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Pediatric Eye Trauma
Symposium on Pediatric Ophthalmology
Pediatric Eye Trauma Lauri D. Ervin-Mulvey, M.D., Leonard B. Nelson, M.D., and Douglas A. Freeley, M.D.
Ocular trauma in childhood is a much more common cause of visual loss than is generally recognized. The National Society to Prevent Blindness estimates that 55 per cent of eye injuries occur prior to age 258 and that one-third of eye loss in the first decade of life is due to traumatic injury. 13 Eye injuries in young children have a significant impact in terms of long-term morbidity and thus are a matter of major socioeconomic importance.
GENERAL PRINCIPLES The diagnosis and treatment of eye injuries in children often pose a challenge. Sedation and even general anesthesia may be required to adequately examine a child. Such a detailed examination should be performed by an ophthalmologist with preparation for surgical repair if necessary. In the child who requires neurologic observation, general anesthesia may be contraindicated, further complicating the situation. Even after accurate diagnosis and treatment, ocular healing in a child may be accompanied by excessive fibrous tissue growth. This may have disastrous consequences in terms of visual prognosis. In addition, one must always remember that any patching of a young child's eye may produce amblyopia, even after several days. Thus, the twatment of children with eye trauma requires careful management with close follow-up to ensure maximum visual recovery. Chemical burns of the eye and occlusion (or impending occlusion) of the central retinal artery are the only true ocular emergencies; occlusion is rare in the pediatric age group. Ocular injuries that require medical attention in hours, not minutes, include severe lid lacerations, lacerations of the globe, hyphemas (blood in the anterior chamber), and intraocular foreign bodies. In this latter group of injuries there is ample time for thorough diagnostic evaluation and management procedures. When evaluating a child with an eye injury, the examiner must always From the Department of Pediatric Ophthalmology Wills Eye Hospital, Philadelphia, Pennsylvania
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make sure that an occult penetrating injury is not present. A child with a conjunctival hemorrhage may have a perforation of the globe that may be missed unless the conjunctiva is carefully inspected for defects. A superficial lid laceration may be sutured and an intraocular foreign body or retinal detachment left undetected. Finally, a thorough ocular examination is vital in the early recognition of associated intracranial damage, and the pupils of both eyes should be evaluated carefully.
EXAMINATION The examination of eye injuries in the pediatric age group may require considerable patience by the examiner. The papoose board may be a useful adjunct, especially in the very young child, although conventional examination techniques may suffice (Fig. 1). If the pediatrician, family practitioner, or emergency room physician has any suspicion that a child's eye has been penetrated or ruptured, no further examination attempt should be made. Instead, the physician should place a protective shield over the eye in such a way that no pressure is applied to the globe (Fig. 2). Pressure applied to an eye with a penetrating wound can cause prolapse of the intraocular content. Extensive examination of such an eye should be performed only by an ophthalmologist.
Figure l. The papoose board may assist the pediatrician in the examination of a young child.
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Figure 2. The eye is protected by a shield following a scleral rupture.
In evaluating children with eye injuries, the following steps are crucial: 1. Take a detailed history to obtain an exact picture of the circumstances and the instrument or chemical involved. The child may be able to give some account of the incident and should be gently questioned. Minor signs of external trauma may harbor severe intraocular injury, and so the history is important. 2. Measure the visual acuity of each eye separately, using the patient's corrective lenses if available. If only bedside examination is possible, obtain a near acuity using a standard vision card or get an estimate of the acuity by having the child read a book or identify pictures or toys. If massive conjunctival or lid edema prevents measurement of visual acuity, record a statement to that effect in the patient's chart. 3. Visual fields can be grossly estimated by confrontation with an object; this may uncover an unsuspected intracranial process or retinal detachment. 4. Examine the lids and adnexa carefully; determine the extent and depth of the injury, as well as the possible involvement of the lacrimal drainage system at the inner border of the lids. 5. Palpate the orbital rim, feeling for crepitus through the lids. This can indicate an orbital or nasal fracture. Appraise the real or apparent displacement of the globe with respect to the lateral orbital rim, using clinical inspection from the patient's side or from above. 6. Examine the pupils and record their size, shape, and reaction to light.
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7. Carefully examine the conjunctiva to detect lacerations, foreign bodies, or underlying scleral perforation. 8. Examine the cornea under magnification, if possible, with a Woo.d' s lamp or slit lamp. Use fluorescein paper to stain the cornea and a Wood's lamp or slit lamp to delineate the abrasion (Fig. 3). 9. Evaluate the anterior chamber for iritis, pus (hypopyon), blood (hyphema), or tremulousness of the iris (iridodenesis) associated with a dislocated lens. 10. Mter the possibility of a perforation has been eliminated, evaluate the ocular motility of both eyes. 11. Obtain x-ray studies whenever the possibility exists of an orbital fracture or a retained foreign body in the globe or orbit. 12. A topical anesthetic may make the exam easier and the child more comfortable. Do not prescribe them or allow the parents to take a bottle home because their continued use can retard healing and promote corneal infection. LID AND LACRIMAL DRAINAGE SYSTEM TRAUMA The eyelids serve as a protective covering for the eyes. They also help lubricate the anterior part of the eye through the accessory tear glands located in the back surface of the lids. In any trauma to the lid a careful evaluation of the extent of the injury must be performed. A thorough search should be made for trauma to the lacrimal drainage system, foreign bodies, and occult perforations of the globe. The physician should consider prophylactic antibiotics and tetanus immunization in all lid lacerations, and prophylaxis against rabies in the situation of a dog bite causing a lid laceration. Lid lacerations may present with startling disfigurement (Fig. 4). Careless and poorly plann,ed repairs prove to be disfiguring on a long-term basis. We strongly feel that, except for superficial lacerations, all brow and lid lacerations in children should be repaired by someone trained in their management.
Figure 3. A Wood's light will help delineate a corneal abrasion following instillation of fluorescein.
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Figure 4. Extensively damaged upper lid without loss of tissue. This injury was caused by dog bite. (From Peyman, G. A., Sanders, D. R., and Goldberg, M. F.: Principles and Practice of Ophthalmology. Philadelphia, W. B. Saunders Co., 1980.)
Lacerations involving the medial fourth of the lid may impair tear drainage to the nose. Lacerations to the puncta, canaliculi, or lacrimal sac may not be recognized initially and may be inadequately repaired. Therefore, in any lid laceration to the medial canthal area, one must have a high index of suspicion of possible trauma to the lacrimal drainage system. An experienced ophthalmic surgeon should evaluate all such children and perform a canalicular anastomosis with the use of a microscope if necessary.
BLOWOUT FRACTURES Blowout fractures are produced when a blunt object (such as a baseball or fist) strikes the orbit and causes a sudden increase in intraorbital pressure (Fig. 5). The force applied to the relatively incompressible soft tissues of the orbit is transferred to the bony orbital walls. The medial wall (lamina papyracea) and the orbital floor (roof of the maxillary antrum) are the weakest bones of the orbit and are most frequently damaged. 14 Orbitalfloor fractures may result in incarceration of orbital fat, the inferior rectus muscle, the inferior oblique muscle, or a combination of these structures. The involvement of these two extraocular muscles helps explain the restriction of vertical ocular motility in blowout fractures (Fig. 6). Extensive ecchymosis of the lids and congestion of the orbital contents may be present. Hemorrhage or edema within the orbit may also produce limitation of ocular movements and even early proptosis of the globe. Following a careful history and examination, the physician should obtain x-ray studies of the orbit. Radiologic evaluation demands meticulous positioning and exposure, which may be difficult in a young child. It is mandatory that the history and the presumptive diagnosis be explained to the radiology team. Frequently, x-rays of suspected blowout fracture are
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Figure 5. Blow-out fracture of orbital floor. The dotted line indicates normal position of globe. Inferior oblique and inferior rectus muscles are restrained by incarcerated orbital tissues. (From Feyman, G. A., Sanders, D. R., and Goldberg, M. F.: Principles and Practice of Ophthalmology. Philadelphia, W. B. Saunders Co., 1980.)
