign body is seen, I refrain from using an anaesthetic drop. Removal of the foreign body from the tarsus will usually afford immediate relief and the anaesthetic will rob you of this wonderful indicator of therapeutic success. Fluorescein may be helpful. A large tarsal foreign body may cause a large staining defect, while a small foreign body beneath the upper lid may, as the lid moves, cause fine superficial vertical staining, helping to localize the foreign body.

The lid should be everted and the fornices examined with good light and magnification. Mucus tends to collect around irritants and if the foreign body is difficult to locate, searching for an area of pooled mucus and stain may be productive. A cotton swab can then be used to wipe the foreign body away. If foreign body sensation persists and no corneal abrasion is present, look for another foreign body.

Conjunctivitis may give symptoms suggestive of a foreign body but the pain is less intense and there is no localization. This diagnosis should be considered when a search is fruitless.

Corneal foreign bodies (Figure 4) should be removed after applying a topical anaesthetic. A slit lamp is usually necessary. Many are metallic in origin and within hours will cause a rust ring complex to form which may extend deep into the cornea. Sharp instrumentation or a drill may be needed and the visibility that a slit lamp offers will be necessary. In an infant, general anesthesia and an operating microscope may be needed to remove a corneal foreign body.

After the corneal foreign body removal, treatment is identical to that of an abrasion, with cycloplegic. topical antibiotics, patching, oral analgesics and followup in 24 hours. The tarsal foreign body, if it has caused no corneal problems, usually need not be seen again unless there are persistent complaints.

It is important to be aware that there may have been more than one foreign body and, more importantly, that one of those tiny missiles may have entered the eye. If the history is compatible, such as a child standing near a grinding wheel and suddenly feeling something sharp and if the vision is decreased inordinately, or if the eye is more inflamed or softer than one would expect, prompt referral to an ophthalmologist for a more detailed examination of that eye should be considered.

Figure 4. Corneal foreign body.

Figure 4. Corneal foreign body.

PENETRATING WOUNDS

One of the most distressing thoughts a physician can have is "what I could have done if only I had known." Any wound about the eye with a potential for penetrating the lids or the globe should be considered to have done just that and a consultation with an ophthalmologist should be promptly requested. The speed in which the problem is recognized and cared for may make the difference between a successful result and a non-seeing eye. Every lacerated eyelid should be considered to have lacerated the globe until proven otherwise. Every dart injury, whether one sees a penetrating area or not. should be considered to have penetrated the globe. Any injury with multiple facial lacerations such as in an automobile accident, should be carefully examined, with the patient asleep if necessary. It is a sad revelation for a traumatized patient who has survived one crisis after another, to finally awaken, open his eyes and complain he cannot see. Recognition that a problem may exist and loo king for it is often the key.

Lid Lacerations

The superficial lid laceration not involving the lid margin can be cared for by any physician with expertise in sewing facial wounds. Lacerations of the lid margin are a different matter. Repair should be done by one who has experience such as an ophthalmologist or plastic surgeon since a less than perfect repair may result in cosmetic blemish or an irritated eye. When the laceration involves the nasal lid margin, the possibility of a torn canaliculus should be considered (Figure 5). The weakest part of the lid margin is the area between the punctum and the nasal canthus. A sudden tearing force may rip the lid margin in this area, lacerating the canaliculus. If not quickly recognized and repaired, this patient may have a serious tearing problem.

Penetrating Globe Injuries

An eye that has been penetrated is an eye at special risk and prompt treatment by an ophthalmologist is essential. Delay may lead to further damage to the eye. to infection. or to vitreous organization with traction on the retina. The prognosis should always be considered guarded, particularly if the injury is extensive, if intraocular contents extrude or if the laceration is posterior and vitreous and retina present at the wound.

Figure 5. Lacerated lid margin with torn canaliculus.

Figure 5. Lacerated lid margin with torn canaliculus.

