AbstractOcular trauma is the most common cause ofuniocular blindness in children. Trauma to theeye and periocular region may occur by manymechanisms and can cause a wide spectrum ofinjuries ranging from superficial to vision-threatening. Injury may occur due to blunttrauma, penetrating injuries, projectile injuries,chemical exposure, explosions/blast injuries,and crush injuries. Open-globe injuries, wherethe eye wall has a full-thickness wound, areassociated with poorer outcomes, compared toclosed globe injuries.
Ocular trauma in children may occur inisolation or with associated head or systemicinjury; therefore, it is vital that any potentiallylife-threatening injuries are identified andtreated as a priority. If a ruptured globe issuspected, manipulation and examination ofthe eye should be kept to a minimum until thepatient is in the operating theatre. Visual prog-nosis varies greatly depending on type andlocation of injury. Presenting visual acuity isa key factor in predicting final visual outcome.
In children less than 7 or 8 years old, visualoutcomes following a traumatic eye injury aredependent upon successful amblyopia man-agement post injury.
Ocular trauma is a leading cause of monocularblindness in children (Mulvihill et al. 1997).Worldwide, as many as six million children annu-ally sustain ocular trauma, with up to a quarter of amillion children requiring hospitalization (Barryet al. 2019). These injuries are disproportionatelycommon in childhood, accounting for approxi-mately one third of cases (Bunting et al. 2013).The injury is preventable in the vast majority ofcases (Sii et al. 2018). Trauma may occur througha variety of mechanisms. Open-globe injuries,where the eye wall has a full-thickness wound,
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are associated with poorer outcomes, compared toclosed globe injuries.
Epidemiology
The incidence of serious ocular trauma in childrenhas been estimated at 11.8 per 100,000 per year(Morris et al. 1993). Eye injuries are the mostcommon cause of uniocular blindness in childrenand account for 8–14% of total injuries in children(Takvam and Midelfart 1993). Risk factors forinjury include: age between 0–5 years, male sex,and lack of parental supervision. Injuries associ-ated with endophthalmitis, retinal detachment,vitreous hemorrhage, hyphema, and posteriorwound location are at higher risk of poor visualoutcome. Most ocular trauma in younger childrenoccurs during casual play, while older childrenusually sustain their injuries while participatingin sports. Dog bites result in a diverse range ofinjuries and complications in the periorbitalregion in young children (Erickson et al. 2019;Bratton et al. 2018).
The use of protective eyewear while participat-ing in sports is crucial in minimizing ophthalmicinjuries. With appropriate eye protection, sports-related ocular trauma can be reduced as much as90% (Erie 1991).
Mechanism of Trauma
Trauma to the eye and periocular region mayoccur by various mechanisms: blunt trauma, pen-etrating injuries, projectile injuries, chemicalexposure, explosions/blast injuries, and crushinjuries.
Ocular Trauma Terminology
There are number of terms used to describetrauma to the globe, with some overlap withinthe terminology.
• Closed Globe Injury: The corneo-scleral wallis intact. This usually occurs following blunttrauma.
• Open Globe Injury: A full-thickness defect inthe corneo-scleral wall. This may be due toblunt trauma or perforating/penetrating/lacer-ating eye injury.
• Penetrating Injury: A full-thickness defectcaused by an object entering the globe withoutexiting – this occurs in association with aretained intraocular foreign body.
• Perforating Injury: An object has entered andexited the globe at two separate sites – usuallyoccurs with a missile type injury.
• Laceration: A partial or full-thickness break inthe corneo-scleral wall caused by a sharpobject at point of impact.
• Rupture: A full-thickness defect in thecorneo-scleral wall secondary to blunt trauma.The defect usually occurs at a weak point, i.e.,beneath insertion of the recti muscles or at aprevious surgical site, not necessarily the pointof impact.
Assessment of Eye Trauma
• Proceed with caution: Assume that any peri-ocular or ocular injury could include a rupturedglobe. Avoid placing pressure on the globeuntil you establish that an open globe injurydoes not exist.
• Evaluate the whole patient: Make sure thechild does not have any concomitant life-threatening injuries that need to be prioritized.
• Make the patient comfortable: Treat the childwith analgesics and anti-emetics as necessary.This will make examination easier, as well asreducing the risk of vomiting or straining,which could cause prolapse of intraocular con-tents in an open globe injury.
• Assess visual acuity and pupils: It can bedifficult to obtain a good visual acuity inyoung children even under normal circum-stances, even more so if the child has justsustained an injury. However, visual acuity isimportant in formulating the visual prognosisso when possible it should be recorded. If a
Ophthalmic Trauma 3
reliable acuity cannot be obtained, carefullyassess for an afferent pupillary defect. If thepupil cannot be visualized in the traumatizedeye, check for an afferent pupillary defect inthe fellow eye.
• Assess the adnexal structures: It is importantto assess for lid or canalicular lacerations,which may be overlooked in the context of aserious globe injury.
• Evaluate the fellow eye: Make sure that youconduct a complete exam on the fellow eye forany signs of trauma or changes in visual acuity.
• Imaging: CT scans may be helpful inconfirming globe rupture and assessing forintraorbital or intraocular foreign bodies, aswell as orbital wall or other facial fractures.
• Arrange for theatre: Make sure the child isfasting, and establish the last time they ate.Determine if the patient has had a recent teta-nus shot. Place a shield over the traumatizedeye. Inform emergency theatre staff andanesthetists.
• Talk with parents: It is vital to discuss thesurgery and visual prognosis for the eye withthe parents preoperatively. Depending on theextent of the globe injury, it may rarely benecessary to discuss the possibility of primaryenucleation/evisceration in cases of severeglobe rupture where surgical repair is notpossible.