Figure 6. Entrapment of the inferior rectus prevented elevation of the left eye (upper). Vertical alignment is normal in primary gaze (middle). Contusion injury to the inferior rectus also prevents full depression of the left eye.
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negative or equivocal, even when an obvious floor fracture is diagnosed clinically. Therefore, repeat x-ray studies with additional views and polytomography may be necessary to localize the precise fracture site. Blowout fractures are seldom, if ever, emergencies. Once the possibility of an intraocular injury is ruled out, a conservative approach is indicated. It is important to reduce swelling with ice during the first 24 hours. Heat is then applied during the next 24 to 48 hours. The use of oral antibiotics (such as a cephalosporin or erythromycin) is a helpful adjunct when sinus disease may contaminate a blowout fracture. Conservative management is usually indicated for seven to 14 days. Because the surgical management of blowout fractures is controversial, no one form of treatment prevails. However, since posttraumatic and postsurgical complications are ophthalmologic, it is imperative that the ophthalmologist be directly involved in the management of all children with blowout fractures.
INJURIES OF THE CONJUNCTIVA
The conjunctiva, a mucous membrane, forms the inner surface of the eyelids and covers the anterior part of the globe up to the cornea. In any trauma to the conjunctiva, one must examine carefully for occult perforations of the globe as well as for the possibility of a foreign body. A thorough investigation of the conjunctiva is accomplished most successfully with the aid of the high magnification of a slit lamp. Conjunctival hemorrhage, another problem in the pediatric age group, is rarely spontaneous except in hematologic disorders. However, in the setting of ocular trauma, it is quite frequent. Subconjunctival hemorrhage occurs when a small conjunctival blood vessel breaks. The resulting hemorrhage usually spreads between the conjunctiva and sclera. The hemorrhage in itself is of no consequence, except that it may obscure an associated foreign body or a small perforation of the globe (Fig. 7). Subconjunctival hemorrhages, which generally appear darker than more superficial hemorrhages, may cause swelling of the conjunctiva between the lids. This can lead to corneal exposure, requiring lubrication with an ointment. Ice compresses applied during the first 24 hours may hasten the regression of the swelling. Subconjunctival hemorrhages usually clear without treatment in about two weeks. They go through the usual stages of resolution from dark red through yellow until they finally clear.
INTRAMUSCULAR HEMORRHAGE AND MUSCLE DISINSERTION
There are six muscles that rotate the eyeball. Blunt orbital trauma or direct trauma to these extraocular muscles may result in hematoma within the muscle or actual disinsertion of the muscle from the globe. This may prevent normal function of a muscle (contraction and relaxation). Therefore, the normal movement of the eye in the direction of the involved muscle may be severely limited and difficult to differentiate clinically from neurogenic paresis. All such children should be referred to an ophthalmol-
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Figure 7. Conjunctival hemorrhage. A, Post-traumatic conjunctival hemorrhage without other ocular or orbital damage. B, Post-traumatic conjunctival hemorrhage from blunt injury, with a small hyphema (arrow). In this case, injury was significant because of presence of blood in anterior chamber. (From Peyman, G. A., Sanders, D. R., and Goldberg, M. F.: Principles and Practice of Ophthalmology. Philadelphia, W. B. Saunders Co., 1980.)
ogist for further examination. A definitive diagnosis of muscle disinsertion may still not be possible clinically but would be based on the findings at the time of surgical exploration.
INJURIES TO THE GLOBE Corneal Abrasion and Foreign Bodies The cornea forms the window of the eye. It is composed of six distinct layers: (1) tear film, (2) epithelium, (3) Bowman's membrane, (4) stroma,
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(5) Descemet' s membrane, and (6) endothelium. It is transparent under normal conditions because of the special arrangement of cells and collagenous fibrils and the absence of a vascular bed. Corneal epithelial defects--or abrasions-are extremely common in the pediatric age group. They may be caused by a foreign body caught under the upper lid or by a scratch from a toy or a fingernail (Fig. 8). Corneal abrasions can be quite painful because of exposure of the cornea's sensory nerve endings. The child may present with lacrimation, photophobia, severe blepharospasm, and blurring of vision. For adequate examination of a patient with a possible corneal abrasion, a topical anesthetic is applied to relieve the ocular discomfort. Since corneal abrasions are commonly caused by a foreign body, a careful search should be undertaken. Eversion of the upper lid is a useful technique that physicians should know how to perform. After the instillation of a topical anesthetic, the upper lid is grasped by the central lashes and is pulled downward; the patient is instructed to look down as well. The examiner's finger or a cotton-tipped applicator is then placed with slight pressure at the upper end of the tarsus (marked by the most prominent skin fold), and the lid margin is flipped into an everted position. If a foreign body is identified either under the upper or lower lid or on the cornea itself, it can usually be removed by forceful irrigation from a plastic squeeze bottle containing balanced salt solution or by a cottontipped applicator. Occasionally a foreign body is deeply embedded in the cornea, and removal requires high magnification and the use of a fine
Figure 8. Common location for air-borne dust particles is tarsal conjunctiva (arrow). Vertical "scratch marks" on cornea are demonstrated with fluorescein staining and suggest tarsal location of foreign body. No anesthetic solution is required for removal of foreign body on tarsal conjunctiva with cotton-tipped applicator, and eye patching is unnecessary in most cases. (From Peyman, G. A., Sanders, D. R., and Goldberg, M.F.: Principles and Practice of Ophthalmology. Philadelphia, W. B. Saunders Co., 1980.)
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needle (Fig. 9). In a child, it may require hospitalization and the use of an operating-room microscope. This procedure should be performed by an ophthalmologist. If no foreign body is found, fluorescein staining can delineate diffuse punctate or focal corneal abrasions. A drop of sterile saline is placed on a fluorescein strip and touched to the palpebral conjunctiva. A Wood's lamp is a valuable instrument for inspecting the cornea for defects. It demonstrates a corneal abrasion by showing a green stain wherever an epithelial defect has collected fluorescein. Corneal abrasions are treated with a moderate-acting cycloplegic, such as Cyclogyl 1 per cent or homatropine 2 per cent. This will alleviate the discomfort from ciliary spasm. A broad-spectrum antibiotic ointment is used to prevent potential infections. This ointment must not contain a steroid preparation, since steroids retard re-epithelialization and promote corneal infection and ulceration. A semi-pressure patch is applied to the eye and taped to the forehead and cheek to relieve discomfort and to allow the epithelial defect to heal. This is made by taking two eye pads and folding one in half. The folded pad is placed over the closed eye. The second eye pad is then placed fully opened on top of the first pad and taped securely to the forehead and cheek. In the pediatric patient, the lids themselves may be directly taped shut to further reduce lid movement. Corneal abrasions heal relatively quickly, usually within 24 hours. However, the patient should be seen for follow-up care the day after injury. Under no circumstances should the patient be maintained on a topical anesthetic, because it retards epithelial healing. 2 Recurrent corneal abrasions or erosions are seen in the pediatric age group and usually represent inadequate epithelialization secondary to lid movement. These are managed by the ophthalmologist by repeated patching or by the placement of a theraputic soft contact lens.
