Keeping an 'Eye' on the Pediatric Patient: An Update on Eye Trauma
Author: Catherine A. Marco, MD, FACEP, Professor, Department of Surgery, Director of Medical Ethics Curriculum, University of Toledo College of Medicine, Toledo, OH.
Peer Reviewer: Dennis Hanlon, MD, FAAEM, Vice Chairman, Emergency Medicine, Allegheny General Hospital, Pittsburgh, PA.
Eye trauma is a common chief complaint among emergency department (ED) pediatric patients. Although many eye injuries can be prevented by appropriate supervision of children's activities and the appropriate use of protective eyewear, eye injuries remain an important cause of visual loss in children. Specific attention to a thorough physical examination is mandatory in the evaluation of pediatric eye trauma, and may include visual acuity, pupillary reactions, external examination, ocular motility, visual field testing, slit-lamp examination, fluorescein staining, funduscopic examination, and intraocular pressure (IOP) when indicated. Since a pediatric eye examination might be challenging, certain tricks of the trade are presented to aid in the physical examination of the patient with a potential eye injury.
Following complete ocular evaluation, many eye injuries can be managed on an outpatient basis with ophthalmologic follow-up and appropriate medical management. Certain eye injuries warrant emergent ophthalmologic consultation, including high-grade hyphema, penetrating globe injury, suspected or known open globe injury, retrobulbar hematoma, or any eye injury resulting in significant vision loss. Prompt evaluation, treatment, and referral are indicated to reduce incidence of long-term complications, which may include deformity, impaired muscle function, and vision loss.
It is estimated that 2.4 million eye injuries occur annually in the United States, accounting for 0.2% of ED visits; approximately one third of eye injuries occur in pediatrics.1,2 Ocular trauma is one of the most significant causes of vision loss in pediatric patients. Many eye injuries can be prevented by appropriate supervision of children's activities and the appropriate use of protective eyewear during sports. The majority of injuries occur in the home, followed by public places such as schools or athletic facilities.3 Injuries often occur related to consumer products, such as sports equipment, household cleaning chemicals, toys, and furniture.4 Eye injuries are the most common type of injury from fireworks in the pediatric population.5 The most common diagnoses include corneal abrasion, blunt trauma, and corneal foreign body.6,7
Eye injuries are often isolated injuries, many of which can be managed on an outpatient basis; 2%3% of patients require inpatient hospital admission.8 Importantly, many eye injuries are also associated with major trauma, particularly in patients with facial fractures, facial contusions, or basilar skull fractures.9,10
Examination of the Injured Eye in the Pediatric Patient
Examining the eye of an injured child may pose a significant challenge. Most patients older than 3 years of age can be successfully examined using interactive distracting techniques and parental assistance; rarely, a papoose board or sedation may be required for an adequate examination. Topical anesthesia may aid in comfort during the eye examination. After collecting a comprehensive history, the physical examination of the eye should include these elements: visual acuity, pupillary reactions, external examination, ocular motility, visual field testing, slit-lamp examination, fluorescein staining, IOP, and funduscopic examination.11 However, certain aspects of a thorough eye examination are age-specific, other areas are independent of age, and most depend on patient cooperation. Remember to perform the more uncomfortable portions of the exam last.
Visual acuity is the vital sign of the eye, and its measurement is essential in the evaluation of eye trauma. The only acceptable delay is in the case of chemical exposure to the eye, which requires immediate irrigation. Visual acuity in the neonate, infant, and toddler is performed by assessing pupillary reaction to light. A light source should be used 13 feet away; the ability to track and fixate on light determines adequate visual acuity. Steady fixation is considered roughly equivalent to 20/40, unsteady fixation is equivalent to 20/100, and inability to fixate is equivalent to 20/400. By the age of 23 years, formal visual acuity testing is performed using a Snellen chart, Allen chart (pictures), or rotating "E" chart at 20 feet. Testing should always be done with correction (if possible) or with a pinhole device if the patient is myopic. A pre-made pinhole device will correct most refractive errors to at least 20/30. If a pinhole device is not available, a quick alternative can be made using an 18-gauge needle and an index card; a metal eye shield with multiple small holes can also be used. If a refractive error exists beyond 20/30, it should not be attributed to simple refractive error. When individuals are unable to read the first line (20/200), shorten the distance to 10 feet and have them read the top line (10/200). Continued inability to read any letters will require the use of counting fingers and recording the distance (e.g., able to count three fingers at a distance of three feet). If the patient is unable to count fingers, then attempt to see if the patient can visualize gross hand motion or perceive light.12,13
Pupil examination should include size, shape, symmetry, and reaction to light. A unilateral dilated pupil raises concern for compression of the third nerve, which may be a sign of uncal herniation, especially when associated with traumatic head injuries. If this finding is present, the physician should perform a more detailed neurological assessment, as there are other causes of unequal pupils, such as anisocoria or direct pupillary injury. A teardrop pupil should alert the emergency physician that ocular perforation has occurred. After a penetrating injury to the eye, the pupillary margin and portions of the iris are drawn into the penetrating wound, causing a teardrop appearance with the apex pointing to the injury. During the pupillary exam, if you suspect a penetrating injury to the eye, avoid any pressure to the eye. Examination of the eye should include evaluation for an afferent pupillary defect. Normal pupils will constrict and accommodate equally when a bright light is shown on the pupil (direct) and light shown on the opposite pupil (consensual light reflex). If the light reflex is diminished, a swinging flashlight test will discriminate between an afferent (retina, optic nerve) injury or efferent (third nerve or papillary muscle) injury. With an injury to the afferent tract, the pupil constricts consensually but not directly, while an efferent injury prevents both direct and consensual pupillary reflex; the unaffected eye maintains both responses.13
External examination of the eye includes observing for proptosis (suggestive of retrobulbar hematoma) and enophthalmos (suggestive of ocular rupture or blow-out fracture). The eyelids should be examined for lacerations, contusions, and punctures. The inner aspects of the eyelids should be examined, looking for foreign bodies and subconjunctival hemorrhage. The cornea, sclera, and conjunctiva should be examined by gross inspection as well as by slit lamp examination. The cornea should be examined after the patient has been upright for several minutes to allow visualization of a hyphema, if present. Evaluate the conjunctiva to detect lacerations, foreign bodies, or underlying scleral perforations.
