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Eye Trauma in Childhood
Symposium on Childhood Trauma
Eye Trauma in Childhood Eugene M. Helveston, MD.*
The eye may be injured by objects that are sharp or dull, of high or low velocity, and by chemicals and other forms of energy which enter the protective cage formed by the orbital rim. These injurious objects include solid projectiles which are a few centimeters or less in diameter, liquids or powder, and energy in the form of heat and light. Larger objects such as a ball, fist, large rock, etc., usually strike the bony orbital rim first and this structure absorbs the shock and protects the eye. The orbital rim may be fractured with or without additional facial fractures in the course of protecting the eye, and any time such a fracture occurs, careful examination of the eyes should be carried out. However, since facial fractures represent an entirely different subject, their diagnosis and treatment with the exception of orbital wall fractures is not ordinarily considered an eye injury. Eye injuries are usually limited to those which involve the globe itself, the soft tissue orbital adnexa including the lids and lacrimal apparatus and the orbital contents, including the optic nerve. As with injury to any part of the body, injury to the eye requires accurate diagnosis and prompt effective treatment. In most cases eye injuries can be diagnosed accurately and either definitive care, in the case of simple injuries, or early supportive care, in the case of more extensive injuries, canbe carried out by a general physician.
THE LIDS The eyelids serve as a useful and unique protective system for the eyes. They keep out excessive light when closed as in sleep, and they keep small windcborne foreign bodies from striking the front surface of the eye with a blink which is executed in only a fraction of a second. The lids further serve to lubricate the anterior part of the eye by means of accessory tear glands embedded in the back surface of the lids. Eyelid motion also produces a mechanical "pumping action" which helps move tears from the lacrimal area which is located under the upper, outer or'Associate Professor of Ophthalmology, University of Indiana School of Medicine, Indianapolis, Indiana Pediatric Clinics of North America- Vol. 22, No.2, May 1975
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bital rim downward across the eyes toward the tear duct system which is made up of the puncta and the canaliculi located medially on the eyelid margins. At the anterior surface of each of the eyelids are found the eyelashes. They serve as a screen or "cow catcher" functioning in a manner similar to the device found on old locomotives. The eyelashes screen out small particles before they hit the cornea and the conjunctiva. Injury to the lids can occur from any type of trauma that can affect skin anywhere on the body. Two particular types of injury which are significant include: contusion and laceration. Contusion to the eyelids can produce the well known "black eye." A blow to the lids often leads to the formation of great subcutaneous swelling. This occurs because the lids contain the least well supported and most susceptible to swelling tissue of the body. The swollen black eye has its dark color because of subcQtaneous hemorrhage. The extent of swelling with a black eye is usually limited by the attachments of the orbital septum to the rim of the orbit. However, the superficial lid swelling of a severe lid contusion call spread across the bridge of the nose and affect the lids of the uninvolvep. eye. This spread of swelling is not a serious condition. A black eye is nqt a joke. A black eye is not treated as is shown in the comic papers with the application of a raw beefsteak! When a black eye occurs the ey~ should be examined carefully for other injuries. Additional injuries which should be ruled out include: orbital rim fracture, orbital floor fracture, hyphema (blood in the anterior chamber), corneal abrasion, conjunctival laceration, lens displacement, cataract, retinal detachment, and globe rupture. The initial workup of any patient with eye injury should always include visual acuity testing in both eyes. This should be followed by an inspection of the lids and the globe. If any question persists about the possibility of rim or floor fracture, x-rays of the orbit should be obtained. If any injury more serious than a skin laceration, ecchymosis, superficial corneal or conjunctival abrasion is encountered or suspected, consultation with an ophthalmologist should be obtained. Treatment with oral enzyme is not especially helpful. Another significant injury that can involve the lid is laceration. Laceration of the lid may be primarily horizontal (Fig. 1) or vertical (Fig. 2), and each carries with it different implications. Horizontal lacerations frequently result in disruption of the levator palpebri, or upper lid
Figure 1.
Horizontal lid laceration.
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Figure 2.
Vertical lid laceration.
elevating muscle. This occurs when the aponeurosis of this muscle which connects it to the superior border of the tarsal plate and the undersurface of the upper lid skin is severed. An "artistic" skin closure of a horizontal lid laceration may be completed with total disregard for the fact that the levator palpebri muscle was severed. Nonunion of a lacerated levator muscle would of course cause a severe ptosis of the upper lid after healing. Because of swelling, ptosis or potential ptosis may be inapparent at the time of initial treatment. Any horizontal lid laceration should be inspected to its depth. These lacerations should, if deep or "through and through," be closed in three layers including conjunctiva, levator aponeurosis, and skin. Scarrjng from a horizontal lid laceration is not a significant factor because of naturally occurring horizontal skin folds found in the upper lid. Upper lid skin loss can be up to 50 per cent without serious complications because of the abundant loose skin in the upper lid area. Vertical lid lacerations present a completely different problem. Such lacerations usually include the lid margin or gray line, a structure which is found just inside the row of lashes. Vertical lid lacerations should always be closed with the lid margin puckering outward (toward the palpebral opening) to avoid post repair "notching" of the upper lid margin. The "figure of 8" suture of Mustarde (Fig. 2) provides a simple and effective means for repairing·a vertical upper lid laceration to avoid such lid notching. A vertical lid laceration occurring near the inner canthus may involve one or both of the canaliculi (Fig. 3). These structures must be repaired carefully at the time of initial repair. Late repair of a severed canaliculus rarely if ever results in adequate post injury functioning, that is, normal tear drainage. Both ends of a severed canaliculus must be identified and a stainless steel splint (Vier's rod) or other splinting
Figure 3.
Disruption of the lacrimal drainage system.