Figure 9. A rust ring surrounds an embedded metallic foreign body on cornea (arrow). (From Peyman, G. A., Sanders, D. R., and Goldberg, M. F.: Principles and Practice of Ophthalmology. Philadelphia, W. B. Saunders Co., 1980.)
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Chemical Burns of the Eye and Adnexa Chemical burns are one of the few true ocular emergencies. The effects of alkalies and acids on ocular tissues are often severe, bilateral, and all too frequent in young people; they may result in significant visual loss or even loss of an eye. Common household agents may cause chemical injuries to the eye (Table 1)9 ; therefore, children are very vulnerable. Alkali burns are usually more damaging to ocular structures than acids. Acids quickly precipitate tissue proteins and result in an injury that is usually more superficial and slower to penetrate the cornea. Alkaline compounds, on the other hand, increase the hydroxyl-ion concentration beyond the limits of tissue-protein stability. They react with fats to form soaps that damage all membranes, allowing rapid penetration deep into the tissues of the eye. The initial treatment for chemical burns of the eye is copious irrigation with water from the nearest available source (drinking fountain, shower, or faucet). Irrigation should be repeated once the child arrives in the hospital emergency room. For adequate benefit from irrigation, the lids should be held apart manually or with a lid retractor. Irrigation should continue for 20 to 30 minutes with normal saline (at least 1000 to 2000 ml) connected to an intravenous tubing set. To determine neutrality, pH paper (pH of tears is between 7.3 and 7. 7) can assist the pediatrician or emergency room physician in treating acidic or basic burns.1 6 The use of pH paper at the onset of irrigation can indicate the relative acidity or alkalinity of solutions in questionable cases. This may be helpful prognostically. Effective irrigation may be facilitated by instillation of a topical anesthetic to ease the patient's discomfort. Systemic analgesics and sedation may be necessary to accomplish effective irrigation in children. Once irrigation has been initiated, a careful investigation of the forTable 1.
Common Household Agents Capable of Causing Eye Burns
Household ammonia (ammonium hydroxide 7%) Other ammonia-containing agents, i.e., window cleaner and jewelry cleaner Scouring cleaners Deodorizing cleaners Disinfectants Toilet bowl cleaners Lye/sodium hydroxide and other drain cleaners Automotive cleaners and degreasers Whitewall tire cleaners Electric dishwasher detergents Lime (calcium hydroxide) and plaster Chlorine for swimming pools Swimming-pool tile cleaners Bleaches
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nices should be performed to detect and remove excess debris. Double-lid eversion and swabbing of the conjunctival recesses with a cotton-tipped applicator should be done in a search for caustic material that could cause additional ocular damage. After irrigation and debridement, a cycloplegic agent is instilled. Atropine 1 per cent is an excellent choice because of its prolonged cycloplegic effect. This reduces the possibility of posterior synechiae (adhesions of the iris to the lens) and ciliary spasm. Infection in an inflamed eye with surface defects and necrotic avascular conjunctiva is a constant threat. Therefore, topical antibiotics, especially against gram-negative organisms, should begin as soon as irrigation and debridement are completed. Above all, an opthalmologist's involvement early in the care of all children with extensive facial chemical burns is essential. Corneal and Scleral Lacerations All cases of ocular trauma must be evaluated carefully for possible penetrating or perforating injuries of the globe (Fig. 10). A penetrating injury refers to a partial thickness laceration of the cornea or sclera that does not involve the entire thickness of these structures. A perforating injury, however, is a complete through-and-through wound of the sclera or cornea. When the pediatrician has determined (or is suspicious) that an eye is lacerated, pressure on the globe must be avoided. The eye should be protected by a shield and the patient referred to an ophthalmologist. The patient should have orbital x-rays to establish the presence or absence of an intraocular or orbital foreign body. Tetanus immunization, broad-spectrum systemic antibiotics, and patient preparation for general anesthesia are initiated promptly when a laceration of the globe is confirmed by an ophthalmologist.
ANTERIOR SEGMENT TRAUMA Traumatic Hyphema Hyphema, or the accumulation of free blood in the anterior chamber, is frequently encountered in children (Fig. 11). It may be caused by a variety of objects and is produced by a rupture of iris or cilliary body blood vessels. Children with hyphemas may present initially to the pediatrician or family practitioner, and these physicians should recognize this condition. Most hyphemas fill less than one-third of the anterior chamber; they usually last five to six days. 1° For an unknown reason, the presence of blood in the anterior chamber (especially in children) can produce drowsiness. However, if a child with a hyphema shows marked somnolence, the presence of associated neurologic trauma must be ruled out. Spontaneous hyphemas can also occur in children with juvenile xanthogranuloma, retinoblastoma, SS or SC disease. These entities must be considered in a child in whom no history of eye trauma is elicited. The management of hyphemas is still controversial. Most children with hyphemas are hospitalized for daily observation by the ophthalmolo-
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Figure 10. Scleral perforation. A, tirow puncture is indicated by arrow. B, Underlying occult perforation of globe. Lower arrow indicates superior limbus; upper arrow shows scleral puncture, initially overlooked. A clue to presence of ocular damage is conjunctival hemorrhage best seen in A. (From Peyman, G. A., Sanders, D. R., and Goldberg, M. F.: Principles and Practice of Ophthalmology. Philadelphia, W. B. Saunders Co., 1980.)
Figure 11. Blood in the anterior chamber (hyphema) obscures iris detail below. (Drawn by Karen Albert.)
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gist. There is no definitive data to support the benefit of strict bed restll and binocular patching. 1 In the absence of definitive guidelines, the use of topical or systemic medications remains arbitrary. Complications of hyphema include rebleeding (usually between the fourth and fifth day), severe elevation in intraocular pressure, corneal bloodstaining (which can cause amblyopia) and the formation of a "black ball" hyphema which can fail to resorb. Surgical evacuation of a hyphema is indicated when medical therapy to control pressure fails or when corneal blood staining or persistent clot formation supervenes. Over the ensuing years, a small percentage of children with resolved hyphemas will develop an increase in intraocular pressure. These children must be followed on a long-term basis to detect this potential complication. 19 Trauma to the Lens After the resolution of ocular trauma, the development of a cataract may ultimately deny the child a good visual outcome. A traumati.c cataract, which is usually unilateral, is considered the most common lens opacity in the young. 7 An ophthalmologist can extract these traumatic cataracts in children. The child will need either corrective glasses or a contact lens, and possibly patching of the good eye to ensure full visual recovery.
POSTERIOR SEGMENT TRAUMA Vitreous Hemorrhage Following ocular trauma, hemorrhage into the vitreous of the eye may result from damage to retinal vessels. The chief symptom is usually a sudden, severe loss of vision. The hemorrhage may obscure fundus details on ophthalmoscopic evaluation. If the hemorrhage is dense enough, the red reflex may be absent when using a hand-held light or ophthalmoscope. After the hemorrhage has cleared, a careful examination of the retinal periphery should be performed by an ophthalmologist. This is extremely important, because a retinal break or detachment may accompany a vitreous hemorrhage. Recently, microsurgical techniques have been developed to remove large amounts of abnormal vitreous. Traumatic Retinal Detachment Ocular trauma is the most common cause of retinal detachment in children. The median age is approximately 15 years, with a statistically significant preponderance of males (84.6 per cent). A dialysis (a tear at the ora serrata or the most peripheral area of the retina) is the most common cause of traumatic retinal detachment. Since many of these detachments originate in the retinal periphery, they may cause few ocular symptoms initially. A unique characteristic of this type of detachment is the latency period that often occurs between the time of trauma and the detection of the detachment (17.3 months). 15 These children require surgical repair by an ophthalmologist trained in retinal surgery.