Ocular motility should be assessed and documented. If a patient is unable to move the eye in a certain direction, concerns for entrapment of a muscle from an orbital blow out fracture, direct muscle injury or central nervous problem should be considered. If the complaint is diplopia after trauma, evaluation should assess whether the diplopia is monocular (typically lens displacement [after a lens surgery]) or binocular (entrapment, muscle injury, or central nervous system injury).
Visual field testing can be brief and simply involve the four major quadrants of vision; formal visual field testing can be done at a later time. Visual field testing is important to perform especially if the history suggests the possibility of retinal detachment or vitreous hemorrhage (e.g., new floaters or flashes of light after eye trauma). The patient should cover one eye; position yourself at eye level and hold your fingers halfway between yourself and the patient. Ask the patient to look at your nose and slowly bring fingers from the outside in, making sure the patient does not look away from your nose and towards the fingers. Binocular visual field loss is typically neurological in nature and not an ophthalmologic issue.
Slit lamp examination in older children is performed using the same technique as for adults. Younger children may feel more comfortable sitting on a parent's lap for the examination. Some tricks to having younger children more cooperative with the exam is to coax them into seeing something fun in the slit lamp (e.g., favorite cartoon character). Have parents place their chin in the device first to reassure the child, and tell them that they will see a pretty blue light. When examining infants, have parents sit and support the child's bottom with one hand, while the other hand rests on the back of the infant's head. If the child is not cooperative, a Wood's lamp may be an alternative to diagnosing corneal defects; however, Wood's lamp examination does not allow the detail of inspection afforded by slit lamp examination.
IOP evaluation is used to assess the significance of some eye injuries. IOP testing is contraindicated in suspected globe perforation, corneal abrasion, and foreign bodies. IOP evaluation is useful in patients with simple hyphemas, when ocular rupture is not suspected. IOP can be measured with a portable tonometer, or using slit lamp applanation tonometry. Normal IOP is 12 mmHg and increases by an estimated 1 mmHg for every decade of age over 40. Errors in tonometry can easily be made by placing too much pressure on the eye, blinking, or crying, all of which may artificially elevate IOP.
Finally, to view the posterior portions of the eye and retina, funduscopic examination is indicated. To assist in good visualization of the optic nerve and retina, have lights in the room turned off, and turn the intensity of the ophthalmoscope to its lowest setting and smallest aperture. While examining infants, making creative noises and clicking sounds will enhance your success. Toddlers may be afraid of the ophthalmoscope, but allowing them to see it up close and possibly hold it may take away some anxiety. Ideally, funduscopic examination is best performed after dilation. Pupils should not be dilated if serial neurologic exams are to be performed or if acute angle closure glaucoma is suspected.
Corneal abrasions are one of the most common eye injuries, and may occur from a variety of mechanisms, including projectiles, foreign bodies, direct trauma, fingernails, contact lenses, bee stings, and others.14,15 Symptoms of corneal abrasion may include pain, tearing, blepharospasm, photophobia, or foreign body sensation.
Examination should include evaluation of the location, depth, and surface area of the abrasion, using fluorescein staining and slit lamp examination. (See Figure 1.) Lid eversion should be performed to exclude a retained foreign body. Current treatment includes pain control, topical antibiotics, topical analgesics, and cycloplegic agents. Eye patching has no demonstrated benefit and is no longer recommended for corneal abrasions.16-19 Patching decreases depth perception and was shown in children to result in difficulty with ambulation.19
A topical antibiotic is indicated to prevent bacterial infection, although antibiotics have not been shown to improve outcomes. Appropriate choices may include sulfacetamide; a topical aminoglycoside; a topical quinolone, such as ciprofloxacin or ofloxacin drops; erythromycin ointment; polymyxin/trimethoprim drops; or numerous others. For contact lens wearers, a fluoroquinolone or aminoglycoside is preferred. Topical analgesics such as dicolfenac (Voltaren) and ketorolac (Acular) have shown a beneficial effect in reducing pain in corneal abrasions. A meta-analysis of five randomized, controlled studies showed a reduction of pain on a visual analog scale.20 Patients using topical nonsteroidal anti-inflammatory drugs (NSAIDs) had greater relief of pain and used fewer oral analgesics and narcotics; however, an increase in initial transient stinging was commonly noted as an adverse effect.20,21 The use of a cycloplegic agent, such as homatropine, or atropine, will relieve pain resulting from ciliary spasm. Home use of topical anesthetics should be avoided, due to negative effects on healing and increased risk of recurrent injury. Tetanus toxoid is routinely recommended for patients without updated immunization status;22 however, a search of the literature has not identified any cases of clinical tetanus developing from a simple corneal abrasion.23
Most corneal abrasions heal well within 24 hours. Rarely, complications may occur, including delayed healing, scarring, infection, vision loss, or missed retained foreign body. Close follow-up is essential to ensure appropriate healing and relief of symptoms. In particular, injuries resulting from vegetable or botanical matter, or contact lens injury, are at higher risk for Pseudomonas infection and require close follow-up.