Birth Trauma
A traumatic or difficult delivery may result inocular injuries at the time of birth, especially invacuum or forceps-assisted deliveries. Facial andeyelid bruising can result from vacuum or forcepsdelivery. Injury to the eye may occur due to place-ment of the forceps blade across the globe andorbit, leading to blunt trauma to Descemet’s mem-brane of the cornea. The Descemet’s tears in birthtrauma tend to be unilateral and central and occurin a vertical or oblique pattern. This can lead todiffuse corneal edema in the postpartum period.Although this may clear within weeks to months,there may be significant residual astigmatismrequiring urgent correction and amblyopia
management. If the corneal damage is severe,more permanent scarring can result, leading tohigh astigmatism and often resistant amblyopia(Lambert et al. 2004; Angell et al. 1981). Lefteyes seem to be more commonly affected thanright eyes as neonates usually present in the left-occiput-anterior position (Wilson 1987). Rigidgas permeable contact lens and patching are thefirst choice of treatment.
Other injuries to the orbit and face from forcepsinclude third and seventh cranial nerve palsies,which may result in ptosis and facial palsy.These may recover spontaneously over time, butrequire attention by the ophthalmologist to cor-rectly diagnose the injury and treat complicationssuch as amblyopia and lagophthalmos from facialnerve palsy (Fig. 1).
Anterior Segment Injuries
Subconjunctival Hemorrhage
A subconjunctival hemorrhage may appear dra-matic and can be alarming for the patient. Theyare usually of virtually no significance, however,and tend to resolve spontaneously within10–14 days. Causes include valsalva maneuvers;if the child has been coughing or vomiting exces-sively, trauma, ocular surgery, infectious conjunc-tivitis, or systemic bleeding diatheses. Notreatment is generally required except reassurance.
Fig. 1 Periorbital ecchymosis and lid laceration followingvacuum delivery. (All figures courtesy of Prof. MichaelO’Keefe)
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If there is a history of trauma associated with asubconjunctival hemorrhage, it is vital to excludemore serious injury, such as globe rupture. Hemor-rhage may mask underlying injuries, so the clini-cian must look carefully for other signs ofpenetrating injury, i.e., peaked pupil, low intraoc-ular pressure, distorted globe (Fig. 2).
Corneal Abrasion
Corneal abrasions occur when the corneal epithe-lium is traumatically removed from the underly-ing basement membrane. An abrasion can resultfrom blunt or sharp trauma. Children with cornealabrasions experience acute pain, photophobia,lacrimation, and blepharospasm. The underlyingbasement membrane will stain transiently withfluorescein and fluoresce beneath a blue light.Depending on the size and location of the abra-sion, they will normally heal over a number ofdays. Most abrasions heal in 2–3 days, whilelarger abrasions that involve more than one halfof the surface area of the cornea may take4–5 days.
Management is with topical antiobiotics, e.g.,chloramphenicol, and a cycloplegic, e.g.,cyclopentolate 1% to reduce pain from iridospasm.Patching of the eye is not necessary (Kirkpatrick etal. 1993), (Turner and Rabiu 2006). Topical anes-thetics should be avoided, except to allow exami-nation, as they delay healing.
Recurrent corneal erosions may sometimesoccur following the initial abrasion, typically inassociation with fingernail injuries. The patientmay experience repeated episodes of superficial,
spontaneous abrasions. Management is with fre-quent use of lubricant drops or gels (Fig. 3).
Corneal Foreign Body
The child will complain of pain or foreign bodysensation. Superficial or loose foreign bodies canbe irrigated away or removed manually with amoist cotton bud. Impacted foreign bodies canbe removed with the tip of a 25 gauge needleadvanced bevel up and parallel to the surface ofthe cornea. In younger or uncooperative children,this may require a general anesthetic. The upperlid should be everted to exclude a subtarsal for-eign body. Once the foreign body is removed, thechild is treated with topical antibiotics for a week.
Chemical Injuries
Chemical injuries are potentially blinding andshould be considered a true ophthalmic
Fig. 2 Subconjunctivalhemorrhage in associationwith a scleral penetratinginjury. The site ofpenetration is just visibleinfero-nasally. (All figurescourtesy of Prof. MichaelO’Keefe)
Fig. 3 Large corneal abrasion, stained with fluoresceindye. (All figures courtesy of Prof. Michael O’Keefe)
Ophthalmic Trauma 5
emergency. Immediate treatment should be com-menced as prompt management may improve thelong-term prognosis (Burns and Paterson 1989).
The severity of the injury depends on thenature and strength of the chemical (acid/alkali),as well as duration and area of contact. Alkaliscause more severe injury as they cause saponifi-cation of the cell membrane allowing deeper pen-etration into the anterior chamber. Acids causeimmediate precipitation of proteins, which limitspenetration of the acid. The most common alkalisimplicated are ammonia and sodium hydroxide.The commonest acids implicated are sulfuric, sul-furous, hydrofluoric, acetic, chromic, and hydro-chloric. Ammonium and sodium hydroxide causesevere damage due to rapid penetration of oculartissues. In children, chemical injury usuallyresults from household chemicals.
There has been a wave of chemical injuries inchildren, associated with liquid detergent capsulessince their introduction to the market over adecade ago. Most capsules consist of a water-soluble polyvinyl alcohol membrane. The mixtureis usually composed of an anionic detergent, acationic surfactant, and a nonionic detergent. Allbrands contain irritants; however, some also con-tain alkaline substances. The colorful appearanceof liquid detergent capsules makes them attractiveto young children, who can easily burst the cap-sule and release the contents within. Ocular expo-sure frequently causes conjunctivitis and keratitis(Bonney et al. 2013). As with all chemical inju-ries, immediate irrigation is crucial to reduce therisk of clinically significant injury.
Severe chemical injuries cause damage in thefollowing order:
• Conjunctival and corneal epithelial necrosis• Occlusion of limbal vasculature• Loss of limbal stem cells causing
conjunctivalization and vascularization of thecornea
• Symblepharon formation• Cicatricial lid disorders• Persistent corneal epithelial defects• Corneal ulceration or perforation
Chemical injuries are graded on the basis ofcorneal clarity and extent of limbal ischemia.Grading injuries are useful for planning treatmentand indicating prognosis.
Chemical Injury Grading (Roper-HallClassification)
• Grade 1:Clear cornea and no limbal ischemia. Excel-
Between one-third to one-half limbal ischemia.Guarded prognosis.