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Intraocular and Intraorbital Foreign Bodies Whenever ocular trauma results in a laceration of the lids or possible penetrating injury to the globe, the presence of a foreign body must be excluded. A painstaking examination must be performed to detect the location of a foreign body and to assess the associated ocular damage. An intraocular or intraorbital foreign body may be localized in several ways. An ophthalmoscopic examination may detect an intraocular foreign body and should be performed as soon as possible after the injury. In many cases, x-ray examination is necessary, especially if the ocular media is hazy, as would be expected with a traumatic cataract, hyphema, or vitreous hemorrhage. Ophthalmic ultrasound is helpful in localizing intraocular foreign bodies. Once the presence and location of a foreign body is established, the ophthalmologist must decide whether a conservative or surgical approach is necessary. OCULAR TRAUMA IN SPORTS
Ocular trauma during sports poses a major threat to school age children in the United States. During 1976, approximately 165,000 traumatic eye injuries occurred in school children between the ages of five and 17.18 Many of these injuries resulted in time lost from school and, in some cases, permanent total disability of an eye. Analysis of eye injuries in school children has shown that approximately two-thirds of the accidents occurred during play or sports activities. 6 Children suffer from a wide range of sports-related eye injuries. A review of 147 eye injuries referred from general ophthalmologic practices indicated the following sports involved in severe eye injuries, in decreasing order: 12 hockey, archery, darts, and BB guns. Other sports-related eye injuries resulted from bicycling, motorcycling, racquet sports, baseball, boxing, and basketball. The types of injuries included hyphema, retinal detachment, vitreous hemorrhage, traumatic cataract, and perforation of the globe. Many of these sports-related eye injuries were preventable. The Canadian experience has shown that legislative efforts can decrease eye injuries in children when instituted on a national scale. The mandatory use of a facial mask and a rule that disallows the use of the stick above the shoulder has significantly decreased annual eye injuries in hockey in Canada.l 7 In the year prior to this legislation, there were 253 hockey-related eye injuries in Canada with 37 eyes legally blind. This figure dropped to 90 injuries in 1976--1977, with only 12 eyes legally blind. In eighty-three of these injuries, the player was wearing no protection. Public education and adequate legislation could reduce the incidence in children of eye injuries caused by bows and arrows, darts, and BB guns. OCULAR MANIFESTATIONS OF CHILD ABUSE
The battered-child syndrome has received increasing attention as a major pediatric problem. The increased awareness of the ocular signs of
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child abuse has emphasized this additional source of eye trauma in children. In 1966, estimates indicated that between 10,000 and 15,000 children in the United States suffered nonaccidental injuries5 ; presently, this estimate is between 75,000 and 100,000 cases annually. 4 Approximately 40 per cent of affected children have associated ocular findings, with 6 per cent initially evaluated by an ophthalmologist. 3 Intraocular hemorrhage, often associated with intracranial bleeding, is the most common ocular finding in the battered-child syndrome. Although many cases of intraocular hemorrhage clear without complication, some may lead to atrophy of the optic nerve, macular scarring, or retinal detachment (Fig. 12). Periorbital swelling and ecchymoses, hyphemas, cataracts, and dislocated lenses may also result from direct ocular trauma. In summary, the spectrum of ocular findings in child abuse includes virtually every type of eye injury. The pediatrician or family practitioner should be suspicious whenever an eye injury cannot be explained adequately, or the parents' history is incompatible with the degree of eye damage. The findings of fractures and soft-tissue injuries in various stages of healing or cigarette burns and/or human bites to the skin should help confirm the diagnosis. Prompt involvement by the ophthalmologist is necessary for maximal visual recovery in these unfortunate children.
Figure 12. Subretinal hematoma in macular area. Resolution of such hemorrhage, although often requiring several weeks, may be followed in rare cases by restoration of vision. (From Peyman, G. A., Sanders, D. R., and Goldberg, M. F.: Principles and Practice of Ophthalmology. Philadelphia, W. B. Saunders Co., 1980.)
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REFERENCES 1. Edwards, W. C., and Layden, W. E.: Monocular versus binocular patching in traumatic hyphema. Am. J. Ophthalmol., 76:359, 1973. 2. Epstein, D. C., and Paton, D.: Keratitis from misuse of corneal anesthetics. N. Engl. J. Med., 279:396, 1968. 3. Friendly, D. S.: Ocular manifestations of physical child abuse. Trans. Am. Acad. Ophthalmol. Otolaryngol., 75:318, 1971. 4. Harley, R. D.: Ocular manifestations of child abuse. J. Pediatr. Ophthalmol. Strabismus, 17:5, 1980. 5. Helfer, R., and Pollack, C.: The battered child syndrome. Adv. Pediatr., 15:9, 1968. 6. Kerby, C. E.: Eye accidents to school children. Sight Sav. Rev., 20:11, 1950. 7. Luntz, M. H.: Clinical Types of Cataracts. In Duane, T. D., and Jaeger, E. A. (eds.): Clinical Ophthalmology. Vol. 1. Hagerstown, MD, Harper & Row, 1982. 8. National Society to Prevent Blindness: Vision Problems in the United States. New York, 1980, pp. 32-33. 9. Ralph, R. A.: Chemical Burns of the Eye. In Duane, T. D., and Jaeger, E. A. (eds.): Clinical Ophthalmology. Vol. 4. Hagerstown, MD, Harper & Row, 1982. 10. Read, J. E.: Trauma: Ruptures and Bleeding. In Duane, T. D.; and Jaeger, E. A. (eds.): Clinical Ophthalmology. Vol. 4. Hagerstown, MD, Harper & Row, 1982. 11. Read, J., and Goldberg, M. F.: Comparison of medical treatment for traumatic hyphema. Trans. Am. Acad. Ophthalmol. Otolaryngol., 78:799, 1974. 12. Rousseau, A. P.: Ocular Trauma in Sports. In Freeman, H. M. (ed.): Ocular Trauma. New York, Appleton-Century-Crofts, 1979. 13. Slusher, M. M., and Keeney, A. H.: Monocular blindness: Analysis of etiology and preventive needs in 424 patients. Sight Sav. Rev., 35:207, 1965. 14. Smith, B., and Regan, W. F., Jr.: Blowout fracture of the orbit: Mechanism and correction of internal orbital fracture. Am. J. Ophthalmol., 44:733, 1957. 15. Tasman, W.: Retinal dialysis following blunt trauma. In Freeman, H. M. (ed.): Ocular Trauma. New York, Appleton-Century-Crofts, 1979. 16. Tenzel, R. R.: Trauma and burns. Int. Ophthalmol. Clin., 10:55, 1970. 17. Vinger, P. R.: The incidence of eye injuries in sports. Int. Ophthalrnol. Clin., 21:21, 1981. 18. Vinger, P. F.: The prevention of ocular trauma in sports. In Freeman, H. M. (ed.): Ocular Trauma. New York, Appleton-Century-Crofts, 1979. 19. Yanoff, M., and Fine, B. S.: Ocular Pathology. Hagerstown, MD, Harper & Row, 1975, pp. 143--177.
