CHAPTER 27
Ocular Trauma in Childhood
Trauma is one of the most important causes of ocular morbidity in childhood. Only amblyopia is responsible for more early monocular vision loss. Management of eye trauma in very young patients requires several special considerations in response to issues specific to this patient group. One issue is the often-difficult nature of evaluation and treatment of accidental and nonaccidental trauma because of inadequate patient cooperation or unreliable history. If the physician uses force to examine the child’s eye, there is a risk of exacerbating the damage caused by penetrating wounds or blunt impact. When preliminary assessment indicates that prompt surgical treatment may be necessary, it is appropriate to defer detailed physical examination of the eye until the patient is in the operating room and under general anesthesia.
Another issue in the care of children with eye trauma is the potential for the injury to lead to vision loss from amblyopia. In children younger than 5–7 years, deprivation amblyopia associated with traumatic cataract or other media opacity may cause severe, long-term reduction of visual acuity that is worse than the original physical damage. Minimizing the interval between the injury and the restoration of optimal media clarity and optics, including adequate aphakic refractive correction, must be a high priority. Monocular occlusion following injury should be kept to a minimum; the expected benefit from an occlusive dressing must be weighed against the risk of disturbing binocular function or inducing amblyopia in a very young child.
Accidental Trauma
In younger children, most accidental ocular trauma occurs during casual play with other children. Older children and adolescents are most likely to be injured while participating in sports. A majority of serious childhood eye injuries could therefore, in principle, be prevented by appropriate adult supervision and by regular use of protective eyewear during sports activities. Fireworks and BB guns are less frequent causes of pediatric ocular trauma, but they are likely to cause severe injuries.
Children aged 11–15 years have a particularly high incidence of severe eye injury compared with other age groups. Injured boys outnumber girls by a factor of 3 or 4 to 1.
American Academy of Pediatrics, Committee on Sports Medicine and Fitness; American Academy of Ophthalmology, Eye Health and Public Information Task Force. Protective eyewear for young athletes. Ophthalmology. 2004;111(3):600–603.
Superficial Injury
Corneal abrasion is one of the most common ocular injuries in children and adults. Topical cycloplegic drops and antibiotic ointment may help reduce discomfort and risk of infection, respectively. Traumatic corneal epithelial defects usually heal within 1–2 days. Use of a pressure patch to keep the eyelids closed is not necessary for most abrasions, since many children find this uncomfortable and patching does not decrease the time required for the abrasion to heal.
Cigarette burns of the cornea are the most common thermal injuries to the ocular surface in childhood. Usually, these occur in toddlers and are accidental, not manifestations of abuse. These burns result from the child running into a cigarette held at eye level by an adult. Despite the alarming initial white appearance of coagulated corneal epithelium, cigarette burns typically heal in a few days and without scarring. Treatment is the same as for mechanical abrasions.
Chemical burns in childhood are generally caused by organic solvents or soaps in household cleaning agents. Even burns involving almost total loss of corneal epithelium are likely to heal in a week or less with or without patching. Acid and alkali burns in children, as in adults, can be much more serious. The initial and most important step in management of all chemical injuries is immediate copious irrigation and meticulous removal of any particulate matter from the conjunctival fornices. See also BCSC Section 8, External Disease and Cornea.
Corneal foreign bodies in children can sometimes be dislodged with a forceful stream of irrigating solution. After topical anesthetic is placed, a cotton swab or blunt spatula can often be used to remove the corneal foreign body, with or without a slit lamp; sharp instruments should be avoided. If these methods are unsuccessful, the child may require sedation in order to facilitate removal of the foreign body.
Penetrating Injury
Unless an adult has witnessed the traumatic incident, the history cannot be relied on to exclude the possibility of penetrating injury to the globe. The anterior segment and fundus must be thoroughly inspected and general anesthesia used, if necessary, when a penetrating injury is suspected. An area of subconjunctival hemorrhage or chemosis or a small break in the skin of the eyelid may be the only surface manifestation of scleral perforation by a sharp-pointed object, such as a pencil or scissors blade (Fig 27-1). Distortion of the pupil may be the most evident sign of a small corneal or limbal perforation. Imaging should be considered if there is any reason to suspect an intraocular or orbital foreign body.
Figure 27-1 A, Small skin entry wound, right brow region, in a 7-year-old boy. The wound was created by a thrown dart. B, Conjunctival exit wound indicates complete perforation of the eyelid. C, Extensive injury to the anterior segment of the same eye.
Corneoscleral lacerations in children are repaired according to the same principles as for adults (see BCSC Section 8, External Disease and Cornea). Corneal wounds heal relatively rapidly in very young patients; thus, sutures should be removed correspondingly earlier. Small conjunctival lacerations are often self-sealing.
Fibrin clots may form quickly in the anterior chamber of a child’s eye after a penetrating injury to the cornea, and these can simulate the appearance of fluffy cataractous lens cortex to a remarkable degree. To avoid unnecessarily rendering the eye aphakic (and thereby compromising vision rehabilitation), the clinician should not perform lens removal in the course of primary wound repair unless absolutely certain that the anterior capsule has been ruptured. Even if lens cortex is exposed,
postponing cataract surgery for 1–2 weeks, until severe posttraumatic inflammation has quieted down, may result in a smoother postoperative recovery and reduced risk of complications without significantly worsening the visual prognosis. See also BCSC Section 11, Lens and Cataract.
Full-thickness eyelid lacerations should be repaired meticulously, especially those involving a canaliculus, and sedation or general anesthesia may be required, even in older children. Working near the eyes with sharp instruments and draping the face to create a sterile field are likely to frighten an awake child and add to the difficulty of the repair. Clearly superficial wounds can be repaired in the emergency department. Use of an absorbable suture is acceptable if the physician wishes to avoid the need for removal of nonabsorbable sutures.
Blunt Injury
Hyphema
As with all forms of pediatric trauma, the precise occurrence that led to the hyphema may be difficult to determine. The possibility of abuse must be considered, as must the possibility of a nontraumatic etiology: retinoblastoma, juvenile xanthogranuloma of the iris, and bleeding diathesis resulting from leukemia or other blood dyscrasia are relatively rare but important causes of spontaneous hyphema during the early years of life. Ultrasonography or magnetic resonance imaging should be performed to rule out intraocular tumor when the findings are suspicious and the iris and fundus cannot be adequately seen. A complete blood count should be performed with coagulation studies if a bleeding disorder is suspected.
Intraocular pressure (IOP), an important parameter for therapeutic decision making with traumatic hyphema, is often difficult to monitor in the pediatric patient. The risks of inaccurate measurements and of further traumatizing the injured eye may outweigh the potential value of obtaining measurements in uncooperative children. With small hyphemas (Fig 27-2), concern about pressure is greatest in patients with sickle cell trait or disease. Sickling may develop in the anterior chamber, elevating IOP and retarding resorption of blood, or in the retinal circulation, causing vascular occlusion. All African American children with traumatic hyphema require sickle cell screening to evaluate for these conditions.
Figure 27-2 Small hyphema. Note layering of blood inferiorly. (Courtesy of Edward L. Raab, MD.)
It was once common practice to admit all patients with hyphema to the hospital and place them on bed rest with bilateral patching of the eyes. These restrictions have never been shown to improve prognosis and are likely to be unproductive in children. However, some decrease in normal childhood activity is reasonable, as is placing a protective metal shield over the affected eye. If parental cooperation is questionable or if the patient has sickle trait, hospitalization for several days after injury, when risk of rebleeding is greatest, remains justifiable. Outpatient management with close follow-up is acceptable.
Medical management of hyphema remains as controversial in children as it is in adults. Many ophthalmologists routinely use cycloplegic and corticosteroid drops to facilitate fundus examination, improve comfort, and reduce the risk of inflammatory complications and possibly of rebleeding as well. The value of these topical agents is unproven, however, and some clinicians prefer to use them selectively for control of pain or obvious inflammation, or to avoid them altogether to minimize manipulation of the eye. Pressure-lowering medication is appropriate for eyes known or strongly suspected to have increased IOP. Aspirin-containing compounds should be avoided because of their antiplatelet action. Nonsteroidal anti-inflammatory drugs can also increase the risk of rebleeding and