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device is placed bridging the severed canaliculus, keeping this fine, endothelially lined tube aligned during lid repair and during the process of healing. The rod is left in place for 10 days to two weeks. Canaliculus repair is best carried out using the operation microscope with 10 times to 16 times magnification. Dog bites of the upper lid which are not infrequent produce irregular, jagged, vertical lacerations which frequently involve the canaliculi. These injuries must be repaired applying the general surgical principles of plasdc repair pertaining to the closure of vertical lid lacerations plus special attention to the canaliculi. Blunt trauma, occurring most frequently in automobile accidents or after a blow such as could be delivered by a baseball bat or other large object, can cause disruption of the lower lacrimal drainage system (lacrimal duct) (Fig. 3). This usually occurs as part of a more extensive mid-facial fracture. The lacrimal duct which is in a long bony canal cannot be reopened successfully after such disruption. Injuries to the lacrimal duct which produce epiphora (tearing) require late treatment which consists of joining the lacrimal sac directly to the nose at a level just under the medial canthus tendon. This drainage operation is called dacryocystorhinostomy.
THE CONJUNCTIVA The conjunctiva lies on the inner surface of the eyelids and also covers the anterior part of the globe up to the cornea. The junction of the cornea and conjunctiva is called the limbus. The conjunctiva is susceptible to chemical injury ranging from mild chlorine irritation caused by swimming in pool water treated with this chemical to severe acid and alkali injuries. Mild irritation may be treated with a prophylactic antibacterial such as 10 per cent sodium sulfacetamide solution or ointment or if mild and chronic, with a mild decongestant and antiseptic solution such as Zincfrin, Albalon, or Visine, among others. The latter solutions may be obtained without prescription. Mild conjunctival irritation is not a serious problem. Severe conjunctival injury caused by strong acid or alkali requires immediate care consisting of copious irrigation for several minutes with water or saline. Follow-up care of such injuries should be supervised by an ophthalmologist and can be long, tedious, and disappointing. Laceration of the conjunctiva requires closure only if the laceration is relatively large (over 2 cm). If such a laceration must be repaired, 5-0 plain catgut or collagen suture is suitable for use. A benign but frightening injury to the conjunctiva is the subconjunctival hemorrhage. This occurs as a result of slight trauma or even as a result of a sneeze. This occurs when a small conjunctival blood vessel breaks. The resultant hemorrhage spreads in a thin sheet between the conjunctiva and sclera. This thin sheet can spread to cover one quarter to one half of the subconjunctival area. It does not spread over the cornea and does not affect the palpebral conjunctiva. A subconjunctival hemorrhage looks serious but is not. Like any bruise, the subcon-
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junctival hemorrhage goes through the usual stages of resolution from dark red through yellow until it finally clears. Subconjunctival hemorrhages clear completely in 14 days with treatment and in about 2 weeks without! As with bruising anywhere on the body, repeated unexplained subconjunctival hemorrhages should be a warning to look for systemic diseases including blood dyscrasias.
THE CORNEA The cornea is the window of the eye. Its most frequent injury is abrasion, with or without retained corneal foreign body. Most abrasions disrupt all or part of the corneal epithelium, a superficial corneal layer made up of five rows of cuboidal epithelial cells. The membrane of Bowman (a glass membrane immediately beneath the epithelium) may also be disrupted in deeper corneal abrasions exposing the corneal stroma. Disruptions of Bowman's membrane leads to some degree of permanent corneal scarring in every case. When the epithelium of the cornea is disrupted, bare corneal nerve endings are exposed (from the ophthalmic division of the fifth nerve) causing severe pain, and copious lacrimation. A corneal abrasion may be extremely painful, particularly if this abrasion is left untreated or is treated improperly. The causes of corneal abrasion are legion, ranging from an infant's fingernail, to a flying rock particle propelled by father's rotary lawn mower, to an errant tree branch in the forest, to a contact lens worn for too long a period of time, etc. A child with a corneal abrasion will present with a painful, usually red, tearing eye. In the acute stage the discharge is always clear, watery tears. Ptosis is often present and except when caused by something which affects both eyes at the same time such as exposure to ultraviolet radiation or contact lens overwearing, a corneal abrasion is unilateral. After obtaining a history from the patient or an adult informant, several drops of 0.5 per cent proparacaine hydrochloride should be placed on the cornea of the involved eye. Proparacaine hydrochloride drops provide instant, dramatic relief from the severe pain of a corneal abrasion. Visual acuity is then recorded for each eye. The cornea should then be inspected using magnification, preferably a slit lamp (biomicroscope) and at this time any remaining corneal foreign body should be removed. A fluorescein dyed paper strip should then be moistened and used to stain the cornea and conjunctiva a bright orange. In a darkened room, the cornea is then inspected using an ultraviolet lamp. Pools of dye which collect in disruptions of the cornea fluoresce under such light, outlining the extent of the corneal disruption. Treatment of a corneal abrasion should continue as follows: 1. The pupil is dilated and the ciliary muscles are relaxed by the instillation of mydriatic and cycloplegic drops. These drops should include Cyclogyl 1 per cent. Neo-Synephrine 10 per cent (for rapid short-acting dilatation), and homatropine 5 per cent (for longer lasting dilatation up to 48 hours). Atropine 1 per cent drops may cause dilatation and cycloplegia for up to two weeks so this should be avoided.
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2. Several drops of 10 per cent sodium sulfacetamide should be applied to the cornea of patients who have no sulfa allergies. If sulfa allergies are present Neo-Sporin or Chloromycetin drops may be used. 3. A tight patch is placed over the eye with special care being taken to insure that the lids are closed. The patch should be applied securely so that the eyelid remains closed with the patch in place. A loosely applied patch under which the lids may open freely can be more of a deterrent to healing than no patch at all. 4. Systemic analgesic should be given ranging from aspirin to meperidine (Demerol). The choice of systemic analgesic depends on the treating physician's appraisal of the patient's need. 5. Never prescribe or dispense topical anesthetic to the patient for home use! Because of the dramatic relief provided by such drops, the patient may be desirous of having them and the treating physician may be tempted to provide them. The use of such drops, however, is analogous to numbing a chronic smoker's fingers so he does not burn himself with the errant use of matches!
