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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
A careful history of the events that led to the ocular injury is crucial in the diagnosis and treatment of ocular trauma.
If the extent of the eye injury is difficult to determine or if it is sight threatening, it is best to cover the eye with a shield and refer to ophthalmology urgently.
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PREVENTION OF OCULAR INJURIES
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Air rifles, paintballs, bungee cords, and fireworks are responsible for many serious eye injuries in children. Golf, baseball/softball, and lacrosse injuries are common and can be very severe. Safety/sport goggles or prescription glasses should be used while in laboratories and industrial arts classes, when operating power tools, hammers, nails, and while participating in organized sports. The one-eyed individual should be specifically advised to always wear polycarbonate eyeglasses at all times and goggles for all sports. High-risk activities such as boxing and the martial arts should be avoided by one-eyed children.
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
The cornea is one of the most sensitive parts of the body. Corneal abrasion can cause severe ocular pain, tearing, and blepharospasm.
Corneal abrasion is most commonly associated with trauma.
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Children often suffer corneal abrasions accidentally while playing with siblings or pets and participating in sports. Contact lens users may develop abrasions due to poorly fitting lenses, overnight wear, and use of torn or damaged lenses.
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Proper contact lens care and parental supervision can prevent activities that can lead to a corneal abrasion.
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Symptom of a corneal abrasion is sudden and severe eye pain, usually after an inciting event. Decreased vision secondary to pain and tearing are common complaints. Eyelid edema, tearing, injection of the conjunctiva, and poor cooperation with the ocular examination due to pain are common signs of a corneal abrasion. Pain improves with instillation of ophthalmic anesthetic drops and can aid in examination. Fluorescein dye will stain the abrasion with bright yellow-green when illuminated with Wood lamp. Both upper and lower eyelids should be everted to evaluate for foreign bodies.
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Differential Diagnosis
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Ocular or adnexal foreign bodies, corneal ulcer, and corneal laceration.
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Possible vision loss from corneal infection and scarring.
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Topical anesthetic should never be given to patients as they can lead to corneal melting. Ophthalmic ointment, such as erythromycin ointment, lubricates the surface of the cornea and also helps prevent infections. Patching the affected eye when a large abrasion is present may provide comfort, but it is not advised for corneal abrasions caused by contact lens wear or other potentially contaminated sources. Frequent follow-up is required until healing is complete.
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Excellent if corneal infection and scarring do not occur.
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OCULAR FOREIGN BODIES
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
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Protective goggles or prescription glasses can help prevent ocular injuries and should be encouraged while participating in sports and activities at risk for eye injuries.
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Foreign bodies on the surface of the globe and palpebral conjunctiva usually cause discomfort, tearing, and a red eye. Pain with blinking suggests that the foreign body may be trapped under the eyelid or on the corneal surface.
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Magnification with a slit lamp may be needed for inspection. Foreign bodies that lodge on the upper palpebral conjunctiva are best viewed by everting the lid on itself and removing the foreign body with a cotton applicator.
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Differential Diagnosis
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Corneal abrasion, corneal ulcer, and globe rupture/laceration.
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Pain, infection, and potential vision loss from scarring.
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When foreign bodies are noted on the bulbar conjunctiva or cornea (Figure 16–7), removal of the foreign body with irrigation or with a cotton applicator after instillation of a topical anesthetic can be attempted. Referral to an ophthalmologist may be necessary if the aforementioned measures fail to remove the foreign body or if a corneal rust ring secondary to a metallic foreign body is present. Patients should be warned that foreign-body sensation may persist for 1–2 days even after removal due to the epithelial defect that occurs after removal. An ophthalmic antibiotic ointment is typically prescribed for several days after foreign-body removal.
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Usually excellent with prompt treatment.
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INTRAOCULAR FOREIGN BODIES & PERFORATING OCULAR INJURIES
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Signs of perforating ocular injuries include irregularly shaped pupil, shallow anterior chamber, hyphema (blood in the anterior chamber), or dark tissue showing through the white sclera (Figure 16–8).
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Intraocular foreign bodies and penetrating injuries/corneal/scleral laceration (ruptured globes) are most often caused by being in close proximity to high-velocity projectiles such as windshield glass broken during a motor vehicle accident, metal grinding without use of protective safety goggles, BB gun injury, and sports-related injuries.
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Use protective eyewear when engaging in activities that may be a risk for ocular injury.
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Sudden ocular pain with vision loss occurs after an inciting event. Diagnosis may be difficult if obvious signs of globe rupture as stated above are not present.
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Computed tomographic (CT) scan is useful in evaluating ocular trauma, including bony injury and intraocular foreign bodies. Nonradiopaque materials such as glass will not be seen on imaging. Magnetic resonance imaging (MRI) must be avoided if a magnetic foreign body is suspected. B scan ultrasound should not be performed on suspected globe injury.
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Differential Diagnosis
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Corneal abrasion and superficial foreign body of the eye or eyelids.
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Traumatic cataract, retinal detachment, intraocular infection, loss of vision or eye.
