Estimates as to the incidence of eye trauma vary widely, but it is clear that ocular injury is a major health problem in the United States. Some 2.4 million eye injuries occur annually, of which 95% are limited to the anterior segment.1 These injuries can be successfully treated with prompt, appropriate intervention. Trauma is one of the more important causes of ocular morbidity in childhood. Only strabismus ranks higher in frequency as an indication for pediatric eye surgery, and only amblyopia causes more acquired monocular vision loss.2 Children from 11 to 15 years old have a particularly high incidence of severe eye injury compared with other age groups, and injuries in boys outnumber those in girls by 4 to I.2 Most ocular trauma in younger children occurs during casual play, whereas older children and adolescents usually sustain their injuries while participating in sports.
Ocular injuries often threaten vision and alter the lifestyle of the injured individual. The pediatrician is in an ideal position to educate families in the prevention of eye injury. The use of protective eye wear while participating in sports and the use of eye flushing or eye washing stations following chemical exposure are crucial in minimizing ophthalmic injuries. Protective measures can reduce ocular trauma by as much as 90%.2
The goal of this article is to guide the pediatrician through the examination of the injured eye and discuss specific evaluation and management strategies for various injuries, emphasizing special pediatric considerations. Issues unique to the care of children with eye trauma include concerns about secondary amblyopia and the limitations in both diagnosis and management created by the lack of cooperation expected from young patients. Children younger than 7 years are at risk for visual deprivation amblyopia due to traumatic cataract or another opacity. The latter includes corneal staining by blood or even a therapeutic eye patch, which can be more likely to cause a severe long-term reduction in visual acuity than the original physical damage. Monocular occlusion following injuries should be kept to a minimum and one must always weigh the expected benefit from occlusion dressing against the risk of amblyopia developing as a result of disturbing binocular function.
OFFICE EVALUaTION OF THE CHILD WITH EYE TRAUMA
Appropriate prehospital care of ocular injuries may contribute to the maintenance of optimal visual acuity. Prior to the physical examination, a detailed description of the traumatic event should be elicited from all parties who witnessed it. Knowledge of the mechanism of injury aids in the overall assessment of the scope and complexity of the injury and guides additional examinations and diagnostic techniques.
Figure 1 . Fluorescein staining of a corneal abrasion with typical sharply demarcated edges.
The initial examination should include measurement of visual acuity and observation of the external adnexa, the ocular motility, the pupils, and the anterior segment, including the conjunctiva, sclera, cornea, iris, and lens. If possible, an examination of the posterior segment with a direct ophthalmoscope should be attempted. Measurement of intraocular pressure (IOP) should probably be deferred until the ophthalmologic consultation.
The difficulty of evaluation and treatment is frequently increased by inadequate cooperation. Overcoming the child's opposition by force is most often counterproductive and makes it difficult to establish the relationship needed for subsequent treatment. This approach may also further traumatize the eye. Examination in cases likely to involve minor injury can be facilitated by instilling topical anesthesia and by giving the child a chance to be calmed. If assessment of the circumstances surrounding the injury is limited and inspection indicates a possible significant injury, a prompt, complete evaluation under anesthesia by an ophthalmologist is warranted.
In pediatric trauma, the need for tetanus prophylaxis must be determined. For ocular trauma, the two factors that must be considered are the status of the injured patient's tetanus immunizations and the nature of the wound. Tetanus is unlikely in superficial corneal injury and prophylaxis is unnecessary. However, full-thickness eye and skin wounds require updated tetanus immunizations.3
The normal cornea is a clear, avascular, curved structure comprising one-fifth of the eye's outer circumference and is continuous with the sclera at the limbus. The cornea is composed of five layers, with the outermost being the epithelium, a nonkeratinized layer. The epithelial surface is regular and smooth. It has its own basement membrane and can regenerate and heal without scar formation. Such corneal epithelial defects heal by migration and proliferation of cells at the margins of the abrasion over the denuded area. This usually occurs within 2 to 3 days without significant sequelae. Although injuries to the epithelial layer heal without scarring, defects extending through the next layer (Bowman's layer) result in scar formation.
Superficial corneal abrasions are among the most common ocular injuries in children. These are often safely managed by pediatricians without the need for ophthalmologic consultation. Patients present with severe eye pain, photophobia, and tearing. On examination, corneal abrasions are easy to evaluate. Appropriate lighting and staining with fluorescein dye reveal sharp borders (Fig. 1).