Department of Pediatric Ophthalmology Wills Eye Hospital Ninth and Walnut Streets Philadelphia, Pennsylvania 19107 (Dr. Nelson)
Pediatric Eye Trauma Lauri D. Ervin-Mulvey, M.D., Leonard B. Nelson, M.D., and Douglas A. Freeley, M.D.
Ocular trauma in childhood is a much more common cause of visual loss than is generally recognized. The National Society to Prevent Blindness estimates that 55 per cent of eye injuries occur prior to age 258 and that one-third of eye loss in the first decade of life is due to traumatic injury. 13 Eye injuries in young children have a significant impact in terms of long-term morbidity and thus are a matter of major socioeconomic importance.
GENERAL PRINCIPLES The diagnosis and treatment of eye injuries in children often pose a challenge. Sedation and even general anesthesia may be required to adequately examine a child. Such a detailed examination should be performed by an ophthalmologist with preparation for surgical repair if necessary. In the child who requires neurologic observation, general anesthesia may be contraindicated, further complicating the situation. Even after accurate diagnosis and treatment, ocular healing in a child may be accompanied by excessive fibrous tissue growth. This may have disastrous consequences in terms of visual prognosis. In addition, one must always remember that any patching of a young child's eye may produce amblyopia, even after several days. Thus, the twatment of children with eye trauma requires careful management with close follow-up to ensure maximum visual recovery. Chemical burns of the eye and occlusion (or impending occlusion) of the central retinal artery are the only true ocular emergencies; occlusion is rare in the pediatric age group. Ocular injuries that require medical attention in hours, not minutes, include severe lid lacerations, lacerations of the globe, hyphemas (blood in the anterior chamber), and intraocular foreign bodies. In this latter group of injuries there is ample time for thorough diagnostic evaluation and management procedures. When evaluating a child with an eye injury, the examiner must always From the Department of Pediatric Ophthalmology Wills Eye Hospital, Philadelphia, Pennsylvania
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make sure that an occult penetrating injury is not present. A child with a conjunctival hemorrhage may have a perforation of the globe that may be missed unless the conjunctiva is carefully inspected for defects. A superficial lid laceration may be sutured and an intraocular foreign body or retinal detachment left undetected. Finally, a thorough ocular examination is vital in the early recognition of associated intracranial damage, and the pupils of both eyes should be evaluated carefully.
EXAMINATION The examination of eye injuries in the pediatric age group may require considerable patience by the examiner. The papoose board may be a useful adjunct, especially in the very young child, although conventional examination techniques may suffice (Fig. 1). If the pediatrician, family practitioner, or emergency room physician has any suspicion that a child's eye has been penetrated or ruptured, no further examination attempt should be made. Instead, the physician should place a protective shield over the eye in such a way that no pressure is applied to the globe (Fig. 2). Pressure applied to an eye with a penetrating wound can cause prolapse of the intraocular content. Extensive examination of such an eye should be performed only by an ophthalmologist.
Figure l. The papoose board may assist the pediatrician in the examination of a young child.
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Figure 2. The eye is protected by a shield following a scleral rupture.
In evaluating children with eye injuries, the following steps are crucial: 1. Take a detailed history to obtain an exact picture of the circumstances and the instrument or chemical involved. The child may be able to give some account of the incident and should be gently questioned. Minor signs of external trauma may harbor severe intraocular injury, and so the history is important. 2. Measure the visual acuity of each eye separately, using the patient's corrective lenses if available. If only bedside examination is possible, obtain a near acuity using a standard vision card or get an estimate of the acuity by having the child read a book or identify pictures or toys. If massive conjunctival or lid edema prevents measurement of visual acuity, record a statement to that effect in the patient's chart. 3. Visual fields can be grossly estimated by confrontation with an object; this may uncover an unsuspected intracranial process or retinal detachment. 4. Examine the lids and adnexa carefully; determine the extent and depth of the injury, as well as the possible involvement of the lacrimal drainage system at the inner border of the lids. 5. Palpate the orbital rim, feeling for crepitus through the lids. This can indicate an orbital or nasal fracture. Appraise the real or apparent displacement of the globe with respect to the lateral orbital rim, using clinical inspection from the patient's side or from above. 6. Examine the pupils and record their size, shape, and reaction to light.
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7. Carefully examine the conjunctiva to detect lacerations, foreign bodies, or underlying scleral perforation. 8. Examine the cornea under magnification, if possible, with a Woo.d' s lamp or slit lamp. Use fluorescein paper to stain the cornea and a Wood's lamp or slit lamp to delineate the abrasion (Fig. 3). 9. Evaluate the anterior chamber for iritis, pus (hypopyon), blood (hyphema), or tremulousness of the iris (iridodenesis) associated with a dislocated lens. 10. Mter the possibility of a perforation has been eliminated, evaluate the ocular motility of both eyes. 11. Obtain x-ray studies whenever the possibility exists of an orbital fracture or a retained foreign body in the globe or orbit. 12. A topical anesthetic may make the exam easier and the child more comfortable. Do not prescribe them or allow the parents to take a bottle home because their continued use can retard healing and promote corneal infection. LID AND LACRIMAL DRAINAGE SYSTEM TRAUMA The eyelids serve as a protective covering for the eyes. They also help lubricate the anterior part of the eye through the accessory tear glands located in the back surface of the lids. In any trauma to the lid a careful evaluation of the extent of the injury must be performed. A thorough search should be made for trauma to the lacrimal drainage system, foreign bodies, and occult perforations of the globe. The physician should consider prophylactic antibiotics and tetanus immunization in all lid lacerations, and prophylaxis against rabies in the situation of a dog bite causing a lid laceration. Lid lacerations may present with startling disfigurement (Fig. 4). Careless and poorly plann,ed repairs prove to be disfiguring on a long-term basis. We strongly feel that, except for superficial lacerations, all brow and lid lacerations in children should be repaired by someone trained in their management.
Figure 3. A Wood's light will help delineate a corneal abrasion following instillation of fluorescein.
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Figure 4. Extensively damaged upper lid without loss of tissue. This injury was caused by dog bite. (From Peyman, G. A., Sanders, D. R., and Goldberg, M. F.: Principles and Practice of Ophthalmology. Philadelphia, W. B. Saunders Co., 1980.)
Lacerations involving the medial fourth of the lid may impair tear drainage to the nose. Lacerations to the puncta, canaliculi, or lacrimal sac may not be recognized initially and may be inadequately repaired. Therefore, in any lid laceration to the medial canthal area, one must have a high index of suspicion of possible trauma to the lacrimal drainage system. An experienced ophthalmic surgeon should evaluate all such children and perform a canalicular anastomosis with the use of a microscope if necessary.
BLOWOUT FRACTURES Blowout fractures are produced when a blunt object (such as a baseball or fist) strikes the orbit and causes a sudden increase in intraorbital pressure (Fig. 5). The force applied to the relatively incompressible soft tissues of the orbit is transferred to the bony orbital walls. The medial wall (lamina papyracea) and the orbital floor (roof of the maxillary antrum) are the weakest bones of the orbit and are most frequently damaged. 14 Orbitalfloor fractures may result in incarceration of orbital fat, the inferior rectus muscle, the inferior oblique muscle, or a combination of these structures. The involvement of these two extraocular muscles helps explain the restriction of vertical ocular motility in blowout fractures (Fig. 6). Extensive ecchymosis of the lids and congestion of the orbital contents may be present. Hemorrhage or edema within the orbit may also produce limitation of ocular movements and even early proptosis of the globe. Following a careful history and examination, the physician should obtain x-ray studies of the orbit. Radiologic evaluation demands meticulous positioning and exposure, which may be difficult in a young child. It is mandatory that the history and the presumptive diagnosis be explained to the radiology team. Frequently, x-rays of suspected blowout fracture are
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Figure 5. Blow-out fracture of orbital floor. The dotted line indicates normal position of globe. Inferior oblique and inferior rectus muscles are restrained by incarcerated orbital tissues. (From Feyman, G. A., Sanders, D. R., and Goldberg, M. F.: Principles and Practice of Ophthalmology. Philadelphia, W. B. Saunders Co., 1980.)