• Grade 4:Cornea is opaque. More than half limbal
ischemia. Poor prognosis.
Initial Management of ChemicalInjuries
Copious irrigation of the eye with normal saline,for at least 30 min, or until the pH neutralizes isthe mainstay of treatment. This should be insti-tuted immediately. Speed and efficacy of irriga-tion is the most important prognostic factorfollowing chemical injury. The volume of irriga-tion fluid necessary for adequate irrigation canrange from a few liters to more than 8 or 10 liters.Topical anesthetic should be applied and the eyemay be held open with a speculum if necessary tofacilitate irrigation. The eyelids should be evertedand the fornices cleared of any particulate matterusing forceps or a swab. Debridement of necroticcorneal tissue may be necessary to promote re-
6 S. Moran and M. O’Keefe
epithelialization. Hospital admission is requiredfor severe injuries to ensure adequate instillationof drops.
Treatment of Chemical Injuries
In children, most chemical injuries are relativelyminor and result in mild corneal epithelial inju-ries, which can be treated with topical antibiotics,lubricants, and cycloplegic agents. In moderate tosevere injuries however, there may be significantepithelial loss, limbal ischemia, corneal clouding,and raised intraocular pressure (IOP). Such casesrequire additional treatment with topical steroids,topical ascorbate, and oral ascorbic acid. In caseof severe chemical injuries with corneal melt/per-foration, corneal glue, amniotic membrane onlay,or tectonic grafting may be required. Complica-tions include dry eye, symblepharon, opacifiedcornea, corneal melt or perforation, glaucoma,and cataract. In the long-term, severe chemicalinjuries may require limbal stem cell transplanta-tion, corneal graft, or keratoprosthesis.
Hyphema
A hyphema is a collection of blood in the anteriorchamber. This is usually as a result of blunt traumacausing traumatic avulsion of iris vessels from thebase of the iris. A large hyphema will be visiblemacroscopically and in some cases may fill theentire anterior chamber; “8 ball hyphema,” how-ever, a small hyphema may only be visible on slit-lamp examination.
Traumatic hyphema in the absence of otherintraocular injuries rarely leads to permanentloss of vision. However, associated trauma (cor-neal blood-staining, traumatic cataract, anglerecession glaucoma, optic atrophy, etc.) maylead to permanent impairment of vision. Thehyphema may rebleed – this tends to occurbetween day 3 and 5 postinjury when the clotretracts. Patients with sickle cell trait/diseasemay be particularly susceptible to rebleeding andelevated intraocular pressure. If rebleedingoccurs, the rates and severity of complications
increase (Gharaibeh et al. 2011). For this reason,initially the child should be managed with strictbed-rest, head elevation, and a protective eye-shield.
Medical management involves topical cortico-steroid, and a cycloplegic agent – although use ofcycloplegics is controversial as movement of theiris may theoretically dislodge a clot and cause arebleed. Use of topical and/or systemic IOP low-ering agents may be required for raised IOP.
In cases of uncontrolled IOP, surgical manage-ment may be required in the form of an anteriorchamber washout. If this is not successful in con-trolling IOP, definitive glaucoma surgery in theform of trabeculectomy may be required. Surgicalmanagement is indicated if there is an IOP of morethan 50 mmHg for 5 days or 35 mmHg for 7 days.Earlier intervention is advised if the optic nerve iscompromised or there is endothelial dysfunction(Fig. 4).
Eye Wall Injuries
Injuries to the wall of the eye can be classified invarious ways depending on the depth and locationof the injury. Lacerations may be partial or fullthickness, corneal, scleral, or corneo-scleral. Afull thickness defect in the corneo-scleral wallsecondary to blunt trauma is termed globe rupture.
LacerationsIn young children, simple lacerations are usuallysustained from a sharp object. Glass, knives, andscissors are among the common causes of open
Fig. 4 Hyphema following blunt trauma to the right eye.(All figures courtesy of Prof. Michael O’Keefe)
Ophthalmic Trauma 7
globe injuries. Other significant causes are sticks,pencils/pens, toys, and projectiles such as pellet/bb guns, and thrown projectiles such as eggs, andsnowballs (Abbott and Shah 2013; Figs. 5 and 6).
Penetrating InjuryA full-thickness defect caused by an object enter-ing the globe without exiting (Figs. 7 and 8).
RuptureGlobe rupture occurs when an eye is pushed orsqueezed so hard that the wall of the eye rupturesunder pressure. The wall will usually break at aweak point, for example, under the insertion of theextra ocular muscles, the limbos, or at a previoussurgical site. The results can be devastating with
Fig. 5 Full thickness corneal laceration following injuryfrom a glass bottle. (All figures courtesy of Prof. MichaelO’Keefe)
Fig. 6 Eye following repair of full thickness corneal lac-eration. A linear scar is seen centrally in the cornea wherethe laceration was sutured. The pupil is irregular secondaryto iris trauma sustained from the initial injury. (All figurescourtesy of Prof. Michael O’Keefe)
Fig. 7 A full thickness penetrating corneal injury withretained foreign body. This child was looking through aletterbox when a spring snapped and hit his eye. (Allfigures courtesy of Prof. Michael O’Keefe)
Fig. 8 Full thickness penetrating corneal laceration withforeign body in situ. (All figures courtesy of Prof. MichaelO’Keefe)
Fig. 9 Globe rupture. This boy was accidentally struck inthe eye with a golf club. He had been standing behind afriend on a golf course when he sustained the injury. (Allfigures courtesy of Prof. Michael O’Keefe)
8 S. Moran and M. O’Keefe
expulsion and loss of intraocular contents occur-ring due to the sudden increase in pressurefollowed by rapid decompression through a defectin the globe. Common causes are blunt traumafrom large objects, often striking the eye at highvelocity, such as bullets, pellets, squash balls, orgolf clubs (Figs. 9, 10, 11, 12, and 13).
Blast InjuryAn explosion or blast can cause devastating ocularinjuries. In noncombat zones, fireworks are themost likely cause of a blast injury to the eye.