Two special types of corneal abrasions occur bilaterally. These result either after a half hour or so of exposure to ultraviolet light (welder's arc, psychedelic "black" lighting effects) or from overwearing of contact lenses. In either event, the corneal disruption with its accompanying pain and lacrimation occurs several hours after the incident and may seem to occur without explanation to the patient. Because the corneal problem has its beginning several hours after the actual cause of the injury, these patients usually present themselves in the small hours of the morning. Disruptions of the corneal epithelium caused by ultraviolet light or overwearing of contact lenses are treated exactly the same way as any corneal abrasion. One word of caution with regard to treatment of such injuries is that bilateral patching of the eyes can be a traumatic experience and if patching can be avoided in such a situation it should be. Laceration of the cornea may occur after trauma produced by any sharp object striking the anterior part of the eye. Such lacerations must be treated with careful suturing using the operation microscope (10 times to 25 times magnification) and employing sutures ranging in size from 7-0 to 10-0. After repair of a corneal laceration the pupil is dilated, prophylactic antibiotics are used and the eye is patched. Since repair of a corneal laceration must be carried out in an operating room with specialized instruments and very fine suture this is done by an ophthalmologist. When seen on an emergency basis, a corneal laceration is merely treated with the application of an eye patch. No drops or ointment should be placed in such an eye when seen initially. Great care should be exercised by the physician who examines the patient initially to avoid exerting unnecessary pressure on the globe. If the eyelids must be separated to inspect the eye, any pressure should be applied over the upper and lower orbital rim. Cotton tipped applicators can be useful for this. Pressure applied over the orbital rim can still be used to spread the lids, but no force is exerted on the globe itself. The injudicious application of force on an eye which is "open" can cause irreparable damage to the injured globe by causing extrusion of the contents of the globe. When a corneal laceration is encountered, the "two R's" must be applied, these are restraint and referral. Another type of corneal injury which is a product of our times is the
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tear gas injury. The ready availability of pen-sized tear gas guns for personal protection makes it possible for children to obtain these for injudicious play. If such a device discharges within a few inches of the eye, serious injury can result. These injuries are treated initially as is any chemical injury to the anterior part of the eye using copious irrigation with water or saline solution. Household ammonia, acids, soaps, and other household industrial liquids may find their way onto the cornea and anterior surface of the eye with ultimate results varying from mild irritation to complete blindness. To date, no specific agent or agents have been found which are a specific antidote to chemical injuries to the eye. The most effective method for treating such chemical injuries is their removal with copious irrigation. The eye may be placed under any source of running water including the kitchen faucets, garden hose, or shower. Every emergency room should have facilities for flushing the eye consisting of a large bottle of sodium chloride connected with intravenous tubing from which the needle has been removed. The late treatment of chemical injuries to the eye are usually carried out by the ophthalmologist and provide one of the more frustrating and discouraging aspects of the treatment of eye injury.
HYPHEMA Blunt contusion injury to the anterior part of the globe produces one of the most difficult to manage of all eye injuries - the hyphema or hemorrhage into the anterior chamber. This hemorrhage occurs because of rupture of a vessel or vessels in the iris or ciliary body. A varying amount of blood, from a small trace to a total filling of the anterior chamber then occurs. The severity of the hyphema is usually indicated by the amount of blood present in the anterior chamber. Trace amounts of blood in the anterior chamber may be absorbed in a day or so with only bed rest as treatment. In such a case no other problems are usually encountered. Larger hyphemas may fill the entire anterior chamber with blood. Regardless of the extent of hyphema, treatment is the same. Bedrest with or without sedation remains the most effective method for treatment. Although many combinations of dilating drops, constricting drops, bilateral patches, pinhole glasses, etc., have been tried, none has been shown superior to bedrest alone either at home or in the hospital. Spontaneous re-hemorrhage may occur after hyphema. If such spontaneous re-hemorrhage does occur, it usually does so within the first five days after the injury. For this reason, patients with hyphema should be watched closely in the early post injury period. Late sequelae of hyphema include glaucoma, cataract, iridodialysis, retinal detachment, etc. Anytime hyphema is seen, further investigation for choroidal, retinal, lenticular, or other globe damage should be carried out after the hyphema is cleared. One should always bear in mind that hyphema may only be the apparent manifestation of another, more serious injury. In some instances, acute glaucoma may accompany hyphema. When this occurs, the anterior chamber clot must be evacuated at surgery.
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THE LENS The lens of the eye is a frequent object of childhood ocular trauma. The lens may be injured by direct, penetrating trauma such as that which could be produced by a thin wire or nail, or by contusion. In either event, when there is disruption of the lens capsule a cataract is the result. Electrical shock may also be the cause of a cataract in childhood. A cataract is defined as any opacity in the crystalline lens. A very tiny opacity or cataract may be benign and require no treatment. An extensive cataract can reduce visual acuity to as low as light perception only and should be removed. Any cataract in childhood from trauma or other causes can be removed at any time that vision is significantly obstructed or if the integrity of the eye is placed in jeopardy by the inflammatory process associated with lens resorption. Newer techniques of lens discission and aspiration make the effective removal of a traumatic cataract safe, and visual rehabilitation with glasses or a contact lens is successful in most instances. One must bear in mind, however, that retinal damage may occur at the time the traumatic cataract is produced.
SYMP ATHETIC OPHTHALMIA Anytime a penetrating ocular injury with prolapse of the uveal tissue (iris or choroid) occurs, sympathetic ophthalmia (sympathetic uveitis) can occur. In this instance, the noninjured eye becomes seriously inflamed because of some unknown, exciting effect caused by the injured eye. Just how this inflammatory process starts or is mediated is not known. Once the inflammatory process starts in the involved eye, removal of the originally injured eye has no beneficial effect. If an extensively damaged eye is removed before 10 days to two weeks after the initial injury, the chance of sympathetic ophthalmia occurring is nearly eliminated. Therefore one should discourage retention of a severely damaged potentially blind eye. Such an eye is of no use to a person and may even be the cause of loss of the other eye and resultant total blindness.