Figure 6. Entrapment of the inferior rectus prevented elevation of the left eye (upper). Vertical alignment is normal in primary gaze (middle). Contusion injury to the inferior rectus also prevents full depression of the left eye.
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negative or equivocal, even when an obvious floor fracture is diagnosed clinically. Therefore, repeat x-ray studies with additional views and polytomography may be necessary to localize the precise fracture site. Blowout fractures are seldom, if ever, emergencies. Once the possibility of an intraocular injury is ruled out, a conservative approach is indicated. It is important to reduce swelling with ice during the first 24 hours. Heat is then applied during the next 24 to 48 hours. The use of oral antibiotics (such as a cephalosporin or erythromycin) is a helpful adjunct when sinus disease may contaminate a blowout fracture. Conservative management is usually indicated for seven to 14 days. Because the surgical management of blowout fractures is controversial, no one form of treatment prevails. However, since posttraumatic and postsurgical complications are ophthalmologic, it is imperative that the ophthalmologist be directly involved in the management of all children with blowout fractures.
INJURIES OF THE CONJUNCTIVA
The conjunctiva, a mucous membrane, forms the inner surface of the eyelids and covers the anterior part of the globe up to the cornea. In any trauma to the conjunctiva, one must examine carefully for occult perforations of the globe as well as for the possibility of a foreign body. A thorough investigation of the conjunctiva is accomplished most successfully with the aid of the high magnification of a slit lamp. Conjunctival hemorrhage, another problem in the pediatric age group, is rarely spontaneous except in hematologic disorders. However, in the setting of ocular trauma, it is quite frequent. Subconjunctival hemorrhage occurs when a small conjunctival blood vessel breaks. The resulting hemorrhage usually spreads between the conjunctiva and sclera. The hemorrhage in itself is of no consequence, except that it may obscure an associated foreign body or a small perforation of the globe (Fig. 7). Subconjunctival hemorrhages, which generally appear darker than more superficial hemorrhages, may cause swelling of the conjunctiva between the lids. This can lead to corneal exposure, requiring lubrication with an ointment. Ice compresses applied during the first 24 hours may hasten the regression of the swelling. Subconjunctival hemorrhages usually clear without treatment in about two weeks. They go through the usual stages of resolution from dark red through yellow until they finally clear.
INTRAMUSCULAR HEMORRHAGE AND MUSCLE DISINSERTION
There are six muscles that rotate the eyeball. Blunt orbital trauma or direct trauma to these extraocular muscles may result in hematoma within the muscle or actual disinsertion of the muscle from the globe. This may prevent normal function of a muscle (contraction and relaxation). Therefore, the normal movement of the eye in the direction of the involved muscle may be severely limited and difficult to differentiate clinically from neurogenic paresis. All such children should be referred to an ophthalmol-
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Figure 7. Conjunctival hemorrhage. A, Post-traumatic conjunctival hemorrhage without other ocular or orbital damage. B, Post-traumatic conjunctival hemorrhage from blunt injury, with a small hyphema (arrow). In this case, injury was significant because of presence of blood in anterior chamber. (From Peyman, G. A., Sanders, D. R., and Goldberg, M. F.: Principles and Practice of Ophthalmology. Philadelphia, W. B. Saunders Co., 1980.)
ogist for further examination. A definitive diagnosis of muscle disinsertion may still not be possible clinically but would be based on the findings at the time of surgical exploration.
INJURIES TO THE GLOBE Corneal Abrasion and Foreign Bodies The cornea forms the window of the eye. It is composed of six distinct layers: (1) tear film, (2) epithelium, (3) Bowman's membrane, (4) stroma,
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(5) Descemet' s membrane, and (6) endothelium. It is transparent under normal conditions because of the special arrangement of cells and collagenous fibrils and the absence of a vascular bed. Corneal epithelial defects--or abrasions-are extremely common in the pediatric age group. They may be caused by a foreign body caught under the upper lid or by a scratch from a toy or a fingernail (Fig. 8). Corneal abrasions can be quite painful because of exposure of the cornea's sensory nerve endings. The child may present with lacrimation, photophobia, severe blepharospasm, and blurring of vision. For adequate examination of a patient with a possible corneal abrasion, a topical anesthetic is applied to relieve the ocular discomfort. Since corneal abrasions are commonly caused by a foreign body, a careful search should be undertaken. Eversion of the upper lid is a useful technique that physicians should know how to perform. After the instillation of a topical anesthetic, the upper lid is grasped by the central lashes and is pulled downward; the patient is instructed to look down as well. The examiner's finger or a cotton-tipped applicator is then placed with slight pressure at the upper end of the tarsus (marked by the most prominent skin fold), and the lid margin is flipped into an everted position. If a foreign body is identified either under the upper or lower lid or on the cornea itself, it can usually be removed by forceful irrigation from a plastic squeeze bottle containing balanced salt solution or by a cottontipped applicator. Occasionally a foreign body is deeply embedded in the cornea, and removal requires high magnification and the use of a fine
Figure 8. Common location for air-borne dust particles is tarsal conjunctiva (arrow). Vertical "scratch marks" on cornea are demonstrated with fluorescein staining and suggest tarsal location of foreign body. No anesthetic solution is required for removal of foreign body on tarsal conjunctiva with cotton-tipped applicator, and eye patching is unnecessary in most cases. (From Peyman, G. A., Sanders, D. R., and Goldberg, M.F.: Principles and Practice of Ophthalmology. Philadelphia, W. B. Saunders Co., 1980.)
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needle (Fig. 9). In a child, it may require hospitalization and the use of an operating-room microscope. This procedure should be performed by an ophthalmologist. If no foreign body is found, fluorescein staining can delineate diffuse punctate or focal corneal abrasions. A drop of sterile saline is placed on a fluorescein strip and touched to the palpebral conjunctiva. A Wood's lamp is a valuable instrument for inspecting the cornea for defects. It demonstrates a corneal abrasion by showing a green stain wherever an epithelial defect has collected fluorescein. Corneal abrasions are treated with a moderate-acting cycloplegic, such as Cyclogyl 1 per cent or homatropine 2 per cent. This will alleviate the discomfort from ciliary spasm. A broad-spectrum antibiotic ointment is used to prevent potential infections. This ointment must not contain a steroid preparation, since steroids retard re-epithelialization and promote corneal infection and ulceration. A semi-pressure patch is applied to the eye and taped to the forehead and cheek to relieve discomfort and to allow the epithelial defect to heal. This is made by taking two eye pads and folding one in half. The folded pad is placed over the closed eye. The second eye pad is then placed fully opened on top of the first pad and taped securely to the forehead and cheek. In the pediatric patient, the lids themselves may be directly taped shut to further reduce lid movement. Corneal abrasions heal relatively quickly, usually within 24 hours. However, the patient should be seen for follow-up care the day after injury. Under no circumstances should the patient be maintained on a topical anesthetic, because it retards epithelial healing. 2 Recurrent corneal abrasions or erosions are seen in the pediatric age group and usually represent inadequate epithelialization secondary to lid movement. These are managed by the ophthalmologist by repeated patching or by the placement of a theraputic soft contact lens.
