Part 2: Disorders of the Eye

Eye Emergencies and Trauma

INTRODUCTION

Ocular trauma is a frequent presenting complaint and a major cause of ocular morbidity and unilateral blindness in children. The magnitude of serious eye injuries in children has been estimated at 11.8 per 100,000 per year. Children in the 11- to 15-year age group have a higher incidence of trauma compared to other age groups. Boys outnumber girls approximately 3 or 4 to 1.

Ocular injuries require prompt evaluation and care in order to preserve vision. Evaluation of the injury is more difficult due to decreased cooperation and understanding in children. The injured patient is frequently young, afraid, in pain, and able to provide only limited compliance. The examination should be as complete as the injury permits; forcible evaluation may risk further damage. Topical anesthesia, local anesthesia, and sedation are all useful for assessing and treating minor trauma. If the pediatrician or emergency room physician cannot perform an adequate examination, or as soon as there is concern for significant ocular damage, the injured eye should be covered with a protective shield (not patched) and ophthalmology consultation should be obtained. It is also important to recognize that managing the eye injury always takes a lower priority than managing life-threatening injuries and serious head trauma. The injured eye can be shielded while emergency procedures are under way to stabilize the child systemically. Yet, with the exception of the uncommon vasovagal response induced by eye examination, the ophthalmologist can conduct a limited brief assessment that will be relatively noninvasive and may offer helpful management guidelines. While that examination is pending, the eye should be shielded (not patched).

CORNEAL ABRASION

Corneal abrasion is one of the most frequent ocular injuries of childhood. The abrasion results from mechanical removal of the superficial epithelial layers of the cornea. This can cause intense pain, protective spasm closure of the lids, tearing, and photophobia, although some children may be surprisingly asymptomatic. Examination is facilitated by a drop of topical anesthetic followed by fluorescein dye. The dye is available as a liquid mixed with anesthetic or in dry impregnated strips. The latter tends to be more effective in diagnosis, as it allows only a small amount of dye to be placed. The strip must be wet with a drop of liquid (water, normal saline, Ringer’s, etc) and then gently touched briefly to the pink palpebral conjunctiva lining the inside of the lower lid or the bulbar conjunctiva on the white of the eye. The fluorescein will define the extent of epithelial cell loss when examined with cobalt blue illumination (blue light on direct ophthalmoscope or Woods lamp; Fig. 573-1).