A history of exposure to power tools or metal striking metal should raise the suspicion of an intraocular foreign body.
Children with sickle cell disease or coagulopathy are more likely to suffer complications associated with a hyphema.
Visual acuity is the vital sign of the eye and should be documented in every child with an ocular injury or visual complaint.
Obtain an ophthalmology consultation in the emergency department (ED) on all patients with hyphemas, suspected globe rupture, or significant visual impairment.
A caustic injury to the eye (acid or alkali) is one of the few situations in which treatment must occur prior to examination and visual acuity testing.
Ocular trauma is the leading cause of non-congenital blindness in individuals younger than 20 years. Every year in the United States approximately 840,000 children injure an eye, with an estimated treatment cost of more than $88 million. Motor vehicle crashes and projectile injuries from nonpowder guns account for the majority of hospitalized eye injuries.1 Recreational and sports injuries are more prevalent in the pediatric population than they are in adults. In addition, ocular trauma may occur as a consequence of child abuse. In preschool children, most injuries are due to falls, motor vehicle collisions, and accidental blows to the eye. In adolescents and teenagers, ocular trauma occurs twice as often in male patients.2 This is also the age group in which sports-related injuries become an important factor—especially baseball, ice hockey, racquet sports, soccer, archery, and fishing injuries.3 Fireworks and paintball-related eye injuries have decreased in incidence in the last 10 years,1 but air guns remain significant causes of pediatric eye injury.4,5
Obtain a full history and note any preexisting eye abnormality and whether or not the child normally wears glasses or contacts. A history of exposure to power tools or metal striking metal should raise the suspicion of an intraocular foreign body. Inquire as to whether the child is having double vision. If so, determine whether the diplopia is monocular or binocular. Monocular double vision implies a problem with the lens or retina, whereas double vision that occurs only with both eyes open is associated with periorbital fractures, extraocular muscle injury, or palsy.
Past medical history is also important. Children with sickle cell disease or coagulopathy are more likely to suffer complications associated with a hyphema. Children with osteogenesis imperfecta have fragile sclera and are more prone to open globe injuries from trauma.6
The physical examination of the eye should be performed early in the emergency department (ED) course, after any life-threatening injuries have been excluded or addressed. Progressive lid edema can prevent an adequate examination of the eye.
Visual acuity is the vital sign of the eye and should be documented in every verbal and conscious child with an ocular injury or visual complaint. In trauma, the best predictor of ultimate visual outcome is initial visual acuity. Assessment should be done before intervention, except in the case of major trauma or caustic exposure. Topical anesthetic given before testing visual acuity decreases pain and blepharospasm and assists in diagnosis (Fig. 98-1).
If the child wears glasses, measure acuity with the glasses on. If the glasses have been lost or damaged, correct refractive error by having the child look through a pinhole on a piece of paper. Lack of correction with pinhole testing suggests significant pathology.
Evaluate preliterate children with an Allen or “E” chart and move a toy or a light to test the young child’s ability to track with each eye. If the child is unable to read an eye chart, ask him or her to finger count at 6 feet; if that fails due to visual loss, assess for light perception.
Test visual fields in older children in the usual fashion. Younger children will glance toward a toy brought into the field of view. Assess for symmetrical ocular motion and symptoms of diplopia.
To avoid missing subtle signs of trauma, begin the examination with the lids and periorbital structures and work centrally in a focused fashion. Examine the lids for swelling or penetrating injury and inspect for ecchymosis. Retract swollen lids with a finger, being careful not to put pressure on the affected eye. Lid retractors or bent paper clips can be used in the case of massive lid edema. Periorbital soft tissue air indicates fracture into a sinus or nasal antrum and is most commonly seen with a blowout fracture. Examine the eye for normal lacrimal drainage. Seemingly minor adnexal lacerations involving the medial third of the eyelid often involve the canalicular system. Injured ducts may require stenting by an ophthalmologist to avoid strictures or disruption of the canalicular system (Figs. 98-2 and 98-3). Epiphora, tears spilling over the lid margins, may be secondary to injury of the canalicular system.
Examine the conjunctiva for injection and presence of ciliary flush around the iris (perilimbal injection), which may indicate iritis. Check for chemosis (edema of the conjunctiva), which can be seen in globe rupture. A circumferential subconjunctival hemorrhage should raise concern for penetrating globe injury. Look at the sclera carefully for any disruption or penetration. The location of any subconjunctival hemorrhage should be documented.
Evaluate the pupils for any asymmetry or irregularity. A pointing pupil indicates iris detachment and possible extrusion (Fig. 98-4). Congenital anisocoria may be detected by obtaining history from the parents or by checking a photograph of the child to see if the asymmetry was preexisting. Pupillary dilatation may occur with direct blows to the eye (posttraumatic mydriasis), with anticholinergic medication, or with a third nerve palsy. A dilated pupil in a conscious patient is not due to a herniation syndrome. Pilocarpine drops will constrict a pupil that is dilated secondary to a third nerve lesion but will have no effect on pharmacologic mydriasis. The emergency physician should also never overlook the possibility of a prosthetic eye.
The lens should be transparent and the margins should not be visible. Examine the anterior chamber for abnormal shallowness or depth. To specifically assess optic nerve function, perform the swinging flashlight test. Swing the flashlight from eye to eye. A pupil that initially dilates when illuminated by light (even if it later constricts) has a sensory (afferent) defect (Marcus Gunn pupil).
Fundoscopic examination should begin with the evaluation of a red reflex. This is best done using the ophthalmoscope light on the widest setting at a distance from the child that enables the examiner to visualize both eyes. Evaluate for equal red reflex. An unequal red reflex indicates a disruption in the visual axis. Possible trauma etiologies include hyphema, lens injury, vitreous hemorrhage, or strabismus due to ocular muscle entrapment. Once the red reflex is visualized, the examiner follows the red reflex into the fundus to perform fundoscopic examination. Fundoscopic examination is difficult in toddlers and young children, particularly after trauma, and generally requires a dilated examination. The vitreous should be clear, allowing visualization of the retina. However, visualization of the retina does not completely exclude retinal detachment, as many cases are anterior and thus undetectable with a direct ophthalmoscope. Do not measure intraocular pressure if globe rupture or penetrating injury is apparent, as this may herniate ocular contents. Normal intraocular pressure is between 10 and 20 mmHg.
Topical anesthetics, such as 0.5% tetracaine or proparacaine, have an onset of action within 1 minute and typically last for 15 to 20 minutes. Topical anesthetics should never be prescribed for home use, as prolonged lack of sensation and loss of normal protective reflexes may lead to corneal damage. Cycloplegics such as homatropine (2%–5%) and cyclopentolate hydrochloride (1%–2%) dilate the eye and decrease pain by overcoming ciliary spasm. Always document the use of such medications to avoid later confusion regarding the etiology of an unreactive pupil. Avoid atropine due to its extremely long duration of action.
Steroids are useful in some inflammatory conditions but may lead to glaucoma, cataract formation, and acceleration of fungal and herpetic infections, resulting in visual loss. Consider ophthalmologic consultation prior to the initiation of ocular steroid drops. Evaluate the need for tetanus prophylaxis in all patients with ocular injuries. To administer medications to young or uncooperative children, lay them down in a dark room, secure the head, and place the drop in the medial canthus. The child will open the eyes and the medication will reach the conjunctiva.
Minor lacerations, superficial to the tarsal plate, that do not involve the lid margins and with no suggestion of injury to deeper structures may be repaired by the emergency physician. Other lacerations require specialty repair.
Related posts:
Full access? Get Clinical Tree