The patient will usually present with a compatible history, but again, any injury that has the potential of penetrating the globe should be considered to have done so. Very often, the child has had nausea and vomiting immediately following the injury. This is the time to ask when the patient last ate and instruct the parents not to feed him until treatment decisions have been made. Information about tetanus shots, etc.. should be garnered. The possibility of a foreign body entering the eye with the penetrating object should be considered and x-rays ordered if that is considered likely.

Examination will usually show decreased vision, sometimes markedly so and the eye will usually be quite inflamed. If the cornea is involved, fluorescein should show the area of involvement. The depth of involvement, however, may only be appreciated with the use of a slit lamp.

The rest of the globe should be carefully, but gentlv. examined. A torn conjunctiva may mean that the sclera beneath it is also torn. A localized area of swelling may signify the area of perforation. Any evidence of iris, indeed any pigment or gelatinous material presenting through the cornea or sclera, signifies penetration.

The anterior chamber should be carefully evaluated. Look for a layer of blood or murky-appearing aqueous. Slit lamp examination will show inflammation with cells and flare. The depth of the anterior chamber should be compared to the other eye. If this space between the cornea and iris of the injured eye appears to be shallower or more slit-like than the uninvolved eye or if it appears that the iris has mushroomed forward and appears to touch the cornea, this should be considered evidence of a penetrated, leaking cornea.

Figure 6. Lacerated cornea: note the straight edge of the temporal pupil. The iris is adherent to the linear vertical laceration.

Figure 6. Lacerated cornea: note the straight edge of the temporal pupil. The iris is adherent to the linear vertical laceration.

The pupil should be carefully observed. A pupil that is not round should raise suspicions. A peaked or pointed pupil or a pupil pulled to one side or a pupil with one flat side (Figure 6). or one that attaches to the undersurface of the cornea signifies a lacerated eye. A small pigmented area on the surface of the cornea at the apex of the pointed pupil means extruding iris and. of course, a violated globe (Figure 7).

The pupil should appear black. A white pupil following trauma means the lens has been involved and the patient has a cataract (Figure 8). Discovery of any of these signs or indeed suspicion of a penetrating wound means immediate referral to an ophthalmologist so that surgical repair can be undertaken (Table 5).

BLUNT TRAUMA

A history of fist or ball suddenly impacting with the orbit leads the clinician in another direction.

The examination again begins with the vision which may be decreased because of bleeding in the anterior chamber, cataract, bleeding in the vitreous, or damage to the retina or optic nerve. The motility status of the patient should be evaluated. Is there diplopia? Is there pain or restriction on eye movement? Double vision, particularly on looking up or down, may mean the patient has a fractured orbit with entrapment of ocular muscles. It may also mean bleeding into one of the extraocular musclesor retrobulbar hemorrhage.

An external examination may show a typical "black eye" and one needs to evaluate this further to rule out orbital or facial fractures. Proptosis means retrobulbar hemorrhage or edema. Marked periorbital edema may also mean leakage of cerebrospinal fluid into the orbital space.

Figure 7. Lacerated cornea with iris prolapse: the pupil is being pulled toward 2 o'clock and is eccentric. Iris tissue can be seen presenting through the wound.

Figure 7. Lacerated cornea with iris prolapse: the pupil is being pulled toward 2 o'clock and is eccentric. Iris tissue can be seen presenting through the wound.

Figure 8. Corneal laceration with traumatic cataract: a horizontal laceration is seen. The anterior chamber is flat and a dense cataract is seen.

Figure 8. Corneal laceration with traumatic cataract: a horizontal laceration is seen. The anterior chamber is flat and a dense cataract is seen.

Table

TABLE 5SIGNS OF A PENETRATED GLOBE

TABLE 5

SIGNS OF A PENETRATED GLOBE

The cornea should be stained with fluorescein since it may have been abraded. The anterior chamber should be examined closely for the presence of blood (hyphema). Blunt trauma of sufficient force may cause a cataract, signified by a white or grey pupil. Finally, the retina and optic nerve should be scrutinized for evidence of edema, hemorrhage, retinal holes, etc.

Figure 9. Blow-out fracture: left eye isenophthalmicand is unable to elevate because of entrapment of inferior rectus.

Figure 9. Blow-out fracture: left eye isenophthalmicand is unable to elevate because of entrapment of inferior rectus.

It is important to keep in mind, too, that the blunt trauma may also have ruptured the globe. An ophthalmologist referral is certainly appropriate.

Blow-out Fractures

The paper-thin floor of the orbit also serves as the roof of the antrum. Sudden external force may cause an explosion ofthat orbital floor with herniation of orbital content down into the antrum.

The patient presents with a "black eye," tender lower orbital rim and. since the infra-orbital nerve is usually involved, numbness to a pin prick along the lower orbital rim, the upper lip. and the upper canine tooth. The eye may be restricted in its movements because of trauma to the eye muscles and there may be proptosis because of orbital swelling or bleeding or enophthalmus because of herniation of orbital contents into the sinus. Persistence of double vision and limitation of vertical movements especially on attempted upward gaze for over a week usually implies entrapment of the inferior rectus in the floor fracture.

X-rays will initially show a cloudy antrum due to bleeding into it. A Water's view (an A-P view of the inferior and lateral orbit images taken with the nose and chin against the cassette) is especially helpful.

The eye itself must be carefully examined, since up to 30% of these eyes have been found to have other traumarelated problems.

Patients with blow-out fractures need to be followed carefully. If the diplopia does not improve after seven to ten days, a tomogram of the orbit to outline the floor defect is probably necessary and surgical repair within several weeks of the injury to free the muscle and repair the floor defect is probably in order (Figure 9). Most surgeons, in the absence of diplopia and a large blow defect, agree that surgical intervention is not necessary.4

Figure 10. Hyphema: bright red blood fills the lower one-third of the anterior chamber.

Figure 10. Hyphema: bright red blood fills the lower one-third of the anterior chamber.

Approximately 20% of patients who sustain mid-facial fractures develop cerebrospinal fluid rhinorrhea, usually within the first 48 hours after injury or sometimes up to four weeks later. The presence of periobital edema should make the clinician suspicious of leakage of cerebrospinal fluid into the orbital space and neurosurgical advice is the prime priority.

Hyphema

A blow to the eye may cause a ripping of tissue including blood vessels in the angle between the ciliary body and the iris or in the ciliary body itself, precipitating bleeding into the anterior chamber. This is a potentially devastating problem. The patient presents with decreased vision and. usually, a level layer of blood in the anterior chamber (Figure 10). This should not be confused with the bright red blots of blood that are seen with subconjunctival hemorrhages (Figure ll) and which, in the absence of other eye pathology, have no significant implications.

The blood will usually disappear within several days and the patient's prognosis is excellent if no re-bleeding occurs. Re-bleeding, unfortunately, does occur in up to 30% of patients, ' usually within three to five days. If no further bleeding occurs, the prognosis for vision of 20 40 or better is in the 90% range. After a re-bleed, however, this figure goes down to 40% to 60%.. The incidence of secondary glaucoma rises dramatically. Surgery to evacuate the blood is rarely necessary after a primary bleed, but may become necessary after re-bleeding. So it is that efforts are made to prevent secondary hemorrhage from occurring.

How to treat the patient with hyphema isa controversial subject. Standard treatment used includes admission to hospital, strict bedrest, and bilateral patching for five days. Some recent studies claim that this is not necessary and that patients do just as well without the patching and the strict bedrest.8 Aminocaproic acid given orally shows some promise in preventing more bleeding. All agree, however, that the patient needs to be recognized early and carefully monitored. The appearance of murky aqueous or inability to see the fundus which may mean floating red cells or a recognizable blood level should mean a prompt referral.

Figure 11. Subconjunctival hemorrhage: in the absence of other findings, this is not a problem. The anterior chamber is free of blood.

