During his inpatient rotation, a pediatric resident assisted in caring for two patients with traumatic ocular injuries.
The first patient was a 3-year-old male who was playing “dress-up” with his sisters. A plastic hair barrette broke and caused a penetrating right globe injury.
The local emergency medical technicians placed an eye shield and he was transported to the local emergency room. He was then transferred to a local children’s hospital for ophthalmological care where he underwent surgery for a prolapse of the right iris.
The second patient was a 5-year old male who was a restrained passenger in the front seat of a car involved in a motor vehicle accident. He was hit in the face by the air bag and sustained injuries to both eyes.
The left eye had a detached retina that required vitrectomy, lensectomy and retinal reattachment.
The diagnosis of ocular trauma was easily made in both cases. The resident used the Internet and PubMed to review literature on the epidemiology of pediatric ocular injuries and the American Academy of Pediatrics recommendations for prevention of these injuries.
The first patient’s clinical course showed him to have some amblyopia and minor decreased vision at 8 months after injury.
The second patient’s clinical course showed him to be able to count fingers with his left eye and had normal vision in his right eye. He required several other surgeries. Both patients were wearing safety glasses daily to prevent additional injuries.
Ocular trauma is unfortunately a common problem. Eighty percent involve contusions to the external ocular tissues or are nonperforating anterior segment trauma.
Below are some indications for ophthalmological consultation and notes about treatment and prognosis.
- Anterior segment injuries (cornea, anterior chamber, iris, and lens)
- Foreign bodies or abrasions of the cornea – usually do well, consult ophthalmology if unable to remove object or patient has suspected retained object or has non-healed abrasion after 24 hours
- Eyelid laceration – any laceration felt to possibly compromise the lacrimal system or involve the eyelid margin should be evaluated by ophthalmology
- Periocular ecchymosis and edema (i.e. “black eye”) – patient should be evaluated by ophthalmology if unable to exam fully because of edema, or there was significant forceful injury as there may be a concurrent posterior segment injury
- Chemical burns – all should be evaluated by ophthalmology
- Fractures – commonly involve the floor and medial bones, all suspected fractures should be evaluated because of possible concurrent posterior segment injury and muscle or nerve entrapment
- Hyphema – all suspected hyphemas should be evaluated by ophthalmology, most problems occur because of glaucoma caused by the red blood cells clogging the anterior chamber outflow tract
- Traumatic cataracts – all should be evaluated by ophthalmology
- Traumatic iritis – all should be evaluated by ophthalmology
- Posterior segment injuries (i.e. vitreous body, retina, optic nerve) – all should be evaluated by ophthalmology
- Optic nerve – presents as edema and decreased vision, outcomes are variable
- Ruptured globe – needs prompt treatment, if in doubt, DO NOT TOUCH, cover eye with an eye shield (1/2 paper cup taped to patient) and call ophthalmology immediately.
Visual outcome is generally poor
- Retinal detachment – visual outcome is generally poor even with prompt treatment. This can occur in patients with significant trauma but can appear to have only anterior segment injuries.
- Post traumatic endopthalmalitis (i.e. intraocular infection) – wounds with organic material tend to be worse, visual outcome is generally poor
Over 2 million eye injuries occur annually in the United States. Between 35-50% occur in the pediatric age group with injuries occurring more in boys than girls (2-3:1). Adolescent males are the highest risk group. Traumatic events reported were due to projectiles (17%), blunt objects (14%), fingers/fists/other body parts (12%), and sharp objects (10%). Motor vehicle crashes accounted for 5% of injuries with 35% of patients reportedly not wearing seat belts, 25% reportedly wearing seat belts and 40% where seat belt use was unknown. Overall the prognosis for traumatic eye injuries was felt to be good by ophthalmologists who reported that 73% of the patients who sustained eye injuries were expected to fully recover, and 12% would experience mild impairment.
One author noted, “As children are sometimes unpredictable, and often exhibit naive behavior, their injuries can be caused by activity that is seemingly harmless to adults.” This would bear out in the case of the boy with the hair barrettes. Other injuries are more predictable. Some of the most serious eye injuries are found with use of all-terrain vehicles, paintball injuries and fireworks. Airbag deployment is known to cause injuries to children including death. Young children should not be positioned in the car near airbags. Additionally sports injuries, particularly basketball and baseball are common.
The American Academy of Pediatrics (AAP) does not recommend use of all-terrain vehicles until a child has a driver’s license and has other specific recommendations for their proper use. The AAP states that all non-powder guns (i.e. air rifles, bb guns, pellet runs and paintball guns) are weapons and should not be characterized as toys. Weapon use is not recommended, but if used, protective eyewear is recommended. Both the AAP and American Academy of Ophthalmology “strongly recommend protective eyewear for all participants in sports in which there is risk of eye injury.”
Questions for Further Discussion
1. What questions should be asked of all athletes regarding vision protection?
2. What are the American Academy of Pediatrics recommendations for child safety seat and seat belt usage?
3. What resources are available in your community for children with visual impairments?
Penetrating Globe Injury
Vision Impairment and Blindness
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Eye Injuries and Vision Impairment and Blindness.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
American Academy of Pediatrics Committee on Sports Medicine and Fitness. Protective Eyewear for Young Athletes. Available from the Internet at http://aappolicy.aappublications.org/cgi/content/full/pediatrics;113/3/619 (rev. 3/3/2004, cited 1/28/09).
American Academy of Ophtlamology. 2007 Eye Injury Snapshot Project Results. Available from the Internet at http://www.aao.org/practice_mgmt/eyesmart/snapshot_2007_results.cfm (cited 1/28/09).
Salvin JH. Systematic approach to pediatric ocular trauma. Curr Opin Ophthalmol. 2007 Sep;18(5):366-72.
Upshaw JE, Brenkert TE, Losek JD. Ocular foreign bodies in children. Pediatr Emerg Care. 2008 Jun;24(6):409-14; quiz 415-7.
American Academy of Pediatrics. Policy Statements. Available from the Internet at http://aappolicy.aappublications.org/policy_statement/index.dtl (cited 1/28/2009).
ACGME Competencies Highlighted by Case
4. Patient management plans are developed and carried out.
6. Information technology to support patient care decisions and patient education is used.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
25. Quality patient care and assisting patients in dealing with system complexities is advocated.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital