AUTHORS
Amanda L. Bogie, MD, FAAP, Section Chief and Fellowship Program Director, Pediatric Emergency Medicine, University of Oklahoma Health Sciences Center, Oklahoma City
Charles Paul Bogie III, MD, PhD, Ophthalmology Private Practice and Trauma, Oklahoma City
PEER REVIEWER
Kim Cooper, MD, Clinical Faculty of Ophthalmology, Lucile Packard Children’s Hospital, Stanford, CA
EXECUTIVE SUMMARY
- Ocular trauma accounts for 8-14% of total childhood injuries, and nearly 8% of children registered in the National Pediatric Trauma Registry sustained ocular injury.
- If the mechanism or observable extent of the injury suggests that the globe may be violated, the practitioner should minimize further attempts at examination, place an eye shield over the affected eye, and consider sedation. Considerable iatrogenic injury may result if intraocular contents are expelled during attempts to restrain and examine an uncooperative child. If an open globe is even suspected, this circumstance requires an exam under anesthesia by an ophthalmic surgeon capable of immediate treatment.
- Sedation can be useful; however, ketamine, which is used commonly for procedural sedation in pediatric EDs, may be contraindicated in the ophthalmic exam because of the induced nystagmus and potential increase in intraocular pressure changes.
- A larger subconjunctival hemorrhage that involves the entire sclera, encircling the cornea in a 360-degree pattern, is highly suggestive of a ruptured globe and deserves further detailed examination and ophthalmologic consultation.
- Traumatic corneal or conjunctival epithelial defects are common in infants and children, with self-induced fingernail injury playing a significant role. Presenting complaints vary from minimal symptoms to unusual irritability, significant foreign body sensation, tearing, and photophobia. In young infants, it has been well reported that corneal abrasions are a potential cause of the irritable, afebrile infant.
- Traumatic iritis typically presents one to three days following blunt trauma and involves complaints of photophobia (sometimes extreme), pain, redness, and possible visual loss. Absence of concurrent corneal injury and lack of response to topical anesthetic are typical.
- Although retinal hemorrhages can be seen with a direct ophthalmoscope, ophthalmological consult is required for verification and confirmation in the face of legal ramifications. Emergency medicine personnel are encouraged to maintain a high index of suspicion for nonaccidental trauma in any case involving retinal hemorrhages.
- Recent focus on pediatric concussive syndromes associated with contact sports has identified an entity called vestibular-ocular motor dysfunction (VOMD) and is associated with visual difficulty and disruption of the vestibular-ocular reflex. This reflex elicits eye movement by stimulating the vestibular system to stabilize images on the retina during movement of the head, thus preserving the image on the center of the visual field. Vestibular-ocular dysfunction associated with concussion may be responsible for some of the vague and poorly described visual complaints common after concussions and may be seen in as many as 60% of sports-related concussions. VOMD often is under-appreciated in concussion; a new screening tool is proposed to identify patients at risk, but its utility remains to be determined.
Eye trauma can be devastating to a child and challenging to the clinician. These authors review common traumatic eye injuries and provide tips for the clinical evaluation of our youngest patients.
— Ann Dietrich, MD, FAAP, FACEP, Editor
Ocular trauma can result from blunt, penetrating, or other traumatic injuries to the eyeball, such as a blast or chemical injury. Ocular adnexal trauma refers to injuries of the adjacent tissues, such as the eyelids, eyebrows, conjunctiva, lacrimal gland, and orbit. It is estimated that 18 million people worldwide are affected by blindness caused by traumatic injury, with a disproportionate number occurring in the pediatric population.1,2 In the United States, approximately 2.4 million eye injuries occur yearly, with 35% in children 17 years of age and younger.3 Cataracts, refractive errors, and glaucoma are the leading causes of blindness in adults, but ocular trauma is the leading cause of acquired blindness and the second leading cause of visual loss in the pediatric population.4,5 Ocular trauma accounts for 8-14% of total childhood injuries, and nearly 8% of children registered in the National Pediatric Trauma Registry sustained ocular injury.5,6
Over a one-year period, it was estimated that more than 7,500 children and young adults (< 20 years of age) across the United States were hospitalized with significant ocular trauma as the primary or secondary diagnosis.4 The demographics suggest a high male-to-female ratio, with a trend toward increasing incidence of sports-related injury for older children.2 More than 440,000 children (< 17 years of age) visited U.S. emergency departments (EDs) between 1990 and 2012 for sports- and recreation-related eye injuries.7 Boys sustain open globe injuries more often than girls, most commonly at home and due to penetration with a sharp object, further emphasizing the importance of prevention and parental oversight in avoiding these injuries in this population.3,8 These statistics justify placing a high priority on ocular injury prevention and treatments supported by sound academic rigor.
Fortunately, from 1992 to 2002 and 2006 to 2014, the annual incidence of pediatric ocular injury declined, which can be attributed to various causes, including improved handgun safety and legislation, airbag modifications, and improvement in household chemical safety.8,9 Even the worrisome trend toward a more sedentary lifestyle in childhood is cited as a cause of declining injury by exposing children to fewer kinetic forces. Other authors have included seat belt usage and automobile glass improvements as additional reasons for the declining trend.10 Despite a general decline of 26% in pediatric ocular trauma from 2006 to 2014, the areas of sport injury and animal bites showed a trend of increasing incidence.8 This is despite the American Academy of Pediatrics’ 2004 recommendations for protective eye wear to be worn while participating in high-risk sports.11
Ocular injuries in children after major trauma are not rare. Serious ocular injuries associated with motor vehicle collisions should be suspected with injury severity scores of 15 or higher. Significant ocular injuries even have been found in the absence of open adnexal wounds in patients with significant mechanism of injury.12
Examination
Examination of the traumatized child can be difficult regardless of the injury’s location. Pain and anxiety are compounded in the presence of an ocular injury. The approach to ocular examination, involving bright lights and positioning in the slit lamp, does little to calm a child’s fear. Careful planning and preparation are required to ensure an adequate exam is accomplished on the first attempt. The age of the child, mechanism of injury, potential extent of the injury, and current level of pain will influence the examiner’s approach. Of primary concern is the presence of an open globe injury. If the mechanism or observable extent of the injury suggests that the globe may be violated, the practitioner should minimize further attempts at examination, place an eye shield over the affected eye, and consider sedation. Considerable iatrogenic injury may result if intraocular contents are expelled during attempts to restrain and examine an uncooperative child. If an open globe is even suspected, this circumstance requires an exam under anesthesia by an ophthalmic surgeon capable of immediate treatment.
When the injury is not suggestive of an open globe, sedation and/or restraint of the child may become necessary. Although children with ocular trauma often will not be able to participate in the exam, planning and a few “tricks of the trade” can elicit participation from initially reluctant children as young as 4 years of age. First, a few drops of any topical anesthetic should be instilled by the ancillary staff. The eventual examiner will not want to participate at this point because of the momentary pain associated with the drops and the physical restraint required to apply them. Then the child can be left alone with the family for a few minutes to allow both the pain and anxiety to subside. The immediate and complete pain relief from a corneal injury that is provided by the topical anesthetic is invaluable in allowing subsequent slit lamp examination, but it can be short lived. A good rule of thumb is that the anesthetic is effective in 20 seconds and lasts 20 minutes.
Prior to approaching the child with a slit lamp, the examiner must be familiar with its operation and assured of its functionality. The window of opportunity for examination may pass while changing bulbs or locating a working electric outlet. Asking a trusted family member to position himself or herself in the slit lamp before moving on to the child also will increase the likelihood of success. Begin the slit lamp examination with a low-intensity beam and slowly increase the light to minimize the initial shock and keep the skittish child in place. Although physically manipulating the eyelids may be required, initially allowing the child to sit in the slit lamp without any contact from the examiner may provide the child with some level of comfort before “helping” with the eyelids. Finally, having a family member hold a toy on the examiner’s ear may help control the patient’s gaze direction. A skilled examiner can convince children as young as 5 years of age into a successful slit lamp examination.
All eye examinations must include an attempt to record visual acuity, as it is one of the most important predictors of visual outcome. Detailed and precise visual acuity measurements rarely are obtainable from the injured child; however, the examiner almost always can develop a rough sense of the level of visual acuity in the injured eye. Children between 6 months and 2 to 3 years of age should be able to fix and follow an object, face, or light source. Sometime after 2 to 3 years of age, visual acuity can be examined using a more objective chart. Most physicians are familiar with the traditional Snellen chart, but similar measurements can be made using a chart with pictures, or “tumbling E,” or using one of the many apps available for smartphones. Patients unable or unwilling to participate in a formal evaluation of visual acuity still can be evaluated by identifying objects in the room or on the television, reading a clock, counting fingers, or identifying the presence and location of a light source. Comparison to the uninjured eye is important, and vision in both eyes should be documented in the medical record.13
Physical restraint and sedation may be necessary for an effective examination in some ocular injuries. It is imperative that the possibility of an open globe injury be considered and eliminated prior to using any physical restraint to aid the exam. Sedation can be useful; however, ketamine, which is used commonly for procedural sedation in pediatric EDs, may be contraindicated in the ophthalmic exam because of the induced nystagmus and potential increase in changes to intraocular pressure. In addition to papoosing in a blanket, it is useful to place the child in a C-collar to control flexion and extension of the head with an assistant holding the head to prevent rotation. Despite sedation, the restrained child will close his or her eyes tightly. Dry gauze beneath a gloved finger helps manipulate the wet periocular skin, but edematous lids still may require more retraction. Although Desmarres eyelid retractors are a common intraoperative tool, they rarely are available in a busy pediatric ED; bent paper clips may serve as a good substitute.14 (See Figure 1.) However, never use any instrument to open the eye or irrigate unless the patient has had topical anesthesia placed in the eye.
Figure 1. Paper Clips as Eyelid Retractors |
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Source: Charles Paul Bogie III, Ophthalmology Private Practice and Trauma |
Anatomy
Ocular adnexal structures include the eyelids, eyebrows, conjunctiva, lacrimal gland, and lacrimal drainage system. Common adnexal injuries include eyelid lacerations, lacrimal duct lacerations, foreign bodies, injury to extraocular muscles, and orbital fractures. The globe is divided into anterior and posterior segments. Anterior segment structures include the cornea, anterior chamber, lens, and ciliary body. Common anterior segment injuries include chemical injury, corneal and conjunctival abrasions and lacerations, corneal foreign bodies, hyphema, traumatic iritis, and traumatic cataract. Posterior segment injuries include damage to the vitreous and retina, retained intraocular foreign bodies, and the retinal or optic nerve effects of blunt trauma.
Types of Injury
Hyphema
A collection of blood in the anterior chamber, hyphema is a common complication of ocular trauma and requires urgent ophthalmologic consultation. A hyphema can vary from a few suspended erythrocytes (Grade 0) visible only by slit lamp to up to 100% of the anterior chamber filled with blood (eight-ball hyphema; Grade IV). (See Figure 2.) Patients will present with pain, photophobia, and decreased visual acuity and may demonstrate either an increase or decrease in intraocular pressure (IOP). A lower-grade hyphema typically will clear within one to two weeks, but the potential for rebleeding occurs around days 5-7 as the initial clot undergoes remodeling. Rebleeding is associated with a greater risk of complications, such as corneal blood staining and glaucoma. Any patient at risk for sickle cell trait or disease must undergo laboratory evaluation when their sickle cell status is unknown. Patients with either sickle cell trait or disease have a significantly increased risk of elevated IOP in the presence of a hyphema.15,16 All hyphemas should be evaluated by an ophthalmologist. See Table 1 for hyphema clinical pearls.
Figure 2. Hyphema Occupying Anterior Half of Eye |
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Source: Author: Rakesh Ahuja, MD. Courtesy of the Creative Commons licensing agreement, Copyright 2006; Wikipedia. Accessed July 26, 2018. |
Table 1. Hyphema Clinical Pearls |
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Eyelid Lacerations
The depth and location of an eyelid laceration guides the need for further ophthalmologic consultation. Partial thickness lacerations that are lateral to the lacrimal puncta and with no lid margin involvement can be closed primarily in the ED. This type of laceration repair in the ED is well within the scope of emergency medicine practice and routinely results in excellent outcomes. However, lacerations that involve the lid margin or medial canthal areas (requiring investigation of the lacrimal drainage system) call for urgent ophthalmologic consultation. (See Figures 3 and 4.) If closure in the ED is elected, the choice of suture material and technique mirrors that of other facial injuries. It is preferable to choose a 6-0 or smaller suture, with a trend toward absorbable suture material in younger patients. With care, tissue adhesives can be used successfully in well-chosen eyelid or eyebrow lacerations. These wounds tend to be smaller, linear, non-gaping, and follow or parallel the eyelid crease. Lacerations resulting from an animal bite should be closed with sutures, not tissue adhesive. See Table 2 for eyelid lacerations clinical pearls.
Figure 3. Eyelid Laceration |
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Source: Charles Paul Bogie III, Ophthalmology Private Practice and Trauma |
Figure 4. Eyelid Laceration With Lid Margin Involvement |
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Source: Image courtesy of Blake Forcina, MD, Children’s Eye Care, Oklahoma City, OK |
Table 2. Eyelid Lacerations Clinical Pearls |
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Subconjunctival Hemorrhage
Subconjunctival hemorrhage (SCH) secondary to trauma occurs because of episcleral and conjunctival blood vessel involvement and usually is uncomplicated.16 The examiner must maintain an index of suspicion for additional significant trauma, such as orbital fractures, corneal or conjunctival lacerations, or a ruptured globe. A larger SCH that involves the entire sclera, encircling the cornea in a 360-degree pattern, is highly suggestive of a ruptured globe and deserves further detailed examination and ophthalmologic consultation.16-19 Isolated and uncomplicated SCH requires no intervention, and most will resolve slowly over one to two weeks. SCH in the setting of significant trauma needs a complete dilated eye exam by an ophthalmologist. In older patients without a history of trauma, check blood pressure for hypertensive crisis and ask about blood thinners (including aspirin, ibuprofen, or homeopathic products) and activities such as heavy lifting, bending, or straining (coughing or vomiting).
Conjunctival and Corneal Abrasions
Corneal abrasions secondary to trauma represent up to 3% of all ED visits and usually are associated with a good prognosis.20 In the cornea, the epithelium can be cleanly abraded or separated from the underlying stroma along a relatively weak dissection plane. This usually results in a complete loss of epithelium in one geographic area without injury to the underlying basement membrane or stroma. (See Figure 5.) Traumatic corneal or conjunctival epithelial defects are common in infants and children, with self-induced fingernail injury playing a significant role.21,22 Presenting complaints vary from minimal symptoms to unusual irritability, significant foreign body sensation, tearing, and photophobia. In young infants, it has been well reported that corneal abrasions are a potential cause of the irritable, afebrile infant.22-24 See Table 3 for corneal abrasion clinical pearls.
Figure 5. Abrasion |
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Source: Image courtesy of Blake Forcina, MD, Children’s Eye Care, Oklahoma City, OK |
Table 3. Conjunctival and Corneal Abrasions Clinical Pearls |
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Infants also may present with a chief complaint of “not waking up” or lethargy because they refuse to open their eyes. The differential diagnosis of the irritable or lethargic infant who is well-appearing and afebrile should include an exam for a corneal abrasion. Topical anesthetics can be both therapeutic (temporary pain relief) and diagnostic, causing the previously “sleeping” infant to become rapidly more alert. Abrasions may be detected with fluorescein dye, which stains the permeable, exposed corneal stroma but not the surrounding intact epithelium. Treatment for corneal abrasions remains controversial, despite its prevalence.
The safety and efficacy of topical nonsteroidal anti-inflammatory drops, topical antibiotics, and patching remain unsupported by good randomized clinical trials.21,25-31 The dogma against the use of topical anesthetics outside of the ED also is questioned. In adults, the short-term use of topical tetracaine for pain control in uncomplicated, noninfectious corneal abrasions has been shown to be safe and efficacious.32,33 Our own randomized clinical trial comparing placebo to topical tetracaine for 24 hours of outpatient use also demonstrated no detrimental side effects. In adult patients, any use of topical anesthetics for outpatient pain management limits the potential for severe and long-term corneal injury by dispensing only 1 to 2 mL of volume. Providers should maintain personal control of the larger bottles of topical anesthetic at all times because of the risk of diversion, abuse, and long-term corneal injury. Although the authors of these studies did not look at pediatric patients specifically, the era of focused pain management, complicated by the national opioid crisis, warrants further study in this area. Given the lack of consensus on corneal abrasion management, tailored patient-specific treatment would appear to be the best option.
Corneal Foreign Body
Ferrous and non-ferrous metals, plant material, and sand represent common retained corneal foreign bodies. (See Figure 6.) In patients complaining of a foreign body sensation, eye rubbing is a complicating factor. Even children who are old enough to tolerate a slit lamp examination may not be stoic enough to allow for foreign body removal. As in the case of corneal abrasion, topical anesthetic is very useful in providing pain relief and allowing an adequate exam. Cotton tip applicators or flexible ear curettes offer a relatively atraumatic means of foreign body removal, but a needle may be used in older children who will remain still. Sedation may be useful in some cases, but ophthalmologic consultation and removal in the OR will avoid the need for repeat sedation if the foreign body is not removed in its entirety in the ED. With successful foreign body removal in the ED, these cases can be managed as corneal abrasions with ophthalmology follow-up. It is imperative to rule out full thickness corneal perforation with any foreign body.
Figure 6. Metallic Foreign Body With Rust Ring |
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Source: Image courtesy of Blake Forcina, MD, Children’s Eye Care, Oklahoma City, OK |
Periorbital Ecchymosis
Periorbital ecchymosis, also known as “panda sign” or “raccoon eyes,” can occur with mild to severe orbital trauma, frontal or midline forehead injuries, and basilar skull fractures.34-37 The soft tissues of the eyelid are connected loosely to the overlying skin, allowing blood to track between them with sometimes dramatic accumulation around the eye.15 Most patients with periorbital ecchymosis will have a history of injury; however, a high suspicion for nonaccidental trauma (NAT) is important in the nonambulatory pediatric patient. Rarely, the presence of spontaneous periorbital ecchymosis also could alert the examiner to the diagnosis of neuroblastoma.38,39
Open Globe
Open globe injuries can occur with either sharp or blunt trauma and represent a true ophthalmologic emergency. Full thickness lacerations to the cornea and/or sclera result from a wide variety of traumatic mechanisms and can be difficult to detect initially. A high index of suspicion is required to avoid missing an injury that has self-sealed or is plugged with iris tissue, as these injuries may be subtle in appearance. Any disruption of corneal or scleral tissue should be considered full thickness until proven otherwise, and the presence of a distorted pupil, exposed pigment beneath the sclera, or a traumatic cataract is highly suggestive. (See Figure 7.) Special attention should be given to the patient who presents with injury from a high-speed mechanism. History of hammering metal on metal, the use of power tools (especially resulting in a broken drill bit or grinding wheel), or any blast injury requires additional consideration. The presence of significant eyelid swelling limiting the exam, extreme discomfort or anxiety, and a high-risk mechanism should be referred for ophthalmologic consultation. Although the diagnosis of an open globe typically is based on the physical exam, particularly if the pupil is irregular, diagnostic imaging maybe useful in identifying the presence of a retained intraocular foreign body (IOFB) and in evaluating the posterior segment of the globe.40 Table 4 summarizes the most common modalities.41-44
Figure 7. Complex Eyelid Laceration With Scleral Rupture |
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Source: Image courtesy of Blake Forcina, MD, Children’s Eye Care, Oklahoma City, OK |
Table 4. Diagnostic Modalities for Possible Retained Intraocular Foreign Body |
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Diagnostic Method |
Benefits |
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X-ray |
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Computerized tomography |
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B-scan ultrasonography |
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Magnetic resonance imaging |
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Seidel testing for open globe injury often is misunderstood. In short, if there is a full thickness corneal injury that is leaking aqueous fluid through the wound, fluorescein dye will be diluted by the aqueous fluid and will exhibit the peculiar characteristic of becoming more vividly fluorescent as it runs down the cornea. This technique can highlight an actively leaking ocular wound. Readers are directed to an informative video: https://www.youtube.com/watch?v=chHTGyKNNwY.
Traumatic Iritis
Detection of traumatic iritis in the pediatric patient by physical exam is difficult in the ED setting. An effective slit lamp examination for iritis requires a dark, calm setting, well-maintained equipment, a compliant patient, and well-honed examiner skills. Most emergency providers would admit that all of these criteria rarely are met, rendering identification of the 10-20 micron immune cells suspended in the anterior chamber nearly impossible. Alternatively, the patient’s history can be very helpful in diagnosis. Traumatic iritis typically presents one to three days following blunt trauma and involves complaints of photophobia (sometimes extreme), pain, redness, and possible visual loss.15 Absence of concurrent corneal injury and lack of response to topical anesthetic are typical. Traumatic iritis has been described in pediatric patients following blunt trauma from air bag deployment, bottle rockets, airsoft guns, water balloon slingshots, and many sports (i.e., high-velocity missile injuries).45-49 Despite previous dogma admonishing the use of topical ophthalmic steroids in the ED, this author routinely advises his emergency medicine colleagues on the use of topical steroids with an intact cornea and close follow-up in the eye clinic.
Traumatic Cataract
Clouding of the human lens or cataract formation can result congenitally, with increasing age, or from systemic disease, certain drugs, or trauma. The lens capsule or basement membrane of the lens’s epithelial cells acts as an osmotic barrier between the aqueous humor and the crystalline lens proteins. Disruption of the lens capsule by either penetrating or blunt injury can result in formation of a cataract seen as a whitening of the substance of the lens. This clouding is seen within minutes or hours of the loss of osmotic control. Formation of a traumatic cataract requires a thorough ophthalmic inspection for penetrating injury and retained IOFB.
Chemical Injury
Chemical injury commonly results in corneal epithelial loss, regardless of the offending agent, but rarely results in deeper long-term injury in acidic injuries. Household detergents, cosmetics, and various hydrocarbons are typical offending agents that result in pain, conjunctivitis, and corneal epithelial loss, but carry a more favorable prognosis. However, alkali or chemicals on the basic side of the pH scale are the obvious exception and can cause profound lifelong injury, in part because of the liquefaction necrosis that occurs under alkaline conditions. Extensive and deep injury occurs within minutes of exposure to basic chemicals. Irrigation in the ED mitigates, but does not eliminate, the caustic tissue damage and long-term visual consequences. Industrial detergents, pool maintenance, and the illicit manufacture of methamphetamines commonly are associated with exposure to basic chemicals. Infants and small children crawling on the floor can get cat litter stuck under their eyelids and will need lid eversion and irrigation to remove this adherent alkali foreign body.
Delayed healing of corneal and conjunctival epithelial loss after chemical exposure is related to the concomitant injury of conjunctival accessory lacrimal glands. These accessory lacrimal glands are required for a healthy tear film and to support the re-epithelialization of the cornea. Injury to these glands at the time of the initial chemical exposure affects the complex environment of the precorneal tear film and slows epithelial growth. Because of the possibility of a retained offending agent, patching is never indicated in chemical exposure.50
Treatment for chemical exposure involves irrigation, irrigation, and more irrigation after instillation of anesthetic eye drops. Checking the pH of the tear film is allowed, as long as it does not delay irrigation. Various sources recommend from one to several liters of irrigation volume. Evidence supports the use of borate buffered eye wash for irrigation, but normal saline or lactated Ringer’s solution is considered adequate.50 Irrigation is continued until the pH normalizes and remains stable; extensive irrigation and examination of the conjunctival fornices are especially important in cases of exposure to granular chemicals. After effective irrigation, subsequent examination of the eye will determine the urgency of referral. Uncomplicated limited chemical injury can be managed as a corneal abrasion with urgent ophthalmologic follow-up, whereas more extensive or alkali injury requires emergent ophthalmology involvement.51
A surprisingly common form of chemical injury is exposure to cyanoacrylate glue. Many Super Glue products are marketed in a bottle that looks similar to eye drops. These products are readily confused by children and adult caregivers. Upon instillation, the glue polymerizes immediately from a liquid to a solid form. At the very least, the lids and lashes are glued shut and, at worst, a shield-like layer of solid, abrasive glue is present beneath the adherent lids and abrades the corneal epithelium with every eye movement. Very rarely, the glue will stick to the cornea or conjunctival surfaces and act as a large retained foreign body held directly against the cornea.52
Treatment involves applying ophthalmic lubricants, trimming the adherent lashes, and physically opening the lids to remove the retained, solid glue. This should be done in consultation with an ophthalmologist. If the older, reliable pediatric patient is not complaining of a painful retained foreign body, a conservative approach may be taken. Sending the patient home with ophthalmic lubricant to be massaged into the lids will allow the lids to open within a few days.53 Pediatric patients rarely glue their own eyes shut, especially both eyes. All pediatric patients with this type of injury should be suspected of being victims of child abuse.