Routine treatment of corneal abrasions includes a broad-spectrum antibiotic to reduce both discomfort and the risk of infection. At times, a cycloplegic agent such as homatropine 2% or cyclopentolate 1% can be added to lessen discomfort. Traditionally, a pressure patch was also used to keep the eyelid closed. This was based on the belief that a patch could prevent blinking and therefore reduce friction between the healing corneal epithelium and the eyelid, leading to faster wound healing.
More recently, the patch has fallen out of favor somewhat because it can decrease corneal oxygenation, thus possibly increasing anaerobic metabolism. This can deplete corneal glycogen reserves and decrease the energy production vital for corneal function. The patch can also raise corneal temperature, possibly predisposing to reduced healing and more infections.4 The Corneal Abrasion Patching Study Group compared patching with no patching for 223 subjects with traumatic corneal abrasions whose injuries were not related to foreign bodies or contact lenses and were not infected.5 Patients treated with antibiotic ointment and cycloplegic agents alone had significantly faster wound healing, less pain, and better compliance with treatment than did those whose treatment differed only by the addinon of a pressure patch. Other studies have reached similar conclusions.67 Abrasions inflicted by plant life may harbor fungal organisms and should not be patched, because fungal organisms are prone to excessive proliferation within the environment of a patched eye.
The Corneal Abrasion Patching Study Group also examined the use of topical nonsteroidal anti-inflammatory drops for the control of pain in corneal abrasions. All patients in the study were adults who were treated with an antibiotic ointment and a cycloplegic agent, but were randomized to receive either nonsteroidal drops or control drops. The two groups exhibited similar healing times, but those receiving nonsteroidal drops had significantly less pain, photophobia, and foreign body sensation at a 24-hour followup. However, the benefit is questionable because nonsteroidal drops generally sting on instillation, making them difficult to administer.
Topical anesthetic agents should not be prescribed because they compromise epithelial wound healing and are toxic to the cornea. Therefore, standard treatment of corneal abrasion in children currently includes broad-spectrum antibiotic ointment with a short-acting cycloplegic agent for pain, if necessary, plus daily follow-up until the abrasion is healed or an ophthalmologic consultation if the abrasion is not entirely healed within 3 days. Again, moderately large traumatic superficial corneal epithelial defects usually heal within 1 to 2 days in young children.
Recurrent corneal erosions can occur after abrasion or trauma involving a compromised epithelium basement membrane adhesion complex.8 Recurrent corneal erosions present with corneal abrasion-like symptoms with an antecedent history of trauma, usually within 3 months of the initial trauma. Recurrent corneal erosions should be treated as corneal abrasions. Ophthalmologic consultation should be requested for treatment of the basement membrane if more than a single episode occurs.
Corneal abrasions associated with contact lenses have become increasingly common in the pediatric population because contact lenses are being prescribed at younger ages. These abrasions can be caused by a foreign body between the lens and the cornea, the extended wear of contact lenses with secondary corneal edema, or direct damage to the cornea from insertion or removal of the lenses. Such abrasions can result in complications varying from minor irritation to corneal ulceration. Pseudomonas species may be prevalent and can cause severe corneal ulcers. Thus, the ocular antimicrobial drops should be effective against Pseudomonas, such as ciprofloxacin or fluoroquinolone.9 With these abrasions, the contact lens itself should be sent for culture. Abrasions associated with contact lenses should never be patched because the resulting ocular surface environment is conducive to proliferation of Pseudomonas species.10 Such abrasions are probably best managed by an ophthalmologist after initial treatment.
Cigarette burns of the cornea are a common injury in children (Fig. 2). These usually occur in children 2 to 4 years old and are generally accidental (ie, they are not manifestations of abuse). They result from a child running into a cigarette held at the child's eye level by an adult. Despite the alarming initial white appearance of coagulation in the corneal epithelium, cigarette burns typically heal rapidly without scarring. Treatment is the same as for mechanical abrasions.
Glue injuries of the cornea are increasingly common (Fig. 3). Despite the impressive appearance of these injuries at times, complete resolution is the rule with appropriate treatment. Eyelashes are frequently glued together and need to be cut away with careful preservation of the eyelash roots. Scrupulous inspection of the upper and lower culde-sacs should be performed for residual foreign bodies, but otherwise these abrasions typically heal rapidly without scarring. Treatment is the same as for mechanical abrasions.