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In cases of suspected intraocular foreign body or perforation of the globe, it may be best to keep the child at rest, gently shield the eye with a metal shield or cut-down paper cup, and keep the extent of examination to a minimum to prevent expulsion of intraocular contents. In this setting, the child should be given nothing by mouth in case eye examination under anesthesia or surgical repair is required. Emergent consultation with ophthalmologist is warranted.
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Prognosis depends on the extent of the trauma.
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
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Blunt trauma to the orbit can lead to orbital fractures. Retrobulbar hemorrhage (bleeding behind the globe within the orbit) can lead to orbital compartment syndrome, which can lead to permanent vision loss.
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Protective eyewear during athletic activities and adequate supervision of children at home and school.
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The orbital floor is a common location for a fracture (called a blowout fracture). Patients can have double vision, pain with eye movements, and restriction of extraocular movements. White-eyed blowout fracture is a greenstick fracture with entrapment of orbital contents within the fracture. It is called “white-eyed” because the only abnormality on examination may be restricted eye movements, especially upward. Entrapment of orbital contents often stimulates the oculo-cardiac reflex resulting in bradycardia and emesis. CT scan is helpful in diagnosing the extent of injuries. Consultation with an ophthalmologist is necessary to determine the full spectrum of the injuries.
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Orbital compartment syndrome is also an emergency requiring immediate treatment. Patients present with severe eyelid edema and proptosis. With true orbital compartment syndrome, eyelids will be too tight to open even with fingers or instruments because of the pressure from behind the orbit. Neuroimaging will show retrobulbar hemorrhage and proptosis.
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Orbital compartment syndrome requires emergent lateral eyelid canthotomy and cantholysis to decompress the orbit. Treatment should not be delayed in order to image the orbits. Prompt treatment can prevent permanent vision loss.
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Patients with clinical signs of muscle entrapment require urgent surgical repair to avoid permanent ischemic injury to the involved extraocular muscle. Large fractures may need nonurgent repair to prevent enophthalmos (sunken appearance to the orbit). Patients with any orbital fracture must be warned not to blow their nose as it can cause orbital emphysema and worsening proptosis.
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Cold compresses or ice packs for brief periods in the first 24 hours after injury may help reduce hemorrhage and swelling.
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The prognosis depends on the severity of the blunt trauma, associated ocular injuries, and extent of the orbit fractures.
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
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Lacerations of the eyelids and lacrimal system often result from dog bites, car accidents, falls, and fights.
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Supervision of children at home and at school.
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Eyelid lacerations may be partial or full thickness in depth. Foreign bodies, such as glass or gravel, may be present depending on the mechanism of the injury.
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Differential Diagnosis
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Globe injury may be associated with eyelid lacerations as well.
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Poor surgical repair of lacerations of the eyelid margin can result in eyelid malposition, which causes chronic ocular surface irritation and possible corneal scarring.
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Superficial lacerations away from the lid margins can be repaired by nonophthalmologists. Lacerations involving the lid margin or canaliculus (Figure 16–9) and those associated with significant tissue loss are best repaired by an ophthalmologist and may require intubation of the nasolacrimal system with silicone tubes.
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Prognosis depends on severity of the injury, tissue loss, and adequacy of surgical repair.
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
For all chemical burns, pH should be checked and eyes irrigated until pH is close to 7.
In severe burns, the eye may not look red due to perilimbal ischemia.
Alkalis tend to penetrate deeper than acids into ocular tissue and often cause severe injury.
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Burns of the conjunctiva and cornea may be thermal, radiant, or chemical. Chemical burns with strong acidic and alkaline agents can be blinding and constitute a true ocular emergency. Examples are burns caused by splash injury with cleaning supplies, spilled drain cleaner, and bleach. Radiant energy causes ultraviolet keratitis. Typical examples are welder’s burn and burns associated with skiing without goggles in bright sunlight. In addition to thermal and blunt trauma, chemical eye injury can occur from airbag deployment as a result of alkaline burn due to the chemical components of the inflation reaction.
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Protective eyewear when engaging in activities that pose a potential risk for exposure to hazardous chemicals, radiant energy, or when explosive conditions is possible.
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Superficial thermal burns cause pain, tearing, and injection. Corneal epithelial defects can be diagnosed using fluorescein dye, which will stain areas of the cornea bright yellows green where the epithelium is absent. Conjunctiva may be injected diffusely. In severe burns, there is relative lack of redness around the cornea indicative of perilimbal ischemia. Eyelashes may be singed due to thermal burns. The fluorescein dye pattern will show a uniformly stippled appearance of the corneal epithelium in ultraviolet keratitis. It is important to check the pH after any suspected chemical burn injury including airbag deployment.
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Differential Diagnosis
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Corneal abrasion, foreign body, and traumatic iritis.
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Significant corneal injury, especially if associated with an alkali burn, may lead to scarring and vision loss. Eyelid scarring can result in chronic exposure, dry eye, and entropion or ectropion.