Child Abuse
All types of ocular trauma can result from NAT of the pediatric patient, and a full discussion of nonaccidental ocular injuries is beyond the scope of this article. Retinal hemorrhages appear to represent the most common orbital manifestations of NAT associated with head injury.15 Although retinal hemorrhages can be seen with a direct ophthalmoscope, ophthalmological consult is required for verification and confirmation in the face of legal ramifications.54,55 Emergency medicine personnel are encouraged to maintain a high index of suspicion for NAT in any case involving retinal hemorrhages.
Traumatic Visual Loss
Traumatic visual loss (TVL) associated with no obvious ocular or intracranial injury can be either organic or nonorganic. Scant literature is available to describe TVL not associated with overt injury. Traumatic asphyxia associated with compression of the chest has been associated with transient TVL in pediatric patients, and transient cortical blindness following closed head trauma is a known cause of TVL.15,56,57
Recent focus on pediatric concussive syndromes associated with contact sports has identified an entity called vestibular-ocular motor dysfunction (VOMD), which is associated with visual difficulty and disruption of the vestibular-ocular reflex. This reflex elicits eye movement by stimulating the vestibular system to stabilize images on the retina during movement of the head, thus preserving the image on the center of the visual field.58,59 Vestibular-ocular dysfunction associated with concussion may be responsible for some of the vague and poorly described visual complaints common after concussions and may be seen in as many as 60% of sports-related concussions. VOMD often is under-appreciated in concussion; a new screening tool is proposed to identify patients at risk, but its utility remains to be determined.60
Nonorganic TVL, or functional visual loss, commonly is seen following stressful traumatic events. Functional visual loss is a complex and fascinating topic and should be suspected in older children in whom the level of visual loss far outweighs the objectively identifiable injury. These patients may claim unilateral (or bilateral) blindness or loss of visual field after a traumatic event but without obvious cause. This form of conversion reaction appears more common after motor vehicle collisions (especially where there may be legal consequences) and in circumstances in which there is palpable conflict within the family members present. Several examination techniques may allow the emergency medicine physician to differentiate this from organic visual loss, although ophthalmologic consultation still may be required. Patients with true visual loss usually are anxious and demonstrate an inability to navigate around their environment, whereas functional patients reflect a very calm demeanor. Despite a claimed tunnel field, functional patients will shake a hand when offered in greeting by the examiner. Functionally blind patients usually will follow their own image reflected in a handheld mirror passed in front of them and claim an inability to legibly sign their own name, while truly blind patients retain the ability to write. Emergency medicine providers are cautioned against approaching these patients cynically, as functional visual loss truly is a diagnosis of exclusion. Functional visual loss is associated regularly with concomitant ocular disease and is highly associated with depression. Not all functional patients are malingering.61,62
Summary
Trauma is a leading cause of morbidity and mortality in the pediatric population, one of the most underrecognized major health problems facing the nation, and, importantly, mostly preventable.63 Although not associated with a high mortality rate, ocular trauma has tremendous financial, physical, and emotional implications. Children have a disproportionate number of ocular injuries that can result in lifelong disability. Prevent Blindness America has established August as Child Eye Health and Safety Month and September as Sports Eye Safety Month, clearly highlighting the impact of this on our pediatric patients.64 The American Academy of Pediatrics, the American Academy of Pediatric Ophthalmology and Strabismus, and the American Academy of Ophthalmology strongly recommend protective eyewear for all pediatric patients participating in sports at high risk for ocular trauma. This is particularly important for athletes who are functionally one-eyed and those athletes who have undergone previous eye surgery or trauma. Further information can be found in the Children’s Sports Eye Safety Position Statement through Prevent Blindness America.
References
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- Cheng LHH, Kumar P. Retraction of oedematous eyelids with paper-clips. Ann R Coll Surg Engl 2008;90:253.
- Levin AV. Chapter 117: Eye Trauma. In: Fleisher GR, Ludwig S, eds. Textbook of Pediatric Emergency Medicine. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2010:1454-1457.
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- Willmann, D, Melanson SW. Corneal Injury. StatPearls. 2017. Available at: https://www.ncbi.nlm.nih.gov/books/NBK459283/. Accessed July 24, 2018.
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Eye trauma can be devastating to a child and challenging to the clinician. These authors review common traumatic eye injuries and provide tips for the clinical evaluation of our youngest patients.
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