Figure 2. Cigarette burn of the cornea.
Figure 3. Glue in an eye. Periorbital edema and adherent eyelashes can be seen.
Figure 4. Acid injury to the eye. Denuded epithelium can be seen.
ANTERIOR SEGMENT TRAUMA
Superficial and embedded foreign bodies of the eye are frequent pediatric emergencies. These objects can become embedded as a consequence of many activities, but mostly by metal striking metal. A consultation is generally indicated because careful examination of the anterior segment and dilated indirect funduscopy are vital to exclude an intraocular foreign body. An area of subconjunctival hemorrhage, ecchymosis, or a small break in the skin of the eyelid may be the only surface manifestation of a scleral perforation by a sharp, pointed, flying object. Distortion of the pupil may also be the only evidence of a small corneal or limbal perforation. A computed tomography scan of the orbits should be obtained to look for a suspected foreign body, but magnetic resonance imaging should never be done when there is any suspicion of intraocular metal. Every attempt should be made to determine the composition of a retained foreign body because this may indicate the possibility of ocular toxicity and guide specific antibiotic prophylaxis.
Superficial foreign bodies may simply be irrigated from the eye with saline or removed with a moist cotton tip. Retrieval of deeply embedded foreign bodies in children should be performed in the operating room. If an abrasion occurs as a result of a foreign body, broad-spectrum antibiotic coverage should be initiated.
Chemical injuries, particularly alkali burns, are among the most devastating type of eye trauma. In children, chemical burns are generally caused by organic solvents or soaps found in household cleaning agents. Although severe, acid burns are often limited to the ocular surface because most cause coagulation of epithelium and stromal proteins, which then form a natural barrier to deep penetration (Fig. 4). In contrast, alkali burns rapidly penetrate the cornea, causing damage to the entire anterior segment.11 Chemical burns are unlike other eye injuries; treatment should be instituted immediately, before the history is taken or a complete examination of the eye is performed. The initial and most vital step in the management of chemical injuries is copious irrigation and meticulous removal of any particulate matter from the conjunctival fornices. The content of the irrigating fluid is not important. The irrigation should continue for at least 30 minutes, or at least until the pH of the ocular surface returns to normal. After that, a more appropriate examination of the ocular adnexa and conjunctiva should be performed to evaluate for foreign bodies and assess the extent of damage. After initial emergent treatment, prompt ophthalmologic referral is appropriate because daily follow-up with additional anti-inflammatory therapy is often necessary. The prognosis is variable, ranging from complete recovery to loss of the eye.
Figure S. A minimal penorbital injury, which was later discovered to have penetrated the globe.
Figure 6. Hyphema secondary to blunt trauma.
In pediatric ocular trauma, the history often cannot reliably exclude the possibility of penetrating injury to the globe. If a thorough inspection of the anterior segment and funduscopic examination are not possible due to limited cooperation or if findings suggest possible penetrating injury, then examination using general anesthesia is indicated (Fig. 5). Again, a computed tomography scan of the eye should be considered if there is any reason to suspect a deeply situated nonmetallic foreign body. Any suspicion of penetrating trauma to the eye warrants ophthalmologic referral.
In a blunt force injury, the nature of the offending object, the estimated force, and the direction of impact are all important factors in arousing suspicion of posterior scleral rupture. If a sharp object is the offending agent, one should diligently search for globe lacerations. The direction and suspected depth of penetration of the sharp object should be ascertained. Sharp objects often cause less damage than blunt objects because sharp objects enter the eye more easily and cause fewer disturbances to the surrounding tissue than do blunt objects. High-velocity projectiles are more likely to penetrate the eye. In penetrating ocular trauma, surgery should be done without significant delay. Corneal wounds heal relatively rapidly.
The accumulation of blood in the anterior chamber of the eye is referred to as a hyphema (Fig. 6). Most hyphemas are traumatic, caused by a projectile that strikes the exposed portion of the eye. Sports injuries account for 65% of traumatic hyphemas in children.12 With traumatic hyphema, one must always consider the possibility of abuse. Nontraumatic etiologies are far less common, but it is important to recognize and include retinoblastoma, juvenile xanthogranuloma of the iris, and bleeding disorder from leukemia or other blood dyscrasia within this category.