Figure 11. Subconjunctival hemorrhage: in the absence of other findings, this is not a problem. The anterior chamber is free of blood.

Blunt Trauma and the Posterior Eye

Blunt trauma can cause retinal edema which may lead to macular degeneration and permanent visual problems (Figure 1 2). Vision sometimes will clear, but no treatment other than hopeful observation is available. Choroidal rupture and permanent visual loss may occur.

Blunt trauma may cause a retinal detachment. It is important to know that there may be a latent period of months to years before the detachment is detected. Secondary glaucoma has been reported to develop ten years after injury. Children who have suffered a hyphema need to be periodically examined for their entire lives.

Optic Nerve

Severe blunt trauma may cause edema of the optic nerve, bleeding into the nerve, laceration or rarely an actual evulsion. The patient with optic nerve involvement will present with profound visual loss. There will be a positive Marcus-Gunn pupil response (the affected pupil will dilate when a bright light is rapidly alternated between the two eyes). The nerve may initially appear normal. Unroofing the orbit has been advocated in the past, but by and large the results have been disappointing for return of vision. Optic nerve involvement, fortunately, is an uncommon occurrence.

The patient with blunt trauma, thus, needs to be evaluated for facial or orbital fractures, hyphema, cataracts, retinal problems and optic nerve involvement. If the trauma is severe enough, one must also consider a ruptured globe. This patient usually has virtually no vision, a soft eye full of blood. An ophthalmologist consultation is the way to proceed.

Figure 12. Pigmentary macular degeneration secondary to blunt trauma.

Figure 12. Pigmentary macular degeneration secondary to blunt trauma.

EYE SIGNS FOLLOWING CLOSED HEAD TRAUMA

Head trauma, especially if severe enough to cause concussion, may result in early or late complaints of decreased vision, double vision, and dilated pupils.

Decreased Vision

Decreased vision following head trauma needs to be evaluated very carefully. A profound decrease in vision, coupled with a positive Marcus-Gunn response and in the absence of pathology in the eye itself, implies optic nerve or chiasmal injury. Careful tomograms of the optic canal may show a fracture but the prognosis for recovery is very guarded and heroic attempts to save vision by unroofing the orbit remain a very controversial option. Less heroic methods such as administering osmotic and antiinflammatory agents certainly should be considered. Retinal detachment may follow severe closed head trauma and a careful ophthalmoscopy soon after and periodically needs to be done.

Diplopia

Double vision may follow closed head trauma. It may rarely be monocular, but more commonly is present only with both eyes open, is eliminated by closing one eye and implies misaligned eyes.

Monocular diplopia is caused by the disruption of light rays as they travel from the cornea to the retina. It may be caused by corneal irregularity, lens irregularity or subluxation or macular swelling or edema.

Binocular diplopia may be on mechanical or neurologic basis. Trauma may cause intramuscular or intraorbital hemorrhage or edema affecting the rotational ability of the eye. This is usually transient and will disappear within two weeks. A muscle may be trapped in a blow-out fracture causing inability to elevate the eye or in a medial wall fracture, limiting abduction. These problems need surgical attention to free the involved muscle.

Figure 13. Left sixth nerve paresis. Patient can not abduct left eye past midline.

Figure 13. Left sixth nerve paresis. Patient can not abduct left eye past midline.

Figure 14. Right superior oblique palsy: there is right hypertropia (high eye) because of the weakened depressing action of the superior oblique. Head tilt to the left to eliminate torsional problems caused by paretic muscle.

Figure 14. Right superior oblique palsy: there is right hypertropia (high eye) because of the weakened depressing action of the superior oblique. Head tilt to the left to eliminate torsional problems caused by paretic muscle.

In the absence of direct trauma to the eye and of a fracture to an orbital bone, paresis of an ocular muscle is the most likely diagnosis if diplopia is present. Because of its long course within the brain, theabducens nerve(VI) is the most common intracranial nerve involved. The patient with a lateral rectus paresis presents with complaints of horizontal diplopia, a head turn toward the involved side, esotropia and inability to abduct the eye fully (Figure 13).