Children who are victims of armed conflict mostcommonly sustain blast injuries from improvisedexplosive devices (Edwards et al. 2012). Injurymay be either due to primary blast injury fromover-pressurization force (blast wave), or second-ary due to projectiles causing penetrating or blunttrauma (flying debris, shrapnel fragments).
The eye is generally resistant to traumatic rup-ture resulting from a blast overpressure wave dueto the protective orbit and tough sclera. Givenenough force, however, rupture can occur. Sec-ondary blast injury, caused by flying debris orfragments, is a particular threat to exposed and
Fig. 10 Globe rupture. This patient had a previous cornealgraft. He fell and struck his eye off a table corner causingglobe rupture at the previous surgical site. (All figurescourtesy of Prof. Michael O’Keefe)
Fig. 11 Penetrating ocular injury with impacted foreignbody. This child fell forwards directly onto a stick, whichpenetrated through the globe and orbit into the temporallobe of the brain. (All figures courtesy of Prof. MichaelO’Keefe)
Fig. 12 Wooden foreign body removed from the orbit.(All figures courtesy of Prof. Michael O’Keefe)
Fig. 13 Wooden foreign body in right orbit, penetratingand displacing the right globe. There is also a displacedfracture of the posterior wall of the orbit, with fragmentsextending into the middle cranial fossa. (All figures cour-tesy of Prof. Michael O’Keefe)
Ophthalmic Trauma 9
unprotected eyes. Rapidly accelerated sharp par-ticles, large or small, can lacerate or rupture thecornea or sclera and enter the eye. Frequently,injuries are bilateral and may range from minorcorneal abrasions and foreign bodies to extensiveeyelid lacerations, open globe injuries, intraocularforeign bodies (IOFB), or orbital fractures. Aboutone third of eye injuries from fireworks result inpermanent blindness (Wilson 1982).
Injuries from fireworks are much more fre-quent in boys or young males than in females.The time of year when the injuries caused byfireworks occur naturally varies depending onthe traditions in different societies, Halloween,New Years, and Guy Fawkes night in the UKand Ireland, the New Year in China, Deewali inIndia, and the Fourth of July in the United States,to mention a few.
Clinical Evaluation
Ocular trauma may occur in isolation or withassociated head or systemic injury, therefore it isvital that any potentially life-threatening injuriesare identified and treated as a priority. The childshould also be evaluated for associated orbital orfacial fractures.
The visual potential of the eye should be eval-uated. Visual acuity should be recorded as accu-rately as possible, even if only a record of whetherthe patient can perceive light or count fingers. Thepupil should be examined for direct and consen-sual light response and also for distortion orpeaking of the pupil, which may indicate a pene-trating injury.
Signs suggestive of an open globe injuryinclude distorted globe, hypotony, shallow ante-rior chamber, full thickness lid, or conjunctivallaceration. Diagnostic signs of an open globeinjury are exposed intraocular contents such asuveal tissue or vitreous or visualization of anintraocular foreign body (IOFB). Clues to occultpenetration include severe 360� subconjunctivalhemorrhage, distorted pupil, wrinkled lens cap-sule, and lowered intraocular pressure particularlycompared to pressure in the fellow uninjured eye,
reduced visual acuity, or an afferent pupillarydefect.
If an IOFB is suspected, a CT orbits (axial andcoronal views: 1 mm slices) should be performed.With anterior lacerations, prompt closure and dailyassessment of the patient’s vision and ocular statusin is advisable. The use of intraocular antibiotics isdebatable. The prompt closure of an eye wall lac-eration seems to be adequate to greatly reduce theincidence of traumatic endophthalmitis.
Treatment
Once the diagnosis of a ruptured globe is made,manipulation and examination of the eye shouldbe kept to a minimum until the patient is in theoperating theatre. A protective shield should beplaced over the eye. The child should be immedi-ately admitted to hospital and kept fasting fortheatre. Systemic antibiotics should be adminis-tered as well as tetanus prophylaxis wherenecessary.
Management
• The primary goal is to restore integrity of theglobe and the secondary goal to restore visionby restoring intraocular structures wherepossible.
• In young children, a concurrent traumatic cat-aract should be removed during primary repair,as delay in cataract extraction runs the risk ofinducing amblyopia. In children over 7 yearsof age, a second operation could be performedand could include intraocular lens implant, solong as the posterior capsule remains largelyintact. Combined lensectomy, vitrectomy, andintraocular lens implantation has been carriedout successfully, although this is controversial.
• In cases where there is severe injury and poorprognosis for vision, enucleation or eviscera-tion may sometimes need to be considered toavoid the risk of sympathetic ophthalmia. Thispossibility should be discussed with the par-ents preoperatively.
10 S. Moran and M. O’Keefe
• From an anesthetic point of view, some advo-cate avoiding a depolarizing agent for fear thatthe contraction of extraocular muscles couldpress on the eye and express intraocularcontents.
Surgical Principles
• Minimize any pressure on the globe from thespeculum.
• Remove any debris.• Make an anterior chamber paracentesis and
reform the anterior chamber with viscoelastic.• If vitreous or lens fragments are prolapsing
through the wound they should be cut flushwith the wound, and if uveal tissue protrudesit should be gently swept back into the eyewhere possible. Uveal tissue should only beexcised if necrotic.
• The corneo-scleral limbus should be repairedfirst – using 9-0 nylon, then the cornea, using10-0 nylon, and burying the knots.
• A conjunctival peritomy is performed toexpose the full extent of the injury. A sclerallaceration can be repaired with a 9-0 nylon oran absorbable suture, beginning anteriorly, andprogressing posteriorly.
• If a laceration extends beneath a muscle thenthe muscle must be placed on a suture, anddisinserted before being re-inserted after theglobe repair.
• Following repair of the globe, repair of intra-ocular injury can be performed either as part ofthe primary procedure, or as a secondaryprocedure.
Postoperative Management
After successful surgery, management is ongoing.A key difference between young children andadults is that children under the age of 7 yearsare at risk for amblyopia as the visual pathwaysare still developing (Puodžiuvien _e et al. 2018).Therefore, management of refractive errors witha contact lens or glasses over a corneal laceration
and patching should be started as soon as possiblewhere appropriate.