Figure 9. A rust ring surrounds an embedded metallic foreign body on cornea (arrow). (From Peyman, G. A., Sanders, D. R., and Goldberg, M. F.: Principles and Practice of Ophthalmology. Philadelphia, W. B. Saunders Co., 1980.)
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Chemical Burns of the Eye and Adnexa Chemical burns are one of the few true ocular emergencies. The effects of alkalies and acids on ocular tissues are often severe, bilateral, and all too frequent in young people; they may result in significant visual loss or even loss of an eye. Common household agents may cause chemical injuries to the eye (Table 1)9 ; therefore, children are very vulnerable. Alkali burns are usually more damaging to ocular structures than acids. Acids quickly precipitate tissue proteins and result in an injury that is usually more superficial and slower to penetrate the cornea. Alkaline compounds, on the other hand, increase the hydroxyl-ion concentration beyond the limits of tissue-protein stability. They react with fats to form soaps that damage all membranes, allowing rapid penetration deep into the tissues of the eye. The initial treatment for chemical burns of the eye is copious irrigation with water from the nearest available source (drinking fountain, shower, or faucet). Irrigation should be repeated once the child arrives in the hospital emergency room. For adequate benefit from irrigation, the lids should be held apart manually or with a lid retractor. Irrigation should continue for 20 to 30 minutes with normal saline (at least 1000 to 2000 ml) connected to an intravenous tubing set. To determine neutrality, pH paper (pH of tears is between 7.3 and 7. 7) can assist the pediatrician or emergency room physician in treating acidic or basic burns.1 6 The use of pH paper at the onset of irrigation can indicate the relative acidity or alkalinity of solutions in questionable cases. This may be helpful prognostically. Effective irrigation may be facilitated by instillation of a topical anesthetic to ease the patient's discomfort. Systemic analgesics and sedation may be necessary to accomplish effective irrigation in children. Once irrigation has been initiated, a careful investigation of the forTable 1.
Common Household Agents Capable of Causing Eye Burns
Household ammonia (ammonium hydroxide 7%) Other ammonia-containing agents, i.e., window cleaner and jewelry cleaner Scouring cleaners Deodorizing cleaners Disinfectants Toilet bowl cleaners Lye/sodium hydroxide and other drain cleaners Automotive cleaners and degreasers Whitewall tire cleaners Electric dishwasher detergents Lime (calcium hydroxide) and plaster Chlorine for swimming pools Swimming-pool tile cleaners Bleaches
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nices should be performed to detect and remove excess debris. Double-lid eversion and swabbing of the conjunctival recesses with a cotton-tipped applicator should be done in a search for caustic material that could cause additional ocular damage. After irrigation and debridement, a cycloplegic agent is instilled. Atropine 1 per cent is an excellent choice because of its prolonged cycloplegic effect. This reduces the possibility of posterior synechiae (adhesions of the iris to the lens) and ciliary spasm. Infection in an inflamed eye with surface defects and necrotic avascular conjunctiva is a constant threat. Therefore, topical antibiotics, especially against gram-negative organisms, should begin as soon as irrigation and debridement are completed. Above all, an opthalmologist's involvement early in the care of all children with extensive facial chemical burns is essential. Corneal and Scleral Lacerations All cases of ocular trauma must be evaluated carefully for possible penetrating or perforating injuries of the globe (Fig. 10). A penetrating injury refers to a partial thickness laceration of the cornea or sclera that does not involve the entire thickness of these structures. A perforating injury, however, is a complete through-and-through wound of the sclera or cornea. When the pediatrician has determined (or is suspicious) that an eye is lacerated, pressure on the globe must be avoided. The eye should be protected by a shield and the patient referred to an ophthalmologist. The patient should have orbital x-rays to establish the presence or absence of an intraocular or orbital foreign body. Tetanus immunization, broad-spectrum systemic antibiotics, and patient preparation for general anesthesia are initiated promptly when a laceration of the globe is confirmed by an ophthalmologist.
ANTERIOR SEGMENT TRAUMA Traumatic Hyphema Hyphema, or the accumulation of free blood in the anterior chamber, is frequently encountered in children (Fig. 11). It may be caused by a variety of objects and is produced by a rupture of iris or cilliary body blood vessels. Children with hyphemas may present initially to the pediatrician or family practitioner, and these physicians should recognize this condition. Most hyphemas fill less than one-third of the anterior chamber; they usually last five to six days. 1° For an unknown reason, the presence of blood in the anterior chamber (especially in children) can produce drowsiness. However, if a child with a hyphema shows marked somnolence, the presence of associated neurologic trauma must be ruled out. Spontaneous hyphemas can also occur in children with juvenile xanthogranuloma, retinoblastoma, SS or SC disease. These entities must be considered in a child in whom no history of eye trauma is elicited. The management of hyphemas is still controversial. Most children with hyphemas are hospitalized for daily observation by the ophthalmolo-
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Figure 10. Scleral perforation. A, tirow puncture is indicated by arrow. B, Underlying occult perforation of globe. Lower arrow indicates superior limbus; upper arrow shows scleral puncture, initially overlooked. A clue to presence of ocular damage is conjunctival hemorrhage best seen in A. (From Peyman, G. A., Sanders, D. R., and Goldberg, M. F.: Principles and Practice of Ophthalmology. Philadelphia, W. B. Saunders Co., 1980.)
Figure 11. Blood in the anterior chamber (hyphema) obscures iris detail below. (Drawn by Karen Albert.)
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gist. There is no definitive data to support the benefit of strict bed restll and binocular patching. 1 In the absence of definitive guidelines, the use of topical or systemic medications remains arbitrary. Complications of hyphema include rebleeding (usually between the fourth and fifth day), severe elevation in intraocular pressure, corneal bloodstaining (which can cause amblyopia) and the formation of a "black ball" hyphema which can fail to resorb. Surgical evacuation of a hyphema is indicated when medical therapy to control pressure fails or when corneal blood staining or persistent clot formation supervenes. Over the ensuing years, a small percentage of children with resolved hyphemas will develop an increase in intraocular pressure. These children must be followed on a long-term basis to detect this potential complication. 19 Trauma to the Lens After the resolution of ocular trauma, the development of a cataract may ultimately deny the child a good visual outcome. A traumati.c cataract, which is usually unilateral, is considered the most common lens opacity in the young. 7 An ophthalmologist can extract these traumatic cataracts in children. The child will need either corrective glasses or a contact lens, and possibly patching of the good eye to ensure full visual recovery.
POSTERIOR SEGMENT TRAUMA Vitreous Hemorrhage Following ocular trauma, hemorrhage into the vitreous of the eye may result from damage to retinal vessels. The chief symptom is usually a sudden, severe loss of vision. The hemorrhage may obscure fundus details on ophthalmoscopic evaluation. If the hemorrhage is dense enough, the red reflex may be absent when using a hand-held light or ophthalmoscope. After the hemorrhage has cleared, a careful examination of the retinal periphery should be performed by an ophthalmologist. This is extremely important, because a retinal break or detachment may accompany a vitreous hemorrhage. Recently, microsurgical techniques have been developed to remove large amounts of abnormal vitreous. Traumatic Retinal Detachment Ocular trauma is the most common cause of retinal detachment in children. The median age is approximately 15 years, with a statistically significant preponderance of males (84.6 per cent). A dialysis (a tear at the ora serrata or the most peripheral area of the retina) is the most common cause of traumatic retinal detachment. Since many of these detachments originate in the retinal periphery, they may cause few ocular symptoms initially. A unique characteristic of this type of detachment is the latency period that often occurs between the time of trauma and the detection of the detachment (17.3 months). 15 These children require surgical repair by an ophthalmologist trained in retinal surgery.