INTRAOCULAR FOREIGN BODY Anytime that the eye is struck by a small size high velocity object, an intraocular foreign body must be suspected. Good or normal visual acuity may be retained even in the presence of such a foreign body. At other times, the ocular media may be cloudy immediately. If the ocular media is clear, careful examination of the anterior segment of the eye, the lens, and the retina should be carried out. If suspicion of an intraocular foreign body persists, an x-ray film should be obtained with special attention directed toward a radiopaque foreign body in the globe or orbit. Special techniques for localization of such foreign bodies can be carried out by the radiologist. Steel foreign bodies remaining in the eye may cause siderosis which in turn may lead to slow, progressive, irreparable intraocular damage.
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Penetration of the globe by any means can cause retinal detachment. If diagnosed properly and treated actively, retinal detachments in children can have a reasonably successful outcome.
BLOWOUT FRACTURE Blunt trauma to the globe can be transmitted to the floor or the medial wall of the orbit. The noncompressable orbital contents cause a "blowout" fracture of one or both of these walls. The floor, however, is the most commonly affected structure. The loss of support to the orbital contents caused by a fracture of the floor or medial wall of the orbit can in turn cause prolapse of orbital tissues into the adjoining area, usually the maxillary sinus. This can result in enophthalmos and restricted ocular motility. Diagnosis of blowout fracture is made by noting that the child has double vision and that the movement of the eye in one or more directions is restricted. Confirmation of a blowout fracture can be obtained by noting positive x-ray findings, but final confirmation should always be deferred until ophthalmologic consultation has been obtained. It must be remembered that the orbit is the container and the eye is the important structure! After an initial wave of enthusiasm for early, vigorous surgical repair of blowout fracture ophthalmologists have now concurred that in many instances more harm than good results from early repair. It is now considered prudent to wait up to two weeks before attempting repair of a blowout fracture in all cases except when severe enophthalmos is encountered. Early, ill-advised repair of blowout fracture has resulted in severely restricted ocular motility, scarring of the lower lid and conjunctiva, and even blindness. It should be stressed that blowout fracture repair should be carried out only if marked displacement of the globe is present or if significant restriction of ocular motility persists from 10 days to two weeks after the injury.
THE ORBITAL NERVES A serious type of ocular, or more correctly orbital injury, occurring in childhood is related to sharp objects which penetrate the orbit, damaging vital nerve structures at the orbital apex. A radio antenna, a nail, a stiff wire or other sharp, small caliber objects have been noted to penetrate the orbit and section nerves at the orbital apex including the optic and oculomotor nerves. The wound of entry is often inapparent, but the resulting effects are devastating to ocular movement and in some cases even vision. No treatment for such nerve injury has been successful. As with any deep penetrating injury tetanus prophylaxis should be carried out and the eye should be observed for infection. X-ray films of the orbit may also be obtained if a retained foreign body is suspected.
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PREVENTION As with any type of injury, prevention of childhood ocular injuries is the best "treatment." Children should be taught careful habits whenever possible. They should not be encouraged to play with functional guns which can propel objects at high rates of speed, and they should avoid careless play with pointed objects. Spring loaded rockets, and other types of projectile launches should also be avoided. Special attention should be given to the BB gun. This weapon in the opinion of many serves no useful purpose to mankind. To those who have cared for the devastating ocular injuries which can result from BB guns, it seems that this weapon exists only to kill birds and put out eyes. For this reason it would seem reasonable to outlaw or at least control the use of these guns but to date this has not been accomplished successfully. On a more positive note, our schools have done a good job in reducing the frequency and severity of eye injuries through the use of safety glasses for all hazardous activities, and safety glass is routinely used in prescription glasses.
. SUMMARY In summary, the following program should be useful for the physician who encounters a child with a suspected eye injury: 1. Obtain a history. What was the child doing when he hurt his eye? 2. Examine the child by first inspecting the lids. Evert the lids with a cotton tipped applicator if necessary and if the globe is intact. Look at the canalicular area and decide whether the lacrimal drainage system is disrupted. Is a lid laceration deep enough to affect the levator? Could the orbital rim or any bony structures be involved? Should an x-ray film for fracture or foreign body be obtained? Is the anterior segment of the globe intact? What is the condition of the conjunctiva and cornea? Should fluorescein stain be applied to the cornea in an attempt to determine the presence of corneal abrasion? Put prop~a.caine hydrochloride 0.5 per cent drops in the eye if it is too sensitive or photophobic to allow opening of the lids. Is there blood in the anterior chamber? Does the lens look opaque? Is the cornea lacerated, is the globe ruptured? Does the patient have double vision? Is the eye obviously displaced relative to the other eye? 3. Check visual acuity! Visual acuity may be checked initially or after examination of the eye, but some recording of the visual acuity should always be made. An elegant chart is not necessary. The child may be asked to identify letters on a prescription pad or merely record the presence of light, count fingers, etc., whichever is nearest maximal visual potential. 4. A decision should be made with regard to further diagnostic techniques including the decision, should an ophthalmologist be consulted? 5. Treat minimal anterior segment or adnexal injuries with or without consultation with an ophthalmologist.
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6. If the injury is extensive, resist the urge to do something immediately; merely patch the eye and put the child in the hands of an ophthalmologist.
REFERENCES 1. Emery, J. M., von Noorden, G. K., and Schlernitzour, D. S.: Orbital floor fractures. Trans. Amer. Acad. Ophthal. Otolaryng, 75:802, 1971. 2. Mustarde, J. C.: Repair and Reconstruction of the Orbital Region. Baltimore, Williams and Wilkins Co., 1966. 3. Paton, D., and Goldberg, M. F.: Injuries of the Eye, the Lids, and the Orbit. Philadelphia, W. B. Saunders Co., 1968. 4. Sullivan, G., and Helveston, E. M.: Optic atrophy after seemingly trivial trauma. Arch. Ophthal., 81 :159-161,1969. Department of Ophthalmology University of Indiana School of Medicine 1100 West Michigan Street Indianapolis, Indiana 46202
Eye Trauma in Childhood Eugene M. Helveston, MD.*
The eye may be injured by objects that are sharp or dull, of high or low velocity, and by chemicals and other forms of energy which enter the protective cage formed by the orbital rim. These injurious objects include solid projectiles which are a few centimeters or less in diameter, liquids or powder, and energy in the form of heat and light. Larger objects such as a ball, fist, large rock, etc., usually strike the bony orbital rim first and this structure absorbs the shock and protects the eye. The orbital rim may be fractured with or without additional facial fractures in the course of protecting the eye, and any time such a fracture occurs, careful examination of the eyes should be carried out. However, since facial fractures represent an entirely different subject, their diagnosis and treatment with the exception of orbital wall fractures is not ordinarily considered an eye injury. Eye injuries are usually limited to those which involve the globe itself, the soft tissue orbital adnexa including the lids and lacrimal apparatus and the orbital contents, including the optic nerve. As with injury to any part of the body, injury to the eye requires accurate diagnosis and prompt effective treatment. In most cases eye injuries can be diagnosed accurately and either definitive care, in the case of simple injuries, or early supportive care, in the case of more extensive injuries, canbe carried out by a general physician.
THE LIDS The eyelids serve as a useful and unique protective system for the eyes. They keep out excessive light when closed as in sleep, and they keep small windcborne foreign bodies from striking the front surface of the eye with a blink which is executed in only a fraction of a second. The lids further serve to lubricate the anterior part of the eye by means of accessory tear glands embedded in the back surface of the lids. Eyelid motion also produces a mechanical "pumping action" which helps move tears from the lacrimal area which is located under the upper, outer or'Associate Professor of Ophthalmology, University of Indiana School of Medicine, Indianapolis, Indiana Pediatric Clinics of North America- Vol. 22, No.2, May 1975
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bital rim downward across the eyes toward the tear duct system which is made up of the puncta and the canaliculi located medially on the eyelid margins. At the anterior surface of each of the eyelids are found the eyelashes. They serve as a screen or "cow catcher" functioning in a manner similar to the device found on old locomotives. The eyelashes screen out small particles before they hit the cornea and the conjunctiva. Injury to the lids can occur from any type of trauma that can affect skin anywhere on the body. Two particular types of injury which are significant include: contusion and laceration. Contusion to the eyelids can produce the well known "black eye." A blow to the lids often leads to the formation of great subcutaneous swelling. This occurs because the lids contain the least well supported and most susceptible to swelling tissue of the body. The swollen black eye has its dark color because of subcQtaneous hemorrhage. The extent of swelling with a black eye is usually limited by the attachments of the orbital septum to the rim of the orbit. However, the superficial lid swelling of a severe lid contusion call spread across the bridge of the nose and affect the lids of the uninvolvep. eye. This spread of swelling is not a serious condition. A black eye is nqt a joke. A black eye is not treated as is shown in the comic papers with the application of a raw beefsteak! When a black eye occurs the ey~ should be examined carefully for other injuries. Additional injuries which should be ruled out include: orbital rim fracture, orbital floor fracture, hyphema (blood in the anterior chamber), corneal abrasion, conjunctival laceration, lens displacement, cataract, retinal detachment, and globe rupture. The initial workup of any patient with eye injury should always include visual acuity testing in both eyes. This should be followed by an inspection of the lids and the globe. If any question persists about the possibility of rim or floor fracture, x-rays of the orbit should be obtained. If any injury more serious than a skin laceration, ecchymosis, superficial corneal or conjunctival abrasion is encountered or suspected, consultation with an ophthalmologist should be obtained. Treatment with oral enzyme is not especially helpful. Another significant injury that can involve the lid is laceration. Laceration of the lid may be primarily horizontal (Fig. 1) or vertical (Fig. 2), and each carries with it different implications. Horizontal lacerations frequently result in disruption of the levator palpebri, or upper lid
Figure 1.
Horizontal lid laceration.
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Figure 2.
Vertical lid laceration.
elevating muscle. This occurs when the aponeurosis of this muscle which connects it to the superior border of the tarsal plate and the undersurface of the upper lid skin is severed. An "artistic" skin closure of a horizontal lid laceration may be completed with total disregard for the fact that the levator palpebri muscle was severed. Nonunion of a lacerated levator muscle would of course cause a severe ptosis of the upper lid after healing. Because of swelling, ptosis or potential ptosis may be inapparent at the time of initial treatment. Any horizontal lid laceration should be inspected to its depth. These lacerations should, if deep or "through and through," be closed in three layers including conjunctiva, levator aponeurosis, and skin. Scarrjng from a horizontal lid laceration is not a significant factor because of naturally occurring horizontal skin folds found in the upper lid. Upper lid skin loss can be up to 50 per cent without serious complications because of the abundant loose skin in the upper lid area. Vertical lid lacerations present a completely different problem. Such lacerations usually include the lid margin or gray line, a structure which is found just inside the row of lashes. Vertical lid lacerations should always be closed with the lid margin puckering outward (toward the palpebral opening) to avoid post repair "notching" of the upper lid margin. The "figure of 8" suture of Mustarde (Fig. 2) provides a simple and effective means for repairing·a vertical upper lid laceration to avoid such lid notching. A vertical lid laceration occurring near the inner canthus may involve one or both of the canaliculi (Fig. 3). These structures must be repaired carefully at the time of initial repair. Late repair of a severed canaliculus rarely if ever results in adequate post injury functioning, that is, normal tear drainage. Both ends of a severed canaliculus must be identified and a stainless steel splint (Vier's rod) or other splinting
Figure 3.
Disruption of the lacrimal drainage system.