Corneal Foreign Bodies
A great variety of intraocular foreign bodies have been described, including metal fragments, wood, plastic, and others. Once determined that the injury to the eye is a simple foreign body and resultant corneal abrasion, removal of the foreign body should be performed under slit lamp visualization to provide consistent and stable removal of the offending irritant.24
Corneal foreign bodies can often be safely removed in the ED. An initial attempt to remove an irritant from the pediatric eye may be performed with a moistened cotton-tipped swab. If this effort is unsuccessful, the use of a needle is indicated to remove the foreign body. It is important to reassure the patient and parents that the needle does not go into the eye, but merely rests on the surface. Attach a standard 18-gauge needle to a 3 mL syringe for stability. Some prefer to bend the needle shaft 30° to facilitate the approach to the eye. The foreign body can then be gently lifted off the surface of the cornea. Once the foreign body is dislodged, use a moist cotton swab to remove it from the surface of the eye, if necessary. If a rust ring remains following removal of a metallic foreign body, this may also be removed in the ED with either the needle or a burr. It is also acceptable to schedule ophthalmology follow up for removal within 2448 hours.25
Following foreign body removal, reexamine the eye for signs of ocular penetration. Pay particular attention for Seidel's sign, a leak of fluid that appears to be a dark stream of fluid on top of a green fluorescein background. After the foreign body is removed and signs of ocular perforation are excluded, the injury may be treated as a simple corneal abrasion.
Penetrating Ocular Injuries
Common causes of penetrating ocular injuries include glass, BBs, metallic fragments, toys, sticks, and wood/plastic particles that have become projectiles.24,26 (See Figure 2.) Bony fracture fragments may also cause intraocular foreign bodies or injury.27 Most injuries could have been avoided if proper safety equipment, mainly safety glasses, were worn.28 Factors associated with worse prognosis include object with higher mass, or objects with a blade shape, as opposed to disc, cylinder, or sphere shapes.29 Clinical factors predictive of poor outcome include visual acuity worse than 20/200, pupillary abnormalities, and hyphema. Children are at higher risk for suffering open globe injuries than adults; open globe injuries are the leading cause of monocular blindness in children world wide.30 Associated injuries may include corneal injury, scleral laceration, retinal detachment, or numerous other injuries. Thus, whenever a penetrating injury to the eye is suspected, a complete ocular examination should be conducted, and ophthalmologic consultation considered.31 Penetrating injuries may present immediately, or be delayed with complications arising up to years following the injury.32
Terms relevant to penetrating eye injuries include:
Laceration: A defect in the cornea or sclera caused by a sharp object;
Rupture: A disruption of the cornea or sclera caused by indirect forces or agents of blunt trauma, including low-velocity missiles such as BBs;
Perforation: Any injury that traverses the full thickness of the sclera; and
Double perforation: Any injury that enters the eye, traverses the intraocular cavity, and exits the sclera on the opposite side.
The anatomy of the bony orbit protects the eye from most oblique and posterior injuries. Smaller missiles and sharp objects are often capable of entering the area within the orbital rim increasing the likelihood of piercing the globe. Therefore, ocular penetration must be suspected whenever there has been a laceration, puncture, or disruption of the eyelids or orbital bone, or periorbital ecchymosis.33 In many cases, high-velocity projectiles that are small may penetrate the eyelid/globe and cause little pain or visual disturbance. The cornea may seal over the entry portal, leading to a paucity of eye findings. Intraocular foreign bodies should be considered in all penetrating eye injuries. If a penetrating globe injury is suspected, no pressure should be exerted on the eye because of risk of expelling intraocular contents. Perform a complete neurologic exam and obtain a thorough history of the events, keeping in mind that children may not tell the entire truth for fear of negative consequences. A detailed ocular exam should include visual acuity testing; pupillary testing; examination of the cornea, sclera, and anterior chamber with slit lamp, when possible; and funduscopic exam. Signs of possible perforation, such as bloody chemosis of the sclera, collapse and hemorrhage in the anterior chamber, pupil and iris irregularities, positive Seidel's test, and traumatic cataract should be sought and noted when present. Seidel's test is administered by instilling fluorescein into the affected eye directly at the site of the suspected perforation, and examining under slit lamp for a bright green stream of fluid resulting from the outflow of aqueous humor. If examination is unable to be adequately performed due to emotional distress or poor cooperation, suspicion of a penetrating injury justifies an evaluation under anesthesia in the operating room, where the nature and extent of the injury may be adequately addressed. (See Table 1.)
All penetrating eye injuries or suspected penetration warrant radiographic imaging. Although plain radiographs may serve to reveal the size and number of metallic foreign bodies, the exact three-dimensional orientation of the foreign body with respect to the globe is not delineated. Plain films also are not adequate for full evaluation of adjacent bony structures, sinuses, soft tissue, and the evaluation of non-metallic objects that may be readily seen on computed tomography (CT). A randomized, retrospective study of the accuracy of CT in evaluating open globe injuries has shown a sensitivity of 75% and specificity of 95% for picking up such injuries in the absence of clinical exam or historical findings.34 It is therefore recommended that patients with suspected intraorbital foreign bodies undergo CT with 1.53.0 mm cuts with coronal reconstruction when available. (See Table 2.)
Ultrasonography may also be helpful in the identification of intraorbital foreign bodies, although suboptimal sensitivity suggests that additional imaging should be performed if suspected clinically.35 In addition, intracranial foreign body may be associated with perforating ocular injuries, and intracranial imaging should be considered.36
Hyphema, blood in the anterior chamber, is a common condition seen after blunt ocular trauma in pediatric patients, and results from rupture of the iris or ciliary body blood vessels.13,37 Hyphema is more common among males, particularly ages 1518 years. Examples of trauma resulting in hyphema include blunt trauma, projectiles, or explosions, including specific examples of fists, balls, motor vehicle collisions, rocks, airbags, sticks, pellet guns, toys, tools, and numerous others.38,39 Hyphema usually occurs from a tear in the anterior portion of the ciliary body. Hyphema should be observed after the patient has been sitting upright for several minutes, to allow layering and visualization of the hyphema. Intraocular pressure may be elevated. Other associated eye injuries may occur, including corneal injuries (26%40% incidence), posterior segment injuries, and rebleeding. Hyphemas are classified according to amount of hemorrhage.
Complications of hyphema may include corneal blood staining, vision loss, secondary glaucoma, secondary hemorrhage, and optic nerve atrophy. Factors related to poor outcome include grade of hyphema, intraocular hypertension, time for hemorrhage absorption, and associated posterior segment lesions.40 (See Table 3.) Good visual recovery occurs in only 35% of patients with total hyphema.
Corneal blood staining occurs in 2%11% of patients with hyphema, and occurs more commonly among higher-grade hyphemas. Corneal blood staining may lead to vision loss or amblyopia. Increased IOP is common; about one-third of patients with hyphema have increased IOP.
Secondary hemorrhage is associated with increased morbidity, including corneal blood staining, secondary glaucoma, optic nerve atrophy, and vision loss. Secondary hemorrhage typically occurs 27 days after the primary injury, and the incidence is higher in patients with poorer initial visual acuity, large hyphema (more than 33% of anterior chamber), delayed medical attention, initial elevated IOP, and use of antiplatelet medications.41 It has been estimated that secondary hemorrhage occurs in 5%22% of patients with hyphema.41
Outpatient management is feasible for most patients with low-grade hyphema.40 Although traditional management in the past included strict bed rest, sedation, and eye patching, these treatments have not demonstrated improved outcomes. Hospital admission is usually not necessary and is not associated with improved outcome, although admission may be indicated for patients with secondary hemorrhage, markedly elevated IOP, sickle cell disease, hemophilia, or vision loss; in cases of child abuse; or for noncompliant patients.42 Elevation of the head to 30° aids in hyphema clearance and facilitates the diagnosis of secondary hemorrhage. Vigorous physical activity should be avoided. The use of eye patching is controversial. Patching may improve comfort and reduce eye movement, although some authors argue that patching may raise the eye temperature and promote bacterial growth. Typically, topical antibiotics, cycloplegic agents, and topical corticosteroids are indicated. (See Table 4.) Other treatments remain controversial, and may include topical cycloplegics, systemic steroids, topical or systemic antifibrinolytics, topical beta-blockers, and carbonic anhydrase inhibitors. Surgical treatment, including paracentesis, hyphectomy, clot irrigation, or trabeculectomy, are indicated only for uncontrolled elevated IOP, corneal staining, or large hyphemas.
Thermal and Chemical Burns
Chemical burns to the eye occur as a result of direct exposure to caustic chemicals. Common sources include household cleaning agents, automotive cleaners, swimming pool chlorine, battery acid, and other chemicals. Chemical burns are classified by tissue damage that is associated with prognosis. (See Table 5.)
Alkali burns are often more extensive than corresponding acid burns. Alkali rapidly penetrates the cornea and leads to increased pH of the aqueous, causing liquefaction necrosis, with extensive loss of corneal epithelium. Widespread tissue damage may follow rapid rise in pH.
Acid burns may also be severe; however, the coagulation necrosis initiated by acid injury limits the extent of tissue injury in many cases. Following acid exposure, protein coagulation in the corneal epithelium produces a barrier to deeper penetration of acid. Hydrofluoric acid is an exception to this mechanism and may result in extensive corneal penetration and injury.
Chemical burns should be managed with immediate and copious irrigation, which improves prognosis and outcome.43,44 Effective irrigation may require topical anesthesia and/or systemic sedatives. Rapid initiation of irrigation is more important than the precise irrigant solution used.45 Irrigation may be performed with a variety of readily available solutions. Normal saline (NS, 0.9%) has a pH 4.56.0 and may be associated with mild discomfort. Alternative irrigants include water (readily available, but hypotonic), lactated Ringer's solution (pH 6.27.5), buffered NS with pH adjusted to 7.4 with sodium bicarbonate, and Balanced Salt Solution Plus (BSS Plus), with a pH of 7.4.46 The use of an intraocular irrigation lens may improve the contact of the irrigant with the cornea. If the pH of the chemical causing injury is unknown, pH testing should be done to ascertain the acidity of the substance. Following alkali burns, regular pH assessment with litmus paper should be performed intermittently until the pH normalizes. Acid burns should be treated with irrigation for 1520 minutes; alkali burns may require several hours of copious irrigation.
Thermal burns are less common, but may occur as a result of splash injuries, cigarettes/cigars, fireworks, matches, lighters, curling iron contact, or other mechanisms. The eye is the most common body site injured by fireworks among pediatric patients, followed by injury to face and hands.5 Thermal burns may be extensive and are proportionate to the time of contact and temperature of the burn surface. Often eye protective mechanisms spare significant eye injury, including the blink, tears, bony orbit structure, and shielding of the face by hands and arms.
Following either chemical or thermal burns, a complete eye examination and assessment should be performed, including visual acuity, IOP, and slit lamp examination. If devitalized tissue or foreign bodies are present, debridement and removal should be performed. Following irrigation for both chemical and thermal burns, supportive measures during the healing process for both chemical and thermal burns should include ocular lubricants, artificial tears, topical corticosteroids, and topical antibiotics. (See Table 6.)47-49 If IOP is elevated, appropriate therapy should be instituted. Appropriate pain management may include systemic NSAIDs or opioids. Ophthalmologic consultation is indicated for most injuries.50 Surgical management may be indicated for significant necrotic tissue or severe injury.
Blunt Eye Trauma
Blunt injuries to the eyes range from a spectrum of simple contusion to retinal detachment or globe rupture. The most common cause of blunt trauma to the eye in children is sporting and recreational events, which make up more than 59% of blunt injuries to the eye.2 Basketball, baseball, water sports, and racquet sports account for most injuries.51 The extent of the damage to the eye is dependent of the size, velocity, hardness of the object, and the amount of direct force placed on the eye. It is well established that penetrating injuries to the eye have a poorer prognosis than blunt injuries; however, serious blunt injuries can cause a significant intraocular disruption that may cause vision-threatening injuries that are critical to be recognized and referred.8 There are two major blunt ocular injury patterns that every emergency physician should be aware of: direct globe injury and orbital fracture. A direct blow to the globe is usually caused by smaller objects that are able to bypass the bony orbital rim and strike the eye directly. Forces that directly hit the eye cause a rapid compression of the globe anteriorposteriorly and corresponding expansion/dilation of the middle of the globe. The transmission of these forces produces extensive tearing and stretching forces, causing several types of injuries.
When the eye is struck, the anterior chamber is compressed, and the pupil is forced to dilate rapidly. The iris may tear, causing rupture of sphincter papillae, which can lead to traumatic mydriasis. Force distributed directly to the peripheral iris can cause the iris to disinsert from its root (iridodialysis). A traumatic cataract may be seen when compressive forces damage the lens. Alternatively, the lens can be dislocated by the tearing of its insertion at the zonules. Signs of lens subluxation or dislocation include blurry vision and monocular diplopia. Damage to any of the structures in the anterior chamber can cause bleeding leading to hyphema. The importance of finding a hyphema on physical exam is that it is an indicator of serious ocular injury and that structures in the anterior as well as posterior segments are likely to be damaged. As forces are distributed beyond the lens, injuries to the posterior segment are possible. The vitreous humor is attached to the retina and large stresses are able to disinsert the retina, leading to retinal detachment. The choroid may be stretched and torn; due to the vascular nature of this structure, choroidal rupture may occur, presenting as subretinal blood on funduscopic exam. Finally, commotio retinae may be seen after stretching and edema of the retina. This localized injury is identified as a whitish discoloration of the retina, on funduscopic exam, caused by edema of the photoreceptor cells in the retina. Significant complications may arise as a result of blunt trauma, including vision loss, disfiguration, secondary glaucoma, or traumatic optic neuropathy.52 General treatment for blunt ocular injuries include prophylactic eye shield, pain control and ophthalmologic consultation. Guidelines for immediate referral include globe rupture or suspected rupture, pupil defect with dense periorbital hematoma, hyphema, significant vision loss, or subconjunctival hemorrhage (may be masking globe rupture). Blunt injuries that may require ophthalmologic consultation within 24 hours include minor reduced visual acuity, retinal hemorrhages, eyelid lacerations, and blowout fractures.