Corneal sutures in children cause corneal vas-cularization and scarring much more quickly thanin adults. Sutures may be removed in a few weeksin young children: failure to do this may result in avascularized cornea and reduced vision (Fig. 14).
Outcomes
Poor prognostic factors following open globeinjury include age less than 5 years, injuries withretrolimbal involvement, wound length greaterthan 5 mm, globe rupture, vitreous hemorrhage,and retinal detachment (Bunting et al. 2013). Pre-senting visual acuity at initial assessment is animportant predictor of final best corrected visualacuity. The prognosis is highly dependent how-ever, upon successful management of amblyopia.
Intraocular Foreign Body (IOFB)
An intraocular foreign body can damage the eyeeither mechanically, through introduced infection,or by toxic effect on the intraocular structures. It isimportant to ascertain the location of the IOFB,which may lodge in any of the structures itencounters on its passage through the eye. Partic-ular mechanical effects that may be caused by an
Fig. 14 Severe central corneal scar 1 year following repairof a full thickness corneal laceration. The original injurywassustained when a stone projected from a lawnmower hit hiseye. (All figures courtesy of Prof. Michael O’Keefe)
Ophthalmic Trauma 11
IOFB include cataract formation, vitreous lique-faction, and retinal hemorrhages or tears.
Intraocular foreign bodies (IOFB) should besuspected in all open globe injuries. A history ofprojectile foreign body or hammering related acti-vated should always raise suspicion of an IOFB.Careful examination, minimizing pressure to theglobe is essential. The signs of an IOFB are sim-ilar to that of a penetrating injury. There may be aclinically detectable corneal or scleral perforationsite, an iris defect, or visible IOFB. Alignment andprojection of identified wounds may allow logicaldeduction of the probable location or a foreignbody. Gonioscopy and fundoscopy should alwaysbe performed. If an IOFB is suspected, a CTorbits(axial and coronal views: 1 mm slices) should beperformed. False-negative CT results may occurwith IOFBs that are small or of wooden, vegeta-ble, plastic or ceramic content. Gentle B-scanultrasonography can also be a useful tool.
If an IOFB is present and accessible, urgentsurgical removal is advised. Endophthalmitis ismore common in open globe injury when thereis a retained IOFB, and the risk of inflammationand infection is reduced if the IOFB is removed. Ifthe patient presents late, removal is indicated inthe following cases:
• Endophthalmitis• The IOFB contains toxic material such as cop-
per or iron• The IOFB contains organic matter which can
provoke a strong inflammatory response• Associated vitreous hemorrhage• IOFB that is impacted on the retina• Secondary surgery is being carried out – i.e.,
retinal detachment surgery
However, if removal of the object is technicallydifficult, attempted retrieval of the object maycause more harm than good. In such cases,removal may not be indicated, especially if theobject is not directly damaging an intraocularstructure and is not expected to cause secondarysequelae. Regular follow-up using visual acuity,slit lamp, and serial electroretinograms (ERGs) isa reasonable option for these cases. The
recommended ERG schedule is monthly tobimonthly for the first 6 months; then a repeatexam 6 months later followed by annual exams.If the ERG shows deterioration, immediate surgi-cal intervention with removal of the object isrequired.
Certain materials such as glass, plastic, stone,aluminum, or gold can be well tolerated within theeye. Stone and organic foreign bodies are associ-ated with a higher rate of infection, and this isparticularly true with soil-contaminated or vege-table matter, when prophylaxis with intravitrealantibiotics is required. Metallic foreign bodieslike iron, lead, and copper may undergo dissocia-tion and should be removed due to their toxiceffects on intraocular tissues.
SiderosisSiderosis bulbi occurs when a ferrous IOFBundergoes dissociation in the eye, resulting iniron deposition in the intraocular epithelial tis-sues, lens epithelium, iris and ciliarybody epithe-lium, and the sensory retina, where it exerts a toxiceffect on cells. Clinically, the condition consists ofrust-colored deposits in the cornea and lens, aswell as iris heterochromia due to reddish-brownstaining of the iris, unreactive pupil, and retinaldegeneration, which can have a profound effecton vision. Electroretinography shows progressiveattenuation of the b-wave over time. Copper isextremely toxic to the eye.
ChalcosisAcute chalcosis results from metals with a coppercontent of 85% or more and results in an aggres-sive endophthalmitis-type picture characterizedby sterile endophthalmitis, corneal and scleralmelt, hypopyon, and retinal detachment. Thismay often progress to phthisis bulbi. However,an alloy with a relatively low copper content cancause chalcosis when it becomes dissociated anddeposits intraocularly. Kayser-Fleischer rings candevelop, as well as an anterior “sunflower” cata-ract. Copper is less retinotoxic than iron, so visualfunction may be preserved.
12 S. Moran and M. O’Keefe
Surgical Removal of IOFBMost IOFBs are extracted from a new openingunless the entrance wound is large. Two types ofinstruments are used: an intraocular magnet and aforceps. The surgical approach depends on theobject’s location in the eye. If the IOFB is visibleand free-floating in the vitreous cavity, a parsplana vitrectomy with removal of the object witha magnet and or forceps may be attempted. If theIOFB is hidden in the angle, an endoscope,inserted through an incision 180� from the object,may be used for visualization. The IOFBmay thenbe removed with a magnet or forceps through anincision created 90� from the object.
EndophthalmitisPenetrating injury with retained foreign bodycauses endophthalmitis in about 8% of cases.The patient is more at risk if there is a delay inprimary repair, retained foreign body or a largeentry wound. The most commonly isolated path-ogens are Staphlococcus and Bacillus species(Parvizi et al. 2019). Treatment involves promptremoval of retained IOFB, primary repair, andintravitreal antibiotics.