Ultrasonography or computed tomography should be performed to rule out an intraocular tumor in suspicious cases, such as those in which the iris and the fundus cannot be adequately seen. A complete blood cell count and coagulation screening should also be performed if a bleeding disorder is suspected. Obtaining the history in the case of a hyphema is similar to that for all other forms of ocular trauma, with the mechanism of injury being crucial. Special attention should be given to any complaints of delayed changes in visual acuity that may indicate a secondary hemorrhage, elevated IOP, or another secondary event. Hyphema, with its associated complications, can threaten vision and an ophthalmologic consultation is most often appropriate. Increased IOP is a common complication of hyphema and is caused by obstruction of the trabecular meshwork, the outflow apparatus of the anterior chamber. Therefore, careful monitoring of the IOP is the standard of care, although this is fraught with difficulties in the pediatric population.
It was once common practice to hospitalize all patients with hyphema and place them on bed rest with bilateral eye patching. However, extreme restriction of activity has never been shown to improve prognosis. Hospitalization during the first 5 days after injury, the period of greatest risk for rebleeding, remains justifiable because it is one way to ensure daily follow-up evaluations and activity restriction. Outpatient management with daily follow-up is an acceptable alternative.
Treatment for hyphema remains as controversial in children as in adults. Cycloplegic and corticosteroid drops are used routinely by many ophthalmologists to improve comfort and reduce the risk of inflammatory complications. This may also reduce the risk of rebleeding. There is, however, a lack of definitive evidence for these topical medications and some clinicians prefer to use them selectively to control pain or reduce obvious inflammation. Others avoid them altogether, thereby minimizing eye manipulation.
Aminocaproic acid retards clot lysis by preventing plasmin from binding to lysine in the fibrin clot.13 This effect can stabilize the clot-vessel-wall interface, and this may decrease the potential for secondary hemorrhage. Several randomized clinical trials have studied the effect of aminocaproic acid versus placebo. Aminocaproic acid in a dosage of 50 mg /kg every 4 hours reduced the incidence of secondary hemorrhage to 3% and 4% in the group treated with aminocaproic acid compared with 28% and 33% in the group treated with placebo.13 Other studies have shown less dramatic results and ophthalmologists frequently reserve aminocaproic acid for high-risk patients such as those with sickle cell disease or hyphemas greater than 50%. A topical preparation of aminocaproic acid is now available mat lowers rebleed rates similar to the systemic preparations, but without the renal or hepatic toxicity.14
The use of aspirin and nonsteroidal antiinflammatory drugs for patients with hyphema is avoided because they adversely affect platelets and enhance bleeding. The use of systemic steroids is more controversial. Theoretical evidence suggests that they might enhance clot stabilization, but several studies have shown no significant reduction in rebleed rates with the use of systemic steroids.15 Topical steroids are commonly used for hyphema to minimize discomfort related to iritis or inflammation of the iris secondary to trauma.
Concerns about pressure from small collections of blood tend to be greatest in patients with sickle cell hemoglobin. Such patients may develop sickling in the anterior chamber, elevating IOP and greatly retarding resorption of blood through the trabecular meshwork. This can result in further elevation of IOP with possible retinal vascular occlusion. Moreover, patients with sickle cell disease are predisposed to optic nerve damage and central retinal artery occlusion when they have only a marginal increase in IOP. This is presumably a consequence of vascular sludging by sickle cells that leads to ischemia and vessel occlusion. Homozygotic SS red blood cell carriers and heterozygotic SA or SC carriers are predisposed to such sickling. Therefore, even carriers of the trait who do not have the clinical manifestations of systemic disease are at increased risk for elevation of IOP and its consequences. All previously unscreened black patients who have hyphemas should undergo immediate screening for sickle cell disease and trait.
Rebleeding occurs in between 4% and 40% of patients with traumatic hyphema. This is most frequent 2 to 5 days after the injury.1617 Rebleeding is likely caused by clot lysis and retraction, which opens a vessel that was incompletely healed. It is generally associated with greater morbidity because it often progresses to total hyphema or causes increased IOP. Approximately 5% of hyphemas will require surgical intervention for rebleeding because of corneal staining or unacceptably high IOP.17 Hyphemas in patients with sickle cell disease, those consisting of greater than 20% of the anterior chamber, those with rebleeding, those that are nonclearing beyond 3 to 4 days of duration, or those associated with significant trauma are probably best managed by an ophthalmologist.