Orbital Wall Fractures
Orbital fractures are typically caused by blunt impact by objects larger than the orbital rim or by impacts with flat surfaces, including falls and motor vehicle collisions Seven bones of the skull come to form the orbit: maxilla, zygoma, lacrimal, ethmoid, sphenoid, palatine, and frontal. The term "blow-out fracture" refers to buckling of the orbital floor, following intense intraorbital pressure associated with blunt trauma, often protecting the eye from more serious internal injury.53 Entrapment of periorbital tissues, commonly including muscle, may occur as a result of phase differences of the movement of various orbital structures.54 Orbital entrapment occurs more commonly in pediatrics, thought to be due to the pliable nature of the orbital floor. The most common area to fracture is the orbital floor and medial wall due to thinner bone in these regions. Orbital roof fractures make up about 5% of injuries. Children younger than 7 years are more prone to these injuries. The orbital roof is a very thin structure, and frontal sinuses are not fully pneumatized until approximately age 7 years. Blunt trauma that impacts the upper portion of the orbit is dissipated by the frontal sinus. Orbital roof fractures may communicate with the brain and result in more serious injuries, including intracranial hemorrhage and leakage of cerebrospinal fluid. Symptoms of an orbital fracture include periorbital ecchymosis, diplopia, hypoesthesia in V2 (lower eyelid, cheek and upper lip) distribution, pain with ocular movement (especially vertical movement), and intraorbital emphysema on plain radiograph. Symptoms of nausea and vomiting may be associated with inferior rectus entrapment and poor outcome.55 Diagnosis is made by radiographic imaging with CT or magnetic resonance imaging (MRI). (See Figure 3.) Plain radiographs of the orbits have a high false negative or non-diagnostic rate ranging from 30%50%. CT is often more widely available, but also carries the risks associated with significant radiation exposure.56,57 MRI typically shows better resolution and causes no radiation exposure, but may require sedation to perform and is less readily available. High-resolution MRI imaging with an orbital coil shows promise in the diagnosis of pediatric orbital fractures.58 Limitations of orbital radiography should be noted, as fractures and entrapment may be missed by radiography alone.59,60
Once the diagnosis is made, two management schema are available surgical or non-surgical. Three specific findings are of particular concern, including diplopia (entrapment), restriction of extraocular movements, and enophthalmous > 2 mm. Careful ophthalmologic examination is essential, as 26% of patients with orbital fractures have associated ocular injuries.61 Most orbital fractures requiring surgical intervention are repaired within two weeks.53 The initial management of orbital blowout fractures includes treatment of the area with ice for 48 hours, nasal decongestants, broad spectrum antibiotics, elevation of head of bed while sleeping, avoidance of aspirin, avoidance of nose-blowing, and ophthalmologic consultation. Consideration for early consultation should be made if mechanism of injury and physical exam suggest a serious intraocular injury.
Retrobulbar hemorrhage is a true emergency that may require urgent intervention to preserve vision. This condition is effectively a compartment syndrome within the orbit and must be managed with the same, if not more, haste as any other compartment syndrome. The time until the oxygen-sensitive tissues of the retina are irreversibly damaged is 60 minutes.62 This sight-threatening injury typically arises from orbital bleeding following a non-displaced fracture of the orbital wall. As with other compartment syndromes, the natural progression of the condition is increased pressure around the globe, resulting in reduced retinal perfusion, compression of ciliary vessels, stretching of the optic nerve, and exophthalmos.63 In most cases, development of retrobulbar hemorrhage occurs within a few hours of injury, but case reports have shown that delayed retrobulbar hemorrhages may appear after the initial injury.64 Retrobulbar hemorrhage must be treated immediately if there is evidence of vision loss. Clinical signs include pain, proptosis, loss of vision, and presence of an afferent pupillary defect. In the unconscious patient, a tense, proptosed globe and a dilated pupil may be all that is apparent in the presence of a retrobulbar hemorrhage. CT scanning of the brain and orbits will help identify orbital wall fractures and retrobulbar blood if the diagnosis is in question. The management of a retrobulbar hemorrhage is surgical and emergent ophthalmologic consultation is warranted. Emergent lateral canthotomy can be performed in the ED as a temporizing measure, until formal decompression can be performed under general anesthesia. Once the lateral canthus is incised and the canthal tendon cut, the globe can move forward, allowing increased retrobulbar volume. Other medical treatments of potential benefit include intravenous steroids, acetazolamide, and mannitol. Definitive treatment is surgical decompression and repair.
Eyelid lacerations are commonly seen in pediatric patients, and are often due to falls, motor vehicle collisions, or direct impact. Evaluation should assess potential globe injury and should include visual acuity, slit lamp examination, IOP measurement, and facial nerve function. Potential bony fractures should be ruled out by examination and radiographs, if indicated. (See Figure 4.)
Simple eyelid lacerations can be successfully repaired in the ED. Superficial wounds not involving the lid margins can be closed with single or two-layer closures with small suture material. Slight eversion of wound edges should reduce scar formation. The dermal layer should not be under tension. Complex wounds, including tarsal plate involvement, canaliculi involvement, lid margin involvement, or scleral involvement may require ophthalmologic or plastic surgery consultation.65 Debridement of devitalized tissue may be indicated. Tetanus toxoid should be administered if indicated.
Certain eye findings may be indicative of child abuse. Any injury which does not fit the characteristic pattern and severity of the described injury should heighten suspicion of possible abuse. Intraocular hemorrhage occurs rarely with accidental head trauma and is commonly associated with shaken-baby syndrome, particularly when seen in association with subdural hemorrhage, abnormal mental status, or seizures.66,67 Bilateral subconjunctival hemorrhages may be seen in infants as a result of asphyxia.68
Eye trauma is a common chief complaint among ED pediatric patients. Many eye injuries can be prevented by appropriate supervision of children's activities and the appropriate use of protective eyewear during sports. Detailed physical examination is indicated for the evaluation of pediatric eye trauma, and should include visual acuity, pupillary reactions, external examination, ocular motility, visual field testing, slit-lamp examination, fluorescein staining, funduscopic examination, and IOP (when indicated). Most eye injuries can be managed on an outpatient basis with ophthalmologic follow-up and appropriate medical management. Certain eye injuries warrant emergent ophthalmologic consultation, including high-grade hyphema, penetrating globe injury, suspected or known open globe injury, retrobulbar hematoma, or any eye injury resulting in significant vision loss.
(Author's Note: With gratitude to Jeffrey Salisbury, MD and his valuable contributions to the first edition of the manuscript.)
1. McCaig L, Burt CW. National Hospital Ambulatory Medical Care Survey: 2002 Emergency Department Summary. Centers for Disease Control: Advance Data from Vital and Heatlh Statistics: no. 340. Hyattsville, Maryland: National Center for Health Statistics, 2004.