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Immediate treatment consists of copious irrigation and removal of precipitates as soon as possible after the injury. Irrigation should be continued until the pH is close to 7. Initial stabilization of the injury is initiated by using topical antibiotics. A cycloplegic agent such as cyclopentolate 1% may be added to reduce ciliary spasm that contributes to pain. Topical steroids may also be necessary but should be guided by an ophthalmologist. Ultraviolet keratitis can be extremely painful, and patients often need opioids for pain control. Patients should be referred to an ophthalmologist after immediate first aid has been given.
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Prognosis depends on the severity of the injury.
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
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Blunt trauma to the globe may cause a hyphema, which is bleeding within the anterior chamber from a ruptured vessel from the iris or in the anterior chamber angle (see Figure 16–10).
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Protective eyewear and appropriate supervision at home and at school.
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Blunt trauma severe enough to cause a hyphema may be associated with additional ocular injury, including lens subluxation, cataract, retinal edema or detachment, and ruptured globe. It is important to note the height and color of the hyphema. Most will be layered inferiorly unless patient has been lying down for a long time, in which case it will be dispersed and have a hazy appearance. Sometimes, it can be seen as a clot over the iris. Total hyphema (100%) may appear black or red. A black total hyphema is referred to as “eight-ball hyphema.” The black color is suggestive of impaired aqueous circulation and decreased oxygen concentration. This distinction is important because an eight-ball hyphema is more likely to cause pupillary block and secondary angle closure. In patients with sickle cell anemia or trait, even a small amount of hyphema can lead to significantly elevated intraocular pressure that can result in permanent vision loss. Therefore, all African Americans should have their sickle cell status determined if hyphema is observed. These patients require extra vigilance in diagnosing and treating hyphema.
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Differential Diagnosis
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Nontraumatic causes of hyphema include juvenile xanthogran-uloma and blood dyscrasias.
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Increased intraocular pressure, glaucoma, permanent corneal staining, and vision loss.
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A shield should be placed over the eye, the head elevated, and arrangements made for ophthalmologic referral.
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Majority of children with isolated traumatic hyphema do well with outpatient treatment, activity restriction, and close follow-up with an ophthalmologist. Prognosis is worse if intraocular pressure is elevated, the patient has sickle cell disease, or if other associated ocular injuries are present.
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ABUSIVE HEAD TRAUMA & NONACCIDENTAL TRAUMA
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Abusive head trauma (AHT), formerly known as shaken baby syndrome, is a form of nonaccidental trauma characterized by a constellation of examination findings, including intracranial injury, retinal hemorrhages, and fractures of long bones or ribs.
The history leading to the diagnosis of AHT is often vague and poorly correlated with the extent of injury.
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AHT includes shaking as a mechanism of injury, shaking with impact, or impact alone. The most widely accepted theory is that retinal hemorrhages occur due to the vitreoretinal traction from accelerating-decelerating forces from shaking alone or combined with impact. Additional injury may result from spinal cord injuries and hypoxia.
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Victims often have multiple-organ system involvement that includes, but is not limited to, traumatic brain injury, bone fractures, and retinal hemorrhages. The presentation can include irritability, change in mental status, or cardiopulmonary arrest.
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Ophthalmic consultation with dilated retinal examination is necessary to document retinal hemorrhages. Hemorrhages may be unilateral or bilateral and may be located in the posterior pole or periphery. Often, retinal hemorrhages are multilayered (intraretinal, preretinal, and subretinal), too numerous to count, and diffuse. Intraretinal hemorrhages may resolve rapidly within days, whereas preretinal or vitreous hemorrhages can take time. If a blood clot lies over the macula, deprivation amblyopia may occur and may require intraocular surgery by a retinal specialist. Other ocular findings associated with AHT include lid ecchymosis, subconjunctival hemorrhage, hyphema, retinal folds, retinoschisis (traumatic separation of the retinal layers), and optic nerve edema.
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Differential Diagnosis
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The differential diagnosis of retinal hemorrhages includes birth trauma (in < 1 month old), sepsis, blood dyscrasia, and severe crush injuries or high-velocity trauma. A team effort between the primary treating physician, neurosurgery, orthopedics, ophthalmology, social services, and law enforcement is crucial in determining the true cause of a patient’s injuries.
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The severity of injuries dictates the long-term outcome. Persistent hemorrhages involving the macula can lead to amblyopia. Often, poor vision results from cortical visual impairment in patients with severe neurologic injuries. Children with history of AHT are at higher risk of strabismus and significant refractive error, requiring glasses correction.
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Management of any systemic injuries is required. Observation by an ophthalmologist for resolution of retinal hemorrhages is the usual management. Vitreous hemorrhages or large preretinal hemorrhages that do not resolve within several weeks may need surgical treatment by a retinal specialist.
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Prognosis depends on the severity of ocular and brain injuries.
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G, Chen
W, Huang
J, Ying
GS, Forbes
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Levin
AV, Cordovez
JA, Leiby
BE, Pequignot
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A: Retinal hemorrhage in abusive head trauma: finding a common language. Trans Am Ophthalmol Soc 2014;112:1–10
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