The most common vertical muscle involved is the superior oblique, caused by damage to the trochlear nerve (IV). This patient presents with vertical diplopia, a hypertropic (high) eye and with his head tilted to the side opposite the higher eye. This head posture is due to the weakened depression and torsional action of the superior oblique of the involved eye (Figure 14).

The patient with a traumatic fourth or sixth nerve paresis needs to be promptly diagnosed and cared for. Misaligned eyes, in a young child, may cause permanent sensory changes in the brain. In an attempt to eliminate diplopia, the child may develop deep suppression areas and failure to deal with the child may result in lifelong amblyopia and or loss of binocularity. Since function may return, it is common to wait six months before attempting a surgical correction, but care must be taken during that waiting period to prevent amblyopia with the use of patches and. if possible, to preserve binocularity with the use of prisms.

Trauma may precipitate transient strabismus with no evidence of paretic muscles. Treatment, again, consists of keeping the eyes straight with glasses, prisms, etc., preventing amblyopia from developing while one waits for more normalcy to return (Table 6).

SUMMARY

The pediatrician, faced with a child with an injured eye, faces a large responsibility. The key to proper disposition is an orderly approach with a good history and with a methodical examination and the use of ophthalmologic aids, such as topical anaesthetics, good light and magnification. The pediatrician can handle many problems in his office, such as tarsal foreign bodies and corneal abrasions, but he should be reassured that he has in the wings an ally, the ophthalmologist, standing to help anywhere along the line.

Table

TABLE 6DIPLOPIA FOLLOWING TRAUMA

TABLE 6

DIPLOPIA FOLLOWING TRAUMA

REFERENCES

1. Vision Problems in the U.S.. Data Analysis: Definitions. Data Sources. Detailed Data Tables. Analysis. Interpretation. New York. National Society to Prevent Blindness. I980. pp 24-33.

2. Friendly DS: Ocular manifestations of physical child abuse. Transactions of the American Academy of Ophthalmology Otolaryngology 1971; 75:318.

3. Leopold IH. Maylath FR: Chemical injuries of the cornea. Fed Pr oc 1971 ; 30:92-95.

4. Wilkins RB. Havins WE: Current treatment of blow-out fractures. Ophthalmology 1982: 89:464-466.

5. Beyer CK. Fabian RF. Smith B: Naso-orbital fractures, complication and treatment. Ophthalmology 1982; 89:456-463.

6. Coles WH: Traumatic hyphema: An analysis of 235 cases. South Med J 1965: 61:813-816.

7. Leone CR Jr: Natural history hyphema. J Pediatr Ophthalmol. 1966; 3:7.

8. Read J. Goldberg MF: Cmparison of medical treatment of traumatic hyphema. Transactions of the American Academy of Ophthalmology Otolaryngology 1974; 78:OP799-OP8l5.

BIBLIOGRAPHY

Harley RD (ed): Pediatric Ophihalmology. Philadelphia. WB Saunders Co. 1975.

Ophthalmic Staff. Hospital for Sick Children. Toronto: The Eye in Childhood. Chicago. Year Book Med Pubs Inc. 1967.

Olglesby R: Eye trauma in children. Pediatr Ann 1977; 6:11-48.

Paton D. Goldberg MF: Management of Ocular Injuries. Philadelphia. WB Saunders Co. 1976.

TABLE 1

MAJOR EYE INJURY CATEGORIES

TABLE 2

EYE CARE "PACKAGE"

TABLE 3

DECREASED VISION FOLLOWING TRAUMA

TABLE 4

DILATED PUPILS FOLLOWING TRAUMA

TABLE 5

SIGNS OF A PENETRATED GLOBE

TABLE 6

DIPLOPIA FOLLOWING TRAUMA

10.3928/0090-4481-19830701-02

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