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device is placed bridging the severed canaliculus, keeping this fine, endothelially lined tube aligned during lid repair and during the process of healing. The rod is left in place for 10 days to two weeks. Canaliculus repair is best carried out using the operation microscope with 10 times to 16 times magnification. Dog bites of the upper lid which are not infrequent produce irregular, jagged, vertical lacerations which frequently involve the canaliculi. These injuries must be repaired applying the general surgical principles of plasdc repair pertaining to the closure of vertical lid lacerations plus special attention to the canaliculi. Blunt trauma, occurring most frequently in automobile accidents or after a blow such as could be delivered by a baseball bat or other large object, can cause disruption of the lower lacrimal drainage system (lacrimal duct) (Fig. 3). This usually occurs as part of a more extensive mid-facial fracture. The lacrimal duct which is in a long bony canal cannot be reopened successfully after such disruption. Injuries to the lacrimal duct which produce epiphora (tearing) require late treatment which consists of joining the lacrimal sac directly to the nose at a level just under the medial canthus tendon. This drainage operation is called dacryocystorhinostomy.
THE CONJUNCTIVA The conjunctiva lies on the inner surface of the eyelids and also covers the anterior part of the globe up to the cornea. The junction of the cornea and conjunctiva is called the limbus. The conjunctiva is susceptible to chemical injury ranging from mild chlorine irritation caused by swimming in pool water treated with this chemical to severe acid and alkali injuries. Mild irritation may be treated with a prophylactic antibacterial such as 10 per cent sodium sulfacetamide solution or ointment or if mild and chronic, with a mild decongestant and antiseptic solution such as Zincfrin, Albalon, or Visine, among others. The latter solutions may be obtained without prescription. Mild conjunctival irritation is not a serious problem. Severe conjunctival injury caused by strong acid or alkali requires immediate care consisting of copious irrigation for several minutes with water or saline. Follow-up care of such injuries should be supervised by an ophthalmologist and can be long, tedious, and disappointing. Laceration of the conjunctiva requires closure only if the laceration is relatively large (over 2 cm). If such a laceration must be repaired, 5-0 plain catgut or collagen suture is suitable for use. A benign but frightening injury to the conjunctiva is the subconjunctival hemorrhage. This occurs as a result of slight trauma or even as a result of a sneeze. This occurs when a small conjunctival blood vessel breaks. The resultant hemorrhage spreads in a thin sheet between the conjunctiva and sclera. This thin sheet can spread to cover one quarter to one half of the subconjunctival area. It does not spread over the cornea and does not affect the palpebral conjunctiva. A subconjunctival hemorrhage looks serious but is not. Like any bruise, the subcon-
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junctival hemorrhage goes through the usual stages of resolution from dark red through yellow until it finally clears. Subconjunctival hemorrhages clear completely in 14 days with treatment and in about 2 weeks without! As with bruising anywhere on the body, repeated unexplained subconjunctival hemorrhages should be a warning to look for systemic diseases including blood dyscrasias.
THE CORNEA The cornea is the window of the eye. Its most frequent injury is abrasion, with or without retained corneal foreign body. Most abrasions disrupt all or part of the corneal epithelium, a superficial corneal layer made up of five rows of cuboidal epithelial cells. The membrane of Bowman (a glass membrane immediately beneath the epithelium) may also be disrupted in deeper corneal abrasions exposing the corneal stroma. Disruptions of Bowman's membrane leads to some degree of permanent corneal scarring in every case. When the epithelium of the cornea is disrupted, bare corneal nerve endings are exposed (from the ophthalmic division of the fifth nerve) causing severe pain, and copious lacrimation. A corneal abrasion may be extremely painful, particularly if this abrasion is left untreated or is treated improperly. The causes of corneal abrasion are legion, ranging from an infant's fingernail, to a flying rock particle propelled by father's rotary lawn mower, to an errant tree branch in the forest, to a contact lens worn for too long a period of time, etc. A child with a corneal abrasion will present with a painful, usually red, tearing eye. In the acute stage the discharge is always clear, watery tears. Ptosis is often present and except when caused by something which affects both eyes at the same time such as exposure to ultraviolet radiation or contact lens overwearing, a corneal abrasion is unilateral. After obtaining a history from the patient or an adult informant, several drops of 0.5 per cent proparacaine hydrochloride should be placed on the cornea of the involved eye. Proparacaine hydrochloride drops provide instant, dramatic relief from the severe pain of a corneal abrasion. Visual acuity is then recorded for each eye. The cornea should then be inspected using magnification, preferably a slit lamp (biomicroscope) and at this time any remaining corneal foreign body should be removed. A fluorescein dyed paper strip should then be moistened and used to stain the cornea and conjunctiva a bright orange. In a darkened room, the cornea is then inspected using an ultraviolet lamp. Pools of dye which collect in disruptions of the cornea fluoresce under such light, outlining the extent of the corneal disruption. Treatment of a corneal abrasion should continue as follows: 1. The pupil is dilated and the ciliary muscles are relaxed by the instillation of mydriatic and cycloplegic drops. These drops should include Cyclogyl 1 per cent. Neo-Synephrine 10 per cent (for rapid short-acting dilatation), and homatropine 5 per cent (for longer lasting dilatation up to 48 hours). Atropine 1 per cent drops may cause dilatation and cycloplegia for up to two weeks so this should be avoided.
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2. Several drops of 10 per cent sodium sulfacetamide should be applied to the cornea of patients who have no sulfa allergies. If sulfa allergies are present Neo-Sporin or Chloromycetin drops may be used. 3. A tight patch is placed over the eye with special care being taken to insure that the lids are closed. The patch should be applied securely so that the eyelid remains closed with the patch in place. A loosely applied patch under which the lids may open freely can be more of a deterrent to healing than no patch at all. 4. Systemic analgesic should be given ranging from aspirin to meperidine (Demerol). The choice of systemic analgesic depends on the treating physician's appraisal of the patient's need. 5. Never prescribe or dispense topical anesthetic to the patient for home use! Because of the dramatic relief provided by such drops, the patient may be desirous of having them and the treating physician may be tempted to provide them. The use of such drops, however, is analogous to numbing a chronic smoker's fingers so he does not burn himself with the errant use of matches!
Two special types of corneal abrasions occur bilaterally. These result either after a half hour or so of exposure to ultraviolet light (welder's arc, psychedelic "black" lighting effects) or from overwearing of contact lenses. In either event, the corneal disruption with its accompanying pain and lacrimation occurs several hours after the incident and may seem to occur without explanation to the patient. Because the corneal problem has its beginning several hours after the actual cause of the injury, these patients usually present themselves in the small hours of the morning. Disruptions of the corneal epithelium caused by ultraviolet light or overwearing of contact lenses are treated exactly the same way as any corneal abrasion. One word of caution with regard to treatment of such injuries is that bilateral patching of the eyes can be a traumatic experience and if patching can be avoided in such a situation it should be. Laceration of the cornea may occur after trauma produced by any sharp object striking the anterior part of the eye. Such lacerations must be treated with careful suturing using the operation microscope (10 times to 25 times magnification) and employing sutures ranging in size from 7-0 to 10-0. After repair of a corneal laceration the pupil is dilated, prophylactic antibiotics are used and the eye is patched. Since repair of a corneal laceration must be carried out in an operating room with specialized instruments and very fine suture this is done by an ophthalmologist. When seen on an emergency basis, a corneal laceration is merely treated with the application of an eye patch. No drops or ointment should be placed in such an eye when seen initially. Great care should be exercised by the physician who examines the patient initially to avoid exerting unnecessary pressure on the globe. If the eyelids must be separated to inspect the eye, any pressure should be applied over the upper and lower orbital rim. Cotton tipped applicators can be useful for this. Pressure applied over the orbital rim can still be used to spread the lids, but no force is exerted on the globe itself. The injudicious application of force on an eye which is "open" can cause irreparable damage to the injured globe by causing extrusion of the contents of the globe. When a corneal laceration is encountered, the "two R's" must be applied, these are restraint and referral. Another type of corneal injury which is a product of our times is the
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tear gas injury. The ready availability of pen-sized tear gas guns for personal protection makes it possible for children to obtain these for injudicious play. If such a device discharges within a few inches of the eye, serious injury can result. These injuries are treated initially as is any chemical injury to the anterior part of the eye using copious irrigation with water or saline solution. Household ammonia, acids, soaps, and other household industrial liquids may find their way onto the cornea and anterior surface of the eye with ultimate results varying from mild irritation to complete blindness. To date, no specific agent or agents have been found which are a specific antidote to chemical injuries to the eye. The most effective method for treating such chemical injuries is their removal with copious irrigation. The eye may be placed under any source of running water including the kitchen faucets, garden hose, or shower. Every emergency room should have facilities for flushing the eye consisting of a large bottle of sodium chloride connected with intravenous tubing from which the needle has been removed. The late treatment of chemical injuries to the eye are usually carried out by the ophthalmologist and provide one of the more frustrating and discouraging aspects of the treatment of eye injury.
HYPHEMA Blunt contusion injury to the anterior part of the globe produces one of the most difficult to manage of all eye injuries - the hyphema or hemorrhage into the anterior chamber. This hemorrhage occurs because of rupture of a vessel or vessels in the iris or ciliary body. A varying amount of blood, from a small trace to a total filling of the anterior chamber then occurs. The severity of the hyphema is usually indicated by the amount of blood present in the anterior chamber. Trace amounts of blood in the anterior chamber may be absorbed in a day or so with only bed rest as treatment. In such a case no other problems are usually encountered. Larger hyphemas may fill the entire anterior chamber with blood. Regardless of the extent of hyphema, treatment is the same. Bedrest with or without sedation remains the most effective method for treatment. Although many combinations of dilating drops, constricting drops, bilateral patches, pinhole glasses, etc., have been tried, none has been shown superior to bedrest alone either at home or in the hospital. Spontaneous re-hemorrhage may occur after hyphema. If such spontaneous re-hemorrhage does occur, it usually does so within the first five days after the injury. For this reason, patients with hyphema should be watched closely in the early post injury period. Late sequelae of hyphema include glaucoma, cataract, iridodialysis, retinal detachment, etc. Anytime hyphema is seen, further investigation for choroidal, retinal, lenticular, or other globe damage should be carried out after the hyphema is cleared. One should always bear in mind that hyphema may only be the apparent manifestation of another, more serious injury. In some instances, acute glaucoma may accompany hyphema. When this occurs, the anterior chamber clot must be evacuated at surgery.
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THE LENS The lens of the eye is a frequent object of childhood ocular trauma. The lens may be injured by direct, penetrating trauma such as that which could be produced by a thin wire or nail, or by contusion. In either event, when there is disruption of the lens capsule a cataract is the result. Electrical shock may also be the cause of a cataract in childhood. A cataract is defined as any opacity in the crystalline lens. A very tiny opacity or cataract may be benign and require no treatment. An extensive cataract can reduce visual acuity to as low as light perception only and should be removed. Any cataract in childhood from trauma or other causes can be removed at any time that vision is significantly obstructed or if the integrity of the eye is placed in jeopardy by the inflammatory process associated with lens resorption. Newer techniques of lens discission and aspiration make the effective removal of a traumatic cataract safe, and visual rehabilitation with glasses or a contact lens is successful in most instances. One must bear in mind, however, that retinal damage may occur at the time the traumatic cataract is produced.
SYMP ATHETIC OPHTHALMIA Anytime a penetrating ocular injury with prolapse of the uveal tissue (iris or choroid) occurs, sympathetic ophthalmia (sympathetic uveitis) can occur. In this instance, the noninjured eye becomes seriously inflamed because of some unknown, exciting effect caused by the injured eye. Just how this inflammatory process starts or is mediated is not known. Once the inflammatory process starts in the involved eye, removal of the originally injured eye has no beneficial effect. If an extensively damaged eye is removed before 10 days to two weeks after the initial injury, the chance of sympathetic ophthalmia occurring is nearly eliminated. Therefore one should discourage retention of a severely damaged potentially blind eye. Such an eye is of no use to a person and may even be the cause of loss of the other eye and resultant total blindness.
INTRAOCULAR FOREIGN BODY Anytime that the eye is struck by a small size high velocity object, an intraocular foreign body must be suspected. Good or normal visual acuity may be retained even in the presence of such a foreign body. At other times, the ocular media may be cloudy immediately. If the ocular media is clear, careful examination of the anterior segment of the eye, the lens, and the retina should be carried out. If suspicion of an intraocular foreign body persists, an x-ray film should be obtained with special attention directed toward a radiopaque foreign body in the globe or orbit. Special techniques for localization of such foreign bodies can be carried out by the radiologist. Steel foreign bodies remaining in the eye may cause siderosis which in turn may lead to slow, progressive, irreparable intraocular damage.
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Penetration of the globe by any means can cause retinal detachment. If diagnosed properly and treated actively, retinal detachments in children can have a reasonably successful outcome.
BLOWOUT FRACTURE Blunt trauma to the globe can be transmitted to the floor or the medial wall of the orbit. The noncompressable orbital contents cause a "blowout" fracture of one or both of these walls. The floor, however, is the most commonly affected structure. The loss of support to the orbital contents caused by a fracture of the floor or medial wall of the orbit can in turn cause prolapse of orbital tissues into the adjoining area, usually the maxillary sinus. This can result in enophthalmos and restricted ocular motility. Diagnosis of blowout fracture is made by noting that the child has double vision and that the movement of the eye in one or more directions is restricted. Confirmation of a blowout fracture can be obtained by noting positive x-ray findings, but final confirmation should always be deferred until ophthalmologic consultation has been obtained. It must be remembered that the orbit is the container and the eye is the important structure! After an initial wave of enthusiasm for early, vigorous surgical repair of blowout fracture ophthalmologists have now concurred that in many instances more harm than good results from early repair. It is now considered prudent to wait up to two weeks before attempting repair of a blowout fracture in all cases except when severe enophthalmos is encountered. Early, ill-advised repair of blowout fracture has resulted in severely restricted ocular motility, scarring of the lower lid and conjunctiva, and even blindness. It should be stressed that blowout fracture repair should be carried out only if marked displacement of the globe is present or if significant restriction of ocular motility persists from 10 days to two weeks after the injury.
THE ORBITAL NERVES A serious type of ocular, or more correctly orbital injury, occurring in childhood is related to sharp objects which penetrate the orbit, damaging vital nerve structures at the orbital apex. A radio antenna, a nail, a stiff wire or other sharp, small caliber objects have been noted to penetrate the orbit and section nerves at the orbital apex including the optic and oculomotor nerves. The wound of entry is often inapparent, but the resulting effects are devastating to ocular movement and in some cases even vision. No treatment for such nerve injury has been successful. As with any deep penetrating injury tetanus prophylaxis should be carried out and the eye should be observed for infection. X-ray films of the orbit may also be obtained if a retained foreign body is suspected.
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PREVENTION As with any type of injury, prevention of childhood ocular injuries is the best "treatment." Children should be taught careful habits whenever possible. They should not be encouraged to play with functional guns which can propel objects at high rates of speed, and they should avoid careless play with pointed objects. Spring loaded rockets, and other types of projectile launches should also be avoided. Special attention should be given to the BB gun. This weapon in the opinion of many serves no useful purpose to mankind. To those who have cared for the devastating ocular injuries which can result from BB guns, it seems that this weapon exists only to kill birds and put out eyes. For this reason it would seem reasonable to outlaw or at least control the use of these guns but to date this has not been accomplished successfully. On a more positive note, our schools have done a good job in reducing the frequency and severity of eye injuries through the use of safety glasses for all hazardous activities, and safety glass is routinely used in prescription glasses.
. SUMMARY In summary, the following program should be useful for the physician who encounters a child with a suspected eye injury: 1. Obtain a history. What was the child doing when he hurt his eye? 2. Examine the child by first inspecting the lids. Evert the lids with a cotton tipped applicator if necessary and if the globe is intact. Look at the canalicular area and decide whether the lacrimal drainage system is disrupted. Is a lid laceration deep enough to affect the levator? Could the orbital rim or any bony structures be involved? Should an x-ray film for fracture or foreign body be obtained? Is the anterior segment of the globe intact? What is the condition of the conjunctiva and cornea? Should fluorescein stain be applied to the cornea in an attempt to determine the presence of corneal abrasion? Put prop~a.caine hydrochloride 0.5 per cent drops in the eye if it is too sensitive or photophobic to allow opening of the lids. Is there blood in the anterior chamber? Does the lens look opaque? Is the cornea lacerated, is the globe ruptured? Does the patient have double vision? Is the eye obviously displaced relative to the other eye? 3. Check visual acuity! Visual acuity may be checked initially or after examination of the eye, but some recording of the visual acuity should always be made. An elegant chart is not necessary. The child may be asked to identify letters on a prescription pad or merely record the presence of light, count fingers, etc., whichever is nearest maximal visual potential. 4. A decision should be made with regard to further diagnostic techniques including the decision, should an ophthalmologist be consulted? 5. Treat minimal anterior segment or adnexal injuries with or without consultation with an ophthalmologist.
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6. If the injury is extensive, resist the urge to do something immediately; merely patch the eye and put the child in the hands of an ophthalmologist.
REFERENCES 1. Emery, J. M., von Noorden, G. K., and Schlernitzour, D. S.: Orbital floor fractures. Trans. Amer. Acad. Ophthal. Otolaryng, 75:802, 1971. 2. Mustarde, J. C.: Repair and Reconstruction of the Orbital Region. Baltimore, Williams and Wilkins Co., 1966. 3. Paton, D., and Goldberg, M. F.: Injuries of the Eye, the Lids, and the Orbit. Philadelphia, W. B. Saunders Co., 1968. 4. Sullivan, G., and Helveston, E. M.: Optic atrophy after seemingly trivial trauma. Arch. Ophthal., 81 :159-161,1969. Department of Ophthalmology University of Indiana School of Medicine 1100 West Michigan Street Indianapolis, Indiana 46202