Introduction

Trauma to the eye and surrounding structures (adnexa) can come from different sources and can vary in intensity from minimal to sightthreatening. This chapter will review some of the most common etiologies of ocular trauma and its management.

Eyelid

Eyelid trauma is a common issue in the pediatric population. The injury can occur from simple blunt trauma, or a laceration can occur from a sharp object. Tissue avulsion of the eyelid may occur in more complicated trauma, such as from a dog bite. Blunt trauma to the eyelid can result in ecchymosis and edema (321). These are selflimiting and can be treated with iced compresses and analgesics. Blunt trauma may also be associated with injuries to the eye and orbit, so careful inspection of the surrounding structures is neccessary.

Eyelid foreign bodies are relatively uncommon but must be removed in an effort to minimize injury to the eye (322). Small, superficial foreign bodies under the upper eyelid can cause linear, vertical abrasions of the cornea (seen with fluorescein). The upper eyelid should be everted and the foreign body removed with a moist cotton swab.

Eyelid lacerations may vary from simple to

complex (323, 324). When evaluating an eyelid laceration examination details should include: depth of the laceration, its location, and if there is involvement of the canaliculus. Most superficial eyelid lacerations may be closed by the primary caregiver, but if the laceration is deep, it should be evaluated by an ophthalmologist. The levator muscle is responsible for elevation of the eyelid and runs deep to the obicularis oculi muscle. If the levator muscle is compromised and not recognized at initial repair, ptosis will occur. If orbital fat is visible in the laceration, the laceration has compromised the skin, obicularis oculi, levator, and orbital septum and must be meticulously repaired to avoid ptosis. Eyelid margin involvement (325) also requires careful repair to avoid notch formation. A residual notch can lead to ocular surface problems in the future, resulting in corneal scarring and loss of vision.

Trauma involving the canaliculus (326) will require repair with intubation of the nasolacrimal duct to avoid future problems with tearing. Canalicular involvement may be subtle, so consideration must be given if there is a laceration medially or if the mechanism is that of avulsion. Finally, with any eyelid injury, the eye must be carefully inspected for damage. For example, it is fairly common in dog-bite trauma for injuries involving the eye, scalp, and extremities to be present for which the child must be examined (327).

Open globe

A penetrating, perforating, or blunt injury resulting in compromise of the cornea or sclera of the eye is one of the most sight-threatening injuries that can be sustained. This is known as an open globe. A penetrating injury extends only partially through the tissue of reference while a perforation extends through the full thickness of the tissue. An open globe is a true ophthalmologic emergency which requires prompt, careful evaluation and repair to minimize vision loss. Vision loss can result from corneal scarring, loss of intraocular contents, or infection. Evaluation involves careful history including time and mechanism of the injury, as well as visual acuity and inspection of the eye. A full-thickness corneal (328) wound will often present with prolapse of iris tissue through the wound. If this is not immediately evident, a peaked or irregular pupil may be seen (329). Scleral compromise may be more difficult to

identify because of overlying structures. The thinnest part of the sclera is at the corneoscleral junction (the limbus) and just posterior to the insertion of the rectus muscles. When an open globe is caused by blunt force injury, these are the two areas most likely involved. The overlying conjunctiva may not be compromised but a subconjunctival hemorrhage may be present, obscuring the view. In these cases, a shallow anterior chamber, low intraocular pressure (IOP), or pigment within the involved area should be identified. If the patient has been diagnosed with an open globe, the examination should be stopped, an eye shield should be placed immediately (330, 331), and the ophthalmologist contacted.

The presence of an intraocular foreign body (332–334) should be suspected in cases of open globe secondary to a high-velocity projectile, such as a BB (pellet). Intraocular foreign bodies must always be surgically removed.

328 Full-thickness laceration with prolapse of intraocular contents.

329 Peaked pupil from iris prolapse,secondary to full-thickness corneal laceration.