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Intraocular and Intraorbital Foreign Bodies Whenever ocular trauma results in a laceration of the lids or possible penetrating injury to the globe, the presence of a foreign body must be excluded. A painstaking examination must be performed to detect the location of a foreign body and to assess the associated ocular damage. An intraocular or intraorbital foreign body may be localized in several ways. An ophthalmoscopic examination may detect an intraocular foreign body and should be performed as soon as possible after the injury. In many cases, x-ray examination is necessary, especially if the ocular media is hazy, as would be expected with a traumatic cataract, hyphema, or vitreous hemorrhage. Ophthalmic ultrasound is helpful in localizing intraocular foreign bodies. Once the presence and location of a foreign body is established, the ophthalmologist must decide whether a conservative or surgical approach is necessary. OCULAR TRAUMA IN SPORTS
Ocular trauma during sports poses a major threat to school age children in the United States. During 1976, approximately 165,000 traumatic eye injuries occurred in school children between the ages of five and 17.18 Many of these injuries resulted in time lost from school and, in some cases, permanent total disability of an eye. Analysis of eye injuries in school children has shown that approximately two-thirds of the accidents occurred during play or sports activities. 6 Children suffer from a wide range of sports-related eye injuries. A review of 147 eye injuries referred from general ophthalmologic practices indicated the following sports involved in severe eye injuries, in decreasing order: 12 hockey, archery, darts, and BB guns. Other sports-related eye injuries resulted from bicycling, motorcycling, racquet sports, baseball, boxing, and basketball. The types of injuries included hyphema, retinal detachment, vitreous hemorrhage, traumatic cataract, and perforation of the globe. Many of these sports-related eye injuries were preventable. The Canadian experience has shown that legislative efforts can decrease eye injuries in children when instituted on a national scale. The mandatory use of a facial mask and a rule that disallows the use of the stick above the shoulder has significantly decreased annual eye injuries in hockey in Canada.l 7 In the year prior to this legislation, there were 253 hockey-related eye injuries in Canada with 37 eyes legally blind. This figure dropped to 90 injuries in 1976--1977, with only 12 eyes legally blind. In eighty-three of these injuries, the player was wearing no protection. Public education and adequate legislation could reduce the incidence in children of eye injuries caused by bows and arrows, darts, and BB guns. OCULAR MANIFESTATIONS OF CHILD ABUSE
The battered-child syndrome has received increasing attention as a major pediatric problem. The increased awareness of the ocular signs of
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child abuse has emphasized this additional source of eye trauma in children. In 1966, estimates indicated that between 10,000 and 15,000 children in the United States suffered nonaccidental injuries5 ; presently, this estimate is between 75,000 and 100,000 cases annually. 4 Approximately 40 per cent of affected children have associated ocular findings, with 6 per cent initially evaluated by an ophthalmologist. 3 Intraocular hemorrhage, often associated with intracranial bleeding, is the most common ocular finding in the battered-child syndrome. Although many cases of intraocular hemorrhage clear without complication, some may lead to atrophy of the optic nerve, macular scarring, or retinal detachment (Fig. 12). Periorbital swelling and ecchymoses, hyphemas, cataracts, and dislocated lenses may also result from direct ocular trauma. In summary, the spectrum of ocular findings in child abuse includes virtually every type of eye injury. The pediatrician or family practitioner should be suspicious whenever an eye injury cannot be explained adequately, or the parents' history is incompatible with the degree of eye damage. The findings of fractures and soft-tissue injuries in various stages of healing or cigarette burns and/or human bites to the skin should help confirm the diagnosis. Prompt involvement by the ophthalmologist is necessary for maximal visual recovery in these unfortunate children.
Figure 12. Subretinal hematoma in macular area. Resolution of such hemorrhage, although often requiring several weeks, may be followed in rare cases by restoration of vision. (From Peyman, G. A., Sanders, D. R., and Goldberg, M. F.: Principles and Practice of Ophthalmology. Philadelphia, W. B. Saunders Co., 1980.)
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REFERENCES 1. Edwards, W. C., and Layden, W. E.: Monocular versus binocular patching in traumatic hyphema. Am. J. Ophthalmol., 76:359, 1973. 2. Epstein, D. C., and Paton, D.: Keratitis from misuse of corneal anesthetics. N. Engl. J. Med., 279:396, 1968. 3. Friendly, D. S.: Ocular manifestations of physical child abuse. Trans. Am. Acad. Ophthalmol. Otolaryngol., 75:318, 1971. 4. Harley, R. D.: Ocular manifestations of child abuse. J. Pediatr. Ophthalmol. Strabismus, 17:5, 1980. 5. Helfer, R., and Pollack, C.: The battered child syndrome. Adv. Pediatr., 15:9, 1968. 6. Kerby, C. E.: Eye accidents to school children. Sight Sav. Rev., 20:11, 1950. 7. Luntz, M. H.: Clinical Types of Cataracts. In Duane, T. D., and Jaeger, E. A. (eds.): Clinical Ophthalmology. Vol. 1. Hagerstown, MD, Harper & Row, 1982. 8. National Society to Prevent Blindness: Vision Problems in the United States. New York, 1980, pp. 32-33. 9. Ralph, R. A.: Chemical Burns of the Eye. In Duane, T. D., and Jaeger, E. A. (eds.): Clinical Ophthalmology. Vol. 4. Hagerstown, MD, Harper & Row, 1982. 10. Read, J. E.: Trauma: Ruptures and Bleeding. In Duane, T. D.; and Jaeger, E. A. (eds.): Clinical Ophthalmology. Vol. 4. Hagerstown, MD, Harper & Row, 1982. 11. Read, J., and Goldberg, M. F.: Comparison of medical treatment for traumatic hyphema. Trans. Am. Acad. Ophthalmol. Otolaryngol., 78:799, 1974. 12. Rousseau, A. P.: Ocular Trauma in Sports. In Freeman, H. M. (ed.): Ocular Trauma. New York, Appleton-Century-Crofts, 1979. 13. Slusher, M. M., and Keeney, A. H.: Monocular blindness: Analysis of etiology and preventive needs in 424 patients. Sight Sav. Rev., 35:207, 1965. 14. Smith, B., and Regan, W. F., Jr.: Blowout fracture of the orbit: Mechanism and correction of internal orbital fracture. Am. J. Ophthalmol., 44:733, 1957. 15. Tasman, W.: Retinal dialysis following blunt trauma. In Freeman, H. M. (ed.): Ocular Trauma. New York, Appleton-Century-Crofts, 1979. 16. Tenzel, R. R.: Trauma and burns. Int. Ophthalmol. Clin., 10:55, 1970. 17. Vinger, P. R.: The incidence of eye injuries in sports. Int. Ophthalrnol. Clin., 21:21, 1981. 18. Vinger, P. F.: The prevention of ocular trauma in sports. In Freeman, H. M. (ed.): Ocular Trauma. New York, Appleton-Century-Crofts, 1979. 19. Yanoff, M., and Fine, B. S.: Ocular Pathology. Hagerstown, MD, Harper & Row, 1975, pp. 143--177.
Department of Pediatric Ophthalmology Wills Eye Hospital Ninth and Walnut Streets Philadelphia, Pennsylvania 19107 (Dr. Nelson)