Traumatic Cataract
Cataracts can occur secondary to blunt or pene-trating ocular trauma causing damage to the lens,or lens capsule. They may take days, months, oryears to develop. Cataracts caused by blunttrauma classically form stellate posterior axialopacities that may be stable or progressive,whereas penetrating trauma with disruption ofthe lens capsule forms cortical changes that mayremain focal if small or may progress rapidly tototal cortical opacification. Cataracts can be seenas an abnormality in the red reflex.
In partial cataracts, deciding whether toremove a cataract depends on the visual functionin the involved eye, and whether the child is of anamblyogenic age. In older children, this can beobjectively measured with a Snellen chart. Inyounger children, an estimate must be made
based upon experience with lens clarity and visualfunctioning.
The decision to surgically remove a cataractdepends on the age of the child and amount ofvisual impairment caused by the cataract. If thechild is below 7 years of age and there is signifi-cant cataract affecting the visual axis, then thecataract should be removed. In older children,beyond amblyogenic age, a wait and see approachmay be appropriate.
Posterior Segment Injuries
Retinal Detachment
Blunt trauma is a significant cause of childhoodrhegmatogenous detachments, although retinaldetachment can occur secondary to blunt or pen-etrating ocular trauma. Penetrating injuries ante-rior to the pars plana (5 mm behind the limbus)will not cut the retina and therefore carry a betterprognosis. However, posterior penetrating inju-ries cut the retina and often result in a complicatedretinal detachment, with a far worse prognosis.
Retinal dialysis is a circumferential breakoccurring at the ora serrate and is the most com-mon cause of retinal detachment following bluntocular trauma. This is due to sudden tractionforces on the vitreous base at the ora serrate.Sudden anteroposterior compression of the globewith a violent expansion leads to retinal avulsion.There may be signs of related orbital injury, orsigns of collateral trauma to the iris, lens, or drain-age angle. Superior quadrant involvement is morefrequent than the lower temporal quadrantinvolvement seen in nontraumatic dialysis.Although the disinsertion may exceed 90� andresemble a giant retinal tear, the vitreous charac-teristically remains attached to the posterior flapso that independent mobility is not a feature. As aresult, dialyses tend to respond well to conven-tional scleral buckling techniques.
While penetrating injuries may cause an imme-diate retinal detachment, there can be a latentperiod of months or years between blunt trauma
Ophthalmic Trauma 13
and retinal detachment. Therefore, careful serialexaminations of patients with blunt trauma arenecessary for early detection of retinal breaks.Compared to the adult population, pediatricpatients present with worse acuity, after greaterdelay, and with a higher percentage of macularinvolvement; 75–85%, as opposed to about 50%in adults (Rumelt et al. 2007).
Commotio Retinae
Photoreceptor damage following blunt traumamay appear as a confluent white sheen in theretina. Visual acuity is unaffected unless the mac-ula is involved. This usually resolves spontane-ously but the patient/parents should be given aretinal detachment warning.
Traumatic Choroidal Rupture
Blunt injury to the eye may result in choroidalrupture, often associated with widespread damageand vitreous hemorrhage caused by mechanicaldisruption of tissue. The choroid may be rupturedat the level of the inner choroid and retinal pig-ment epithelium, and often at the macula. Ifaccompanied by a serious or hemorrhagic retinaldetachment, the full nature of the injury may beobscured. Once the detachment resolves, thepatient may be left with reduced vision if therehas been scarring at the macula. Choroidal rupturecan predispose the patient to development of cho-roidal neovascularization (O’Connor 1993).
Purtschers Retinopathy
Purtschers retinopathy can result from severetrauma to the head or torso, but not direct ocularinjury. Multiple cotton wool spots and areas ofretinal whitening are seen in a configurationaround the optic nerve. It is thought to be due toembolic occlusion of precapillary arterioles typi-cally occurring following visceral or orthopedicinjury. There is no specific treatment for this prob-lem, which may resolve leaving anything from
mild to profound visual loss (Agarwal andMcKibbin 2007).
Traumatic Optic Neuropathy
Head and facial injuries may result in direct orindirect damage to the optic nerve. This maycause partial or complete loss of vision and maybe unilateral or bilateral. Primary damage to theoptic nerve can occur due to transection of theoptic nerve by orbital bony fragments, or in decel-eration injuries where avulsion of the nerve fromits nutrient vessels causes ischemia. Secondarydamage may occur due to optic nerve compres-sion from edema or hemorrhage.
A new RAPD (relative afferent pupillarydefect) not accounted for by any other pathologyis essential for the diagnosis. Vision may varyfrom mild reduction to NPL (no perception oflight). There may be variable field loss andreduced color vision. Although there may besigns of optic nerve swelling or avulsion, theoptic nerve usually appears normal initially, thenbecomes pale as optic atrophy develops. Anurgent CT brain and orbits should be arranged tooutrule a displaced orbital fracture.
A small percentage of cases will improve spon-taneously. High dose steroids have been advo-cated in some cases; however, there is noevidence that this influences the outcome (Yu-Wai-Man and Griffiths 2013). In cases of second-ary damage due to compression, unless there isevidence of a hematoma or bone fragment causingcompression, surgery is rarely indicated.
Traumatic Retrobulbar Hemorrhage
Retrobulbar hemorrhage is an ocular emergencyresulting from arterial bleeding in the orbital cav-ity behind the eye. Due to the fact that the orbit is alimited space, increasing volume will increaseorbital and intra-ocular pressure, resulting in com-pression of orbital structures and ischemia of theeyeball and optic nerve. Left untreated, this canprogress to permanent vision loss. Prompt recog-nition of retrobulbar hemorrhage is vital, given
14 S. Moran and M. O’Keefe
that a delay in treatment of as little as 90–120 mincan result in permanent vision loss (Radius andAnderson 1981).
Critical signs include proptosis with resistanceto retropulsion, diffuse subconjunctival hemor-rhage, tight eyelids (“rock-hard”), and visionloss. If suspected, emergent consultation with anophthalmologist is required; a computed tomog-raphy scan to verify diagnosis is rarely performed,as it delays treatment.
In the presence of an RAPD, decreased vision,elevated IOP, proptosis, or impaired extraocularmovements, a lateral canthotomy and cantholysisshould be performed immediately to protect theorbital tissues from damage resulting from com-partment syndrome.