Canalicular and Periocular Lacerations
Lacerations of the eyelid margin or marginal lid lacerations lateral to the punctum are unlikely to involve the canaliculus. In contrast one should have a high suspicion for canalicular disruption in those medial to the punctum (Fig. 7). The depth of the laceration is crucial. A full-thickness laceration medial to the punctum virtually guarantees canalicular injury. Lid margin lacerations medial to the punctum may be easily overlooked because they often seal in proper anatomic alignment and occur with minimal avulsive force. Consequently any eyelid laceration that is directed toward the medial canthus should be inspected to exclude a canalicular injury.
Even in older children, full-thickness eyelid lacerations should be repaired in the operating room under general anesthesia. There is some flexibility in the timing of repair for isolated periocular trauma because this area is well vascularized and therefore will generally heal well without infection. In general, periocular lacerations should be repaired within 24 hours of the insult. Nonabsorbable sutures should be used in cases where there is a high index of suspicion that the wound is contaminated, such as with dog bites. In contrast to eyelid lacerations and deep wounds, superficial wounds can be repaired in the emergency department using absorbable sutures.
Similar to adults, children may sustain isolated fractures of the orbital bones due to blunt impact. The most common such injury in early childhood is fracture of the orbital roof. This injury is relatively rare in older children. Isolated roof fractures result from impact to the brow region, typically after a fall from a height of only a few feet.18 The principal external manifestation is a hematoma of the upper eyelid that usually appears an hour or more after injury. This delay is caused by the time required for blood to extend to the eyelid from disrupted vessels in the periorbital region.
Cranial computed tomography images are particularly sensitive in confirming the isolated orbital roof fracture. Most are simple linear breaks, which heal uneventfully without intervention and without a persistent disturbance of ocular motility or eyelid function. When a fragmented bone is displaced inferiorly or evidence suggests a dural tear, neurosurgical repair should be considered because of the possibility of herniations of brain tissue into the orbit. Surgical intervention is also warranted where there is significant enophthalmos or strabismus, although the timing of that intervention is a subject of some debate. Antibiotic coverage in the case of nondisplaced orbital wall fractures is also debated.
Figure 7. Canalicular laceration with minimal tissue avulsion and silicone tube intubation.
Child Abuse and Nonaccidental Trauma
Most eye injuries in childhood are accidental and innocently caused by other children. A significant minority, however, result from physical abuse by adults.19 Child abuse is pervasive in our society, with an estimated 2 million victims per year in the United States.19 A reliable history is often difficult to obtain, but suspicion should be aroused when accounts of the injury or the history obtained from different individuals are inconsistent. Suspicion should also be raised when the events described seem to conflict with the extent of the injuries.
An ocular injury is the presenting sign of child abuse in approximately 5% of cases and ocular manifestations are detected in the course of evaluating many other injuries of child abuse. Periorbital ecchymosis, subconjunctival hemorrhage, and hyphemas should raise suspicion of recent abuse if the explanation provided is less than completely plausible. The most common posterior segment finding of child abuse is retinal hemorrhage.
The essential features of what is now generally known as shaken baby syndrome were first identified in the early 1970s and the syndrome became widely recognized as one of the most important forms of child abuse during the 1980s. Victims of shaking are always younger than 3 years and usually younger than 12 months. Intracranial injuries almost always include subdural hematoma (typically bilateral). Evidence of subarachnoid bleeding is also usually apparent.
Figure 8. Multiple layers of retinal hemorrhages associated with shaken baby syndrome.
Pre-retinal, intraretinal, and subretinal localization may be seen to the retinal hemorrhages (Fig. 8). Hemorrhages tend to be concentrated in or near the macular region, but, not uncommonly, they are so extensive that they occupy nearly the entire fundus. Vitreous hemorrhage may also develop, usually as a secondary phenomenon resulting from migration and blood that was initially intraretinal. Retinal hemorrhages of shaken infants routinely resolve within 1 to 2 weeks to several months. The prognosis varies from full recovery to a significant reduction in vision.
Treatment of corneal abrasions in minor ocular trauma is a common part of pediatric practice. This article has outlined some new developments in the treatment of corneal abrasions and indications for appropriate ophthalmologic referral for eye injuries.
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