have ranged from 8.5 to 15.2 per 100,000 per year [6, 8]. These injuries occur 4 times more often in boys than girls, with 3% occurring under the age of 5, 36% occurring between ages 5 and 14 years, 29% occurring between ages 15 and 24, and 31% occurring in individuals over the age of 25 years [6, 8, 9]. This disparity between genders reflects boys’ more adventurous or aggressive behavior. This difference may also relate to the higher potential for injuries associated with activities in which boys usually engage, such as contact sports or hunting and fishing.

More than 50% of eye accidents occur at home [6]. This reflects both the amount of time that children spend at home and risks around the home. Children also spend approximately 10–15% of their waking hours in school. In one study only 1% of injuries occurred at school; the authors suggest that greater safety at school relates to greater supervision [10].

18.3  Etiology of Trauma

18.3.1  Sports

The most common cause of childhood eye injuries, particularly in boys, is sports [5, 6, 11, 12]. Baseball is the leading sport, followed by basketball and tennis [12–14]. These injuries are largely preventable. Pro­ tective goggles are available for most sports, and if used properly, they can prevent most injuries. Barriers do exist for the use of eye protection, including lack of adult supervision for most sports, informality of many sports activities, and lack of compliance.

18.3.2  Assault

Assaults have been recognized as a frequent cause of eye injury in the young [15]. The term assault usually suggests malicious intent, but children’s play often turns into physical conflicts. These injuries are often unintentional accidents. Flying toys, fists, and other objects are the instruments of these injuries. They are more difficult to prevent since children are not always supervised while playing and are not always aware of the consequences of their action.

18.3.3  Birth Trauma

Injuries to the eye and adnexa can occur during birth. In fact, 20–25% of normal deliveries and 40–50% of protracted and assisted labors result in ocular injuries. Retinal hemorrhage is the most common injury followed by subconjunctival hemorrhage [16]. Birth related retinal hemorrhages are usually benign and clear spontaneously without sequelae. Their incidence has been reported between 2.6 and 59% of deliveries. This variation depends on many factors, including the type of delivery and the duration of labor. Forceps have been associated with a variety of ocular crush injuries, including retinal hemorrhage, lid lacerations, hyphema, Purtscher’s retinopathy, subconjunctival hemorrhage, and breaks in Descemet membrane [16, 17]. Choroidal rupture associated with forceps delivery, and traumatic optic neuropathy after birth-induced orbital fractures have also been reported with particularly devastating visual consequences [18, 19]. Milder neonatal hemorrhages may be caused by the compression of the head within the birth canal, with associated elevations in intracranial pressure. These result in a mixture of splinter-shaped, flame-shaped, and dot and blot hemorrhages concentrated in the posterior pole; they usually clear within a few days. Macular hemorrhages have been found in about 4% of births. These usually resolve completely, but prolonged hemorrhage may cause deprivation amblyopia and require vitrectomy.

18.3.4  Projectile Injury

In the 1980s, a new sport known as “paintball” became popular among adolescents and young adults. The objective of this combat-simulating game is to shoot the opponent with dye-filled gelatin or latex pellets. These are fired from a carbon dioxide-powered gun with a muzzle velocity of 300–400 feet/s [20]. The pellets measure 14 mm in diameter, small enough to fit into the orbit and strike the globe. Severe eye injuries occur when players (1) are not using adequate eye protectors,

(2) temporarily remove protective eyewear during the game, or (3) have eye protection dislodged during the game. Thach et al. [21] reported 13 patients with ocular injuries from paintball pellets. The male to female ratio was 12:1 with an average age of 21 years. Eleven of the

13 patients were not wearing protection at the time of injury for one of the above reasons. Posterior segment findings were vitreous hemorrhage in nine, retinal tear or detachment in six, and choroidal rupture in three. The final visual acuity in 8 of the 13 patients was 20/200 or worse. With these devastating consequences, it is important for the eye care professionals to be aware of the risks of paintball and strongly advise the patients to wear adequate protection at all times.

BB-guns have enjoyed a well-established and welldeserved reputation of inflicting severe ocular devastations since their conception. There are two different variations of air-powered guns with different ocular consequences. The spring-powered gun fires at a muzzle velocity of 84–99 m/s, sufficient to perforate most corneas. The CO2-powered version travels at greater speeds, 45–152 m/s, with enough force to perforate the eye and enter the orbit [22]. Hence CO2-powered guns may strike with over twice the energy of a spring action model.

It has been estimated that 1,200 ocular injuries from nonpowder firearms are evaluated yearly in United States emergency departments [23]. These injuries occur in males 90% of the time [23]. The circumstances surrounding the injury were studied in a series of 140 ocular air-gun injuries. In half of cases, the victim were the intended target, whereas in the other half, the weapon was unintentionally fired, the shooter believed the weapon to be unloaded, or the victim was hit by a ricochet [24]. The visual consequence relate to the type of injury. If the BB grazes the eye without perforating it, the visual prognosis is substantially improved. While retinal detachment and vitreous hemorrhage may still occur, these appear to be more amenable to successful surgery. However, these eyes are prone to chorioretinits sclopetaria as a consequence of extensive disorganization and contusive necrosis of the retinal layers, pigment epithelium, and choriocapillaris (3S).

Perforating BB-gun injuries have historically been devastating. Early studies reported enucleation in nearly 90% of eyes [25]. Unfortunately, there is little evidence that advances in the vitreoretinal surgery and technique have improved the prognosis of these injuries. In Sternberg et al. report of 32 eyes that underwent aggressive vitreoretinal surgery, 19 went on to enucleation [26]. In perforating injuries, where the BB penetrates the sclera and then exits into the obit, the prognosis is poor. In another report, despite vitrectomy and/or scleral buckling at the first sign of retinal traction or retinal detachment, 77% of eyes developed an

inoperable retinal detachment and were removed [27]. The unusual severity of perforating BB injuries is likely related to the velocity, mass, and the relative size of the projectile in relation to the eye. Despite their capacity to cause blindness or severe bodily injury [28], airpowered guns are not sufficiently hazardous to warrant the same regulations or scrutiny given to firearms. Only prevention by adult supervision, proper use of safety glasses, and education by eye care providers will reduce the inevitable morbidity associated with BB injuries.

18.3.5  Miscellaneous Causes

Other reported causes of ocular trauma in the kids include elastic cords, sticks and tree branches, eating utensils, knives, physical abuse, motor vehicle accidents, falls, toys, pencils, animals or pets, fingers, and chemicals [8, 10, 12, 29, 30].

18.3.6  Sympathetic Ophthalmia

Sympathetic ophthalmia is a bilateral granulomatous panuveitis with nodular or diffuse infiltration of the uveal tract by lymphocytes and epithelioid cells. Sympathetic ophthalmia classically occurs after penetrating injury to one eye, although ocular surgery, including pars plana vitrectomy, is also a well-recognized mechanism [31]. This is a rare disease with a reported prevalence in 0.1–0.3% of patients following traumatic ocular injury and in 0.015% of patients following ocular surgery [31–33]. A report of 105 cases of sympathetic ophthalmia attributed 53.5% of the cases to trauma and 40.4% to ocular surgery [31].

Both males and females are affected equally, although a male predominance has been reported. This has been attributed to a greater rate of injury in males [34]. Sympathetic ophthalmia also occurs more frequently in children because of a high risk of accidental trauma. In one study of 32 cases, 11 patients had the initial injury at 16 years of age or less. All but one case was a result of prior trauma [35]. This tendency for children to represent a disproportionately higher prevalence of sympathetic ophthalmia make diagnosis, intervention, and treatment of great importance given the increased morbidity in young patients.