2. Brophy M, Sinclair SA, Hostetler SG, et al. Pediatric eye injury-related hospitalizations in the United States. Pediatrics 2006; 117: 1263-1271.
3. McGwin G, Owsley C. Incidence of emergency department-treated eye injury in the United States. Arch Ophthalmol 2005; 123:662-666.
4. Cross JM, Griffin R, Owsley C, et al. Pediatric eye injuries related to consumer products in the United States, 1997-2006. J AAPOS 2008; 12:626-628.
5. Witsaman RJ, Comstock RD, Smith GA. Pediatric fireworks-related injuries in the Unites States: 1990-2003. Pediatrics 2006;118: 296-303.
6. Kumar NL, Black D, McClellan K. Daytime presentations to a metropolitan ophthalmic emergency department. Clin Experiment Ophthalmol 2005;586-592.
7. MacEwen CJ, Desai PS, Baines PS. Eye injuries in children: The current picture. Br J Ophthalmol 1999;83:933-936.
8. MacEwen CJ. Ocular injuries. J R Coll Surg Edinb 1999;44:317-323.
9. Garcia TA, McGetrick BA, Janik JS. Ocular injuries in children after major trauma. J Pediatr Ophthalmol Strabismus 2005;42:349-354.
10. Garcia TA, McGetrick BA, Janik JS. Spectrum of ocular injuries in children with major trauma. J Trauma 2005;59:169-174.
11. Handler J A, Ghezzi KI. General ophthalmologic examination. Emerg Clin North Am 1995;13:521-538.
12. Datner E M, Jolly T. Pediatric ophthalmology. Emerg Clin North Am 1995;13:669-679.
13. Ervin-Mulvey LD, Nelson LB, Freely DA. Pediatric eye trauma. Pediatr Clin North Am 1983;30:1167-1183.
14. Baumeister M, uhli-Hattenbach C, Luchtenberg M. Corneal ulcer caused by a wooden foreign body in te upper eyelid 6 months after minor injury. Ophthalmologica 2006;220:397-379.
15. Caca I, Ari S, Ulu K, et al. Bee sting of the cornea: A case study and review of the literature. Ann Ophthalmol 2006;38:77-79.
16. Turner A, Rabiu M. Patching for corneal abrasion. Cochrane Database Syst Rev 2006;CD004764.
17. Kaiser PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology 1995;102: 1936-1942.
18. Wilson SA, Last A. Management of corneal abrasions. Am Fam Phys 2004:70:123-128.
19. Michael JG, Hug D, Dowd MD. Management of corneal abrasions in children: A randomized clinical trial. Ann Emerg Med 2002;40:67-72.
20. Calder LA, Balusubramanian S, Fergusson D. Topical nonsteroidal anti-inflammatory drugs for corneal abrasion: Meta-analysis randomized trials. Acad Emerg Med 2005;12;467-473.
21. Weaver CS, Terrell KM. Evidence-based emergency medicine. Update: Do ophthalmic nonsteroidal anti-inflammatory drugs reduce the pain associated with simple corneal abrasions without delaying healing? Ann Emerg Med 2003;41:134-140.
22. Benson WH, Snyder IS, Granus V, et al. Tetanus prophylaxis following ocular injuries. J Emerg Med 1993;11:677-683.
23. Mukherjee P, Sivakumar A, et al. Tetanus prophylaxis is superficial corneal abrasions. Emerg Med J 2003;20:62-64.
24. Gallin PF. Pediatric Ophthalmology: A Clinical Guide. New York: Thieme Medical; 2000.
25. Webb LA. Manual of Eye Emergencies: Diagnosis and Management. 2nd Edition, Philadelphia: Elsevier Limited; 2004.
26. Gopal L, Banker AS, Deb N, et al. Management of glass intraocular foreign bodies. Retina 1998;18:213-220.
27. Garg SJ, Benson W, Fineman M, et al. Bone from an orbital floor fracture causing an intraocular foreign body. Am J Ophthalmol 2005;139:543-545.
28. Smith D, Wrenn K, Stack LB. The epidemiology and diagnosis of penetrationg eye injuryies. Acad Emerg Med 2002;9:209-213.
29. Woodcock MG, Scott RA, Huntbach J, et al. Mass and shape as factors in intraocular foreign body injuries. Ophthalmology 2006;113: 2262-2269.
30. Narang S, Gupta V, Simalandhi P, et al. Pediatric open globe injuries. Indian J Ophthalmol 2004;52:29-34.
31. Lubeck D. Penetrating ocular injuries. Emerg Med Clin North Am 1988;1:127-146.
32. McGimpsey SJ, Rankin SJ. Presentation of intraocular foreign body 25 years after the event. Clin Experiment Ophthalmol 2005;33: 665-666.
33. Ghazi-Nouri SM, Vote BJ, Sullivan PM. Periorbital ecchymosis as a sign of perforating injury of the globe. Clin Experiment Ophthalmol 2005;33:194-196.
34. Joseph DP, Pieramici DJ, Beauchamp NJ. Computed tomography in the diagnosis and prognosis of open-globe injuries. Am Acad Ophthalmol 2000;107:1899-1906.
35. Shiver SA, Lyon M, Blaivas M. Detection of metallic ocular foreign bodies with handheld sonography in a porcine model. J Ultrasound Med 2005;24:1341-1346.