If a patient has an orbital hemorrhage but notan APD, elevated IOP, or decreased vision, thenthe hemorrhage may be observed closely,assessing vision, pupils, and IOP frequently. If atany point the patient worsens clinically, acanthotomy and cantholysis should be performed.It is much easier to repair a detached canthus thanto treat a vascular occlusion, which can occur inthe setting of an orbital hemorrhage.
Canthotomy and CantholysisIn adults, this can be performed under local anes-thesia; however, in children, sedation or a generalanesthetic will be required. Only two instrumentsare necessary to perform the procedure: blunt-tipped scissors, and forceps with heavy teeth.The scissors is placed across the lateral canthus,and a full thickness incision is performed. Thisallows access to the lateral canthal tendon so aninferior cantholysis can be performed. The lowereyelid should be grasped at the inner edge of theincised canthus and traction directed upwards.With scissors open just below the skin, and tipspointing towards the nose, the lateral canthal ten-don can now be cut. As the canthal tendon isreleased, the eyelid should come completelyaway from the globe. Depending on the timingof the cantholysis in relation to the hemorrhage,vision may dramatically improve.
Eyelid and Lacrimal Trauma
Eyelid lacerations may occur from either blunt orsharp injury to the lid margin. Injury to the medialeyelid margin can damage to the canalicular sys-tem. This is seen commonly in dog bite injuries inchildren (Savar et al. 2008). Repair of eyelid lac-erations involves careful re-approximation of the lidmargins to avoid notch formation and exposure ofthe ocular surface. The grey line should be re-approximated first using a wide and deep 6-0 vicrylsuture. A 6-0 vicryl suture can also be used to fortarsal plate and orbicularis. The skin can then beclosed with 7-0 vicryl. If the canaliculus is involved,a canalicular stent should be placed at the same timeas the primary repair to prevent long-term canalicu-lar obstruction (Figs. 15 and 16).
Fig. 15 Full thickness lower eyelid laceration with cana-licular involvement, sustained from a dog bite. (All figurescourtesy of Prof. Michael O’Keefe)
Fig. 16 Full thickness upper lid laceration. (All figurescourtesy of Prof. Michael O’Keefe)
Ophthalmic Trauma 15
Pediatric Orbital Fractures
Orbital fractures are the third most common facialfractures in children, with the medial wall andfloor most commonly affected (Gerber et al.2013). Orbital fractures may occur either fromdirect trauma to the orbital rim, or via transmittedforces. The classic “blowout fracture” occurswhen pressure on the eye and surrounding softtissue is transmitted to the orbit causing outwardfracturing of the wall. Trapdoor fractures resultfrom an acute transient increase in orbital pres-sure, causing a linear orbital wall fracture. A flapof bone is outwardly displaced and then returnsimmediately to its original position – this mecha-nism is facilitated by the elastic nature of chil-dren’s bone. Orbital soft tissue may becomeincarcerated in the fracture, restricting ocularmotility. In contrast, the less elastic adult bone ismore likely to result in a comminuted fracture.
Inferior trapdoor fractures may presentuniquely with restricted extraocular motility anddiplopia, nausea, and vomiting and minimal signsof external trauma (Wei and Durairaj 2011). Ifthere are few or no clinical signs, but oculocardiacreflex is present, it is highly suggestive of trapdoorinjury. Orbital trapdoor fractures with muscleentrapment should be treated urgently to preventtissue ischemia and diplopia. Prompt surgicalrepair results in superior clinical outcomes todelayed treatment (Jordan et al. 1998)
The specific surgical technique can be variable,but involves releasing the entrapped soft tissuefrom the fracture. If the bone remains in a normalposition, no implant is required. However, oftenreleasing the soft tissue may require enlarging thefracture, in which case an implant may be placedover the defect in the orbital wall (Phan et al. 2012).
Central Nervous System Trauma
Cortical Visual Impairment
Cortical visual impairment mayoccur through var-ious mechanisms following head trauma (Good etal. 1994). A cerebral contusion can cause transientor prolonged cortical visual impairment due to
cerebral edema. Seizures following head traumacan lead to cortical visual impairment. Hypoxicinjury as a result of blood loss or vasospasm canoccur, and the occipital region may be selectivelyinvolved.
The child will have normal pupillary reflexes,normal fundal examination but partial or completeloss of vision. A relatively minor blow to the headcan cause transient cortical blindness. Electro-physiology can be helpful to confirm the diagno-sis. Overall, most patients with cortical visualimpairment show some recovery, with the prog-nosis for recovery better in children who sustaincortical visual impairment at a very early age (Huoet al. 1999).
Cranial Neuropathy
The sixth nerve is the most commonly affectedcranial nerve following trauma. The patient isunable to abduct the eye, and an esotropia maybe seen which is greater for distance than near.Bilateral sixth nerve palsies may occur.
A third nerve palsy results in ptosis, dilatedpupil, and inability to adduct, depress, or elevatethe eye, such that the position of the eye is “downand out.” Partial third nerve palsies may occur.
Fourth nerve palsy are more subtle and can bebilateral in 30%. The affected eye is slightlyhypertropic with inferior oblique overaction.
Initial management is observation as mostcases resolve spontaneously (Holmes et al.1998). If the child is symptomatic with doublevision, occlusion with an eye pad may be used.In young children alternate day occlusion of eacheye will help prevent amblyopia. Most casesimprove within 3 months and many resolve by6 months. Residual palsy at 6 months is likely tobe permanent and surgical treatment may beneeded, but only if the palsy if stable.
Pediatric Eye Injury and Sport
Sport is the second most common cause of eyetrauma in developed countries. Prevention ofsports related eye injuries is paramount for
16 S. Moran and M. O’Keefe
avoiding vision loss. The American Academy ofOphthalmology (AAPO/AAO policy statement2004) reported 42,000 sports and recreationrelated eye injuries in 2000, with 72% of injurieshappening in people under 25 years of age and43% occurring in those under 15 years of age. It isthought that children and adolescents are suscep-tible because of aggressive or reckless play, ath-letic maturity, and poor supervision in somerecreational situations. Appropriate and well-fitted eye protectors are shown to be 90% effectiveat preventing significant eye injury.