36. Turkcuoglu P, Aydogan S. Intracranial foreign body in a globe-perforating injury. Can J Ophthalmol 2006;41:504-505.
37. Brandt MT, Haug RH. Traumatic hyphema: A comprehensive review. J Oral Maxillofac Surg 2001;59:1462-1470.
38. Saunte JP, Saunte ME. 33 cases of airsoft pellet ocular injuries in Copenhagen, Denmark, 1998-2002. Acta Ophthalmol Sccand 2006; 84:755-758.
39. Listman DA. Paintball injuries in children: More than meets the eye. Pediatrics 2004;113:e15-18.
40. Rocha KM, Martins EN, Melo LA Jr., et al. Outpatient management of traumatic hyphema in children: Prospective evaluation. J AAPOS 2004;8:357-361.
41. Fong LP. Secondary hemorrhage in traumatic hyphema. Predictive factors for selective prophylaxis. Ophthalmology 1994;101: 1583-1588.
42. Walton W, Von Hagen S, Grigorian R, et al. Management of traumatic hyphema. Surv Ophthalmol 2002;47:297-334.
43. Ikeda N, Hayasaka S, Hayasaka Y, et al. Alkali burns of the eye: Effect of immediate copious irrigation with tap water on their severity. Ophthalmologica 2006; 220:225-228.
44. Kuckelkorn R, Schrage N, Keller G, et al. Emergency treatment of chemical and thermal eye burns. Acta Ophthalmol Scand 2002;80: 4-10.
45. Herr RD, White GL, Bernhisel K, et al. Clinical comparison of ocular irrigation fluids following chemical injury. Am J Emerg Med 1991;9: 228-231.
46. Saidinejad M, Burns MM. Ocular irrigant alternatives in pediatric emergency medicine. Pediatr Emerg Care 2005;21:23-26.
47. Hammerton ME. Burns to the eye: An overview. Austral Fam Phys 1995;24:998-1003.
48. Hammerton ME. Management of ocular burns. Austral Fam Phys 1995;24:1006-1010.
49. Spencer T, Hall AJH, Stawell RJ. Ophthalmologic sequelae of thermal burns over ten years at the Alfred Hospital. Ophthalmic Plast Reconstr Surgery 2002;18:196-201.
50. Bouchard CS, Morno K, Perkins J, et al. Ocular complications of thermal injury: A 3-year retrospective. J Trauma 2001;50:79-82.
51. Rodriguez JO, Lavina AM, Agarwal A. Prevention and treatment of common eye injuries in sports. Am Fam Physician 2003:67; 1481-1488.
52. Wang BH, Robertson BC, Girotto JA et al. Traumatic optic neuropathy: a review of 61 patients. Plast Reconstr Surgery 2001;107: 1755-1764.
53. Brady SM, McMann MA, Mazzoli RA, et al. The diagnosis and management of orbital blowout fractures: Update 2001. Am J Emerg Med 2001;19:147-154.
54. Fujino T, Makino K. Entrapment mechanism and ocular injury in orbital blowout fracture. Plast Reconstr Surg 1980;65:571-576.
55. Cohen SM, Garrett CG. Pediatric orbital floor fractures: Nausea/vomiting as signs of entrapment. Otolaryngol Head Neck Surg 2003;129:43-47.
56. Mauriello JA, Huey JL, Nguyen I. CT of soft tissue injury and orbital fractures. Radiol Clin North Am 1999:37;241-252.
57. Mills DM, Tsai S, Meyer DR, et al. Pediatric ophthalmic computed tomographic scanning and associated cancer risk. Am J Ophthalmol 2006;142:1046-1053.
58. Kolk A, Stimmer H, Klopfer M, et al. High resolution magnetic resonance imaging with an orbital coil as an alternative to computed tomography scan as the primary imaging modality of pediatric orbital fractures. J Oral Maxillofac Surg 2009;67:348-56.
59. Parbhu KC, Galler KE, Li C, et al. Underestimation of soft tissue entrapment by computed tomography in orbital floor fractures in the pediatric population. Ophthalmol 2008;115:1620-1625.
60. Criden MR, Ellis FJ. Linear nondisplaced orbital fractures with muscle entrapment. J AAPOS 2007;11:142-147.
61. Cook T. Ocular and periocular injuries from orbital fractures. J Am Coll Surg 2002;195831-834.
62. Perry M, Dancey A, Mireskandari K, et al. Emergency care in facial traumaA maxillofacial and ophthalmic perspective. Injury 2005:36; 875-896.
63. Gerbino G, Ramieri G A, Nasi A. Diagnosis and treatment of retrobulbar haematomas following blunt orbital trauma: a description of eight cases. Int J Oral Maxillofac Surg 2005:34;127-131.
64. Ghufoor K, Sandhu G, Sutcliffe J. Delayed onset of retrobulbar haemorrhage following severe head injury: A case report and review. Injury 1998:29;139-141.
65. Chang EL, Rubin PAD. Management of complex eyelid lacerations. Int Ophthalmol Clin 2002;42:187-201.
66. Pierre-Kahn V, Roche O, Dureau P, et al. Ophthalmologic findings in suspected child abuse victims with subdural hematomas. Ophthalmology 2003;110:1718-1723.
67. Bechtel K, Stoessel K, Leventhal JM, et al. Characteristics that distinguish accidental from abusive injury in hospitalized young children with head trauma. Pediatrics 2004;114:165-168.
68. Spitzer SG, Luorno J, Noel LP. Isolated subconjunctival hemorrhages in nonaccidental trauma. J AAPOS 2005;9:53-56.