Certain sports are high risk for eye injury:those using hard, small, and fast projectiles suchas squash, paintball, baseball/softball, and cricketand those sports where there is intentional injurysuch as boxing or martial arts. In such sports,protective eyewear should be considered. Whilethis cannot eliminate the chance of eye injury, therisk of a significant trauma can be dramaticallyreduced. Doctors should strongly recommend thatathletes who are functionally one-eyed wearappropriate eye protection during all sports, andrecreational activities.
If the better eye is injured, functionally one-eyed athletes may be severely handicapped andunable to obtain a driver’s license in many states.Athletes who have had eye surgery or trauma tothe eye may have weakened eye tissue that is moresusceptible to injury. These athletes may also needadditional eye protection or may need to berestricted from certain sports; they should be eval-uated and counseled by an ophthalmologist priorto sports participation.
Nonaccidental Injury
Retinal hemorrhage is a cardinal manifestation ofabusive head trauma in infants. The incidence ofretinal hemorrhage in shaken baby syndrome is85% (Levin 2010). Extensive retinal hemorrhagescorrelate with severe intracranial injury and poorvisual outcome (Morad et al. 2002). The mecha-nism is repeated acceleration-deceleration forces,with or without blunt head impact.
The hemorrhages may range from a fewscattered hemorrhages to widespread and
extensive hemorrhages, often multilayered, andhave a predilection for the peripheral retina, peri-vascular areas, and posterior pole. Bilateral retinalhemorrhages occur in the majority of cases, butcan occur unilaterally (Arlotti et al. 2007).
It is important to note that hemorrhages mayoccur commonly in normal infants in the perinatalperiod. They usually resolve completely in lessthan 1 month, occasionally in up to 3 months.
Assessment
• External eye examination should includedescriptions, drawings, and photography ofany periocular injury or subconjunctivalhemorrhages.
• Assessment of visual acuity and ocular motilityshould be noted where possible.
• Pupillary reactions, anterior chamber, and lensposition should be examined before the pupilsare dilated for assessment of the fundus. Poorpupillary responses are strongly associatedwith increased mortality and poor visual out-comes (Kivlin et al. 2000).
• Examination of the retina with an indirect oph-thalmoscope and a wide field lens followingdilation of the pupils with short-actingmydriatics(phenylephrine 2.5%and tropicamide 0.5%–1%)is standard practice.
• Descriptions of retinal findings should includetheir distribution, and location in terms of theretinal layers.
• Fundal photographs should be taken wherepossible for documentation purposes. (Figs.17, 18, and 19).
Approach to Eye Trauma
• Proceed with caution: Assume that any peri-ocular or ocular trauma could include a rup-tured globe. Avoid placing pressure on theglobe until you establish that an open globeinjury does not exist.
Ophthalmic Trauma 17
• Evaluate the whole patient: Make sure thechild does not have any concomitant life-threatening injuries that need to be prioritized.
• Make the patient comfortable: Treat the childwith analgesics and anti-emetics as necessary.This will make examination easier, as well asreducing the risk of vomiting or straining,which could cause prolapse of intraocular con-tents in an open globe injury.
• Assess visual acuity and pupils: It can bedifficult to obtain a good visual acuity inyoung children even under normal circum-stances, and especially so if the child has justsustained an injury. However, visual acuity isimportant in formulating the visual prognosisso when possible it should be recorded. If areliable acuity cannot be obtained, carefullyassess for an afferent pupillary defect. If thepupil cannot be visualized in the traumatizedeye check for an afferent pupillary defect in thefellow eye.
• Assess the adnexal structures: It is importantto assess for lid or canalicular lacerations,which may be overlooked in the context of aserious globe injury.
• Evaluate the fellow eye: Make sure that youconduct a complete exam on the fellow eye forany signs of trauma or changes in visual acuity.
• Imaging. CT scans may be helpful inconfirming globe rupture and assessing forintraorbital or intraocular foreign bodies, aswell as orbital wall or other facial fractures.
• Arrange for theatre: Make sure the child isfasting, and establish the last time they ate.Determine if the patient has had a recent teta-nus shot. Place a shield over the traumatizedeye. Inform emergency theatre staff andanesthetists.
• Talk with parents: It is vital to discuss thesurgery and visual prognosis for the eye withthe parents preoperatively. Depending on theextent of the globe injury, it may rarely benecessary to discuss the possibility of primaryenucleation/evisceration in cases of severeglobe rupture where surgical repair is notpossible.
Fig. 17 Severe retinal hemorrhages in nonaccidentalinjury. (All figures courtesy of Prof. Michael O’Keefe)
Fig. 18 Severe retinal hemorrhages in nonaccidentalinjury. (All figures courtesy of Prof. Michael O’Keefe)
Fig. 19 Retinal hemorrhages in nonaccidental injury. (Allfigures courtesy of Prof. Michael O’Keefe)
18 S. Moran and M. O’Keefe
Conclusion and Future Directions
Pediatric ocular trauma remains a leading cause ofunilateral blindness in children, although themajority of injuries are preventable. Factors suchas endophthalmitis, retinal detachment, vitreoushemorrhage, hyphema, and wound location areassociated with a poor visual outcome. Approachto pediatric ocular trauma should include systemicevaluation to outrule life-threatening injuries, aswell as visual acuity assessment, and examinationof the fellow eye. Presenting visual acuity is a keyfactor in predicting final visual outcome.
Conclusions can be drawn regarding eye safeenvironments. Schools and childcare facilitieshave a very low risk of eye injuries, partly due todesign and adequate supervision. There is a needfor better education of parents, carers, and sport-ing groups to recognize the risks certain environ-ments pose for children, and that behavior in suchenvironments is modified to minimize risk.
Cross-References
▶Birth Trauma▶Burns in Children▶ Facial Trauma▶ Foreign Bodies▶Head Trauma▶ Injury Prevention in Children▶ Physical and Sexual Child Abuse
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