See also

Penetrating eye injuries

Background

Serious eye injuries can be under-appreciated when children present with a painful eye or blurred vision.

The following traumatic conditions threaten vision:

• Ruptured globe
• FB- either intraocular or deep corneal 
• Large hyphaemas (causing acute glaucoma)
• Retinal detachment
• Corneal burns, either chemical or thermal- alkalis penetrate deeper and have greater potential for serious and delayed burns.
• Contact lens-related corneal infections (bacterial keratitis)

Assessment

History:

When assessing the painful eye, the following questions should be asked:

• Proximity to chemicals or high velocity projectiles (particularly lawn-mowers, power tools, hammering or motor vehicle accidents) 
• Prolonged contact lenses use
• Pain, foreign body sensation, tearing or photophobia
• Visual disturbance, either temporary or persisting, including flashes (retinal detachment) or floaters (intra-ocular) in vision
• Eye discharge
• First aid provided

Eye examination:

If an adequate examination is not possible due either to the child's age or cooperation level, specialist assistance should be sought.

• Adequate analgesia will aid assessment. Topical anaesthetic such as amethocaine 1% (one drop) may be used once in the emergency department (local anaesthetic causes direct epithelial toxicity and should not be used repeatedly).

Globe

For obvious penetrating eye injuries (see  penetrating eye injury guidelines). 

• Signs of potential globe rupture or perforation:
  • Severe loss of vision or loss of red reflex
  • Loss of ocular motility
  • Asymmetric pupil
  • Hyphaema
  • Distorted appearance of globe
  • Localised conj. haemorrhage or chemosis (bulging of the conjunctiva)

Visual Acuity

• Use age-appropriate charts and the patient's normal corrective lenses or pinhole:
  • Snellen charts: from school-age
  • 'E' chart: useful from about 3 years of age
  • Kay picture book (available in ED), useful from 2-3 years of age.
  • Fingers or fix and follow, <2- 3 years of age
  • A young child may become distressed if the 'good' eye is occluded. 
  • Test each eye separately, then together (for diplopia) with appropriate chart.
  • A difference of greater than 2 lines (on an eye chart) between the eyes is likely to be significant.

Eye movements

• Exclude entrapment of extraocular muscles with orbital fractures

Fields

• Four quadrant confrontation testing in older children. Traumatic visual field loss is usually gross, however subtle changes may occasionally occur with retinal detachment and intra-ocular FB.

Lids, conjunctiva and sclera

• Examine the lids including the undersides for trauma and foreign bodies. A topical anaesthetic may aid examination. 
• For lid lacerations, examine to exclude full-thickness laceration and penetration of globe.
• Subconjunctival haemorrhage- if localised, may suggest penetrating injury (but can be due to valsalva manoeuvre). If the posterior extent of the haemorrhage cannot be visualised, an orbital or base of skull fracture is possible.

Cornea, Anterior Chamber, Iris and Pupil

• Before fluoroscein: Look for pupillary light reflex, pupil shape and size, symmetry with other eye, presence of hyphema or cloudy cornea (prior to blood settling) or epithelial defects.
• After fluoroscein:  For corneal, conjunctival abrasions or lacerations (apply fluoroscein 1 drop to each eye, or for strips- wet strip and touch to lower lid only). 
• Look particularly for vertically-linear corneal abrasions, as these particularly suggest a FB under the upper-lid.

Fundus

• Vitreous haemorrhage can cause diminished red reflex, difficulty visualising fundus or red splotches on retina. 
• Retinal detachment may be seen as a grey flap out of focus with optic disc on direct ophthalmoscopy.

Management

For potential blunt or penetrating eye injuries, see flow chart below and  penetrating eye injury guidelines.

Corneal abrasions/ Foreign bodies

• If very large or deep defect seen, presume full thickness.
• Exclude foreign body, including under eyelid.
• Avoid removing large, deep or central corneal foreign bodies, refer these to ophthalmology.
• Gently use moistened cotton bud for small superficial FB. A small gauge needle may be used in older, cooperative children, using slit lamp with approach to the patient from the temporal aspect of the eye.
• Chloramphenicol ointment/ drops
• Pad the eye for four hours (to prevent accidental further eye injury due to anaesthetic effect). Occasionally, prolonged eye pad may help ease pain, but be aware not to apply too tightly as this can impair epithelial healing.
• Cycloplegic eye drops (cyclopentolate 1% or homatropine 2%) can be used for relief of a very painful eye
• Patients need daily review until corneal ulceration healed

Corneal burns

• Discuss all eye burns with the ophthalmologist.

Chemical (strong acid/ alkali)

• Urgent, copious irrigation, after local anaesthetic, including under top lid. Use 3 litres of N. saline through an open giving set over about 15 minutes and until pH normal (6-8). A urine dipstick can be used to measure tear pH (carefully trimmed to the pH marker, avoiding sharp edges of the strip). Sedation or urgent GA may be required.
• Particulate alkaline matter needs urgent, total removal.

Thermal burns

• If corneal damage present, manage as for other corneal abrasions.

Contact lens associated red eye

• Anaesthetise eye and remove contact lenses if possible
• Stain eye and check for corneal abrasions or FB.
• Swab if discharge present- Gram-negatives including P. aeruginosa are frequently the cause, thus requiring broader-spectrum antibiotics.
• If ulcer identified refer urgently to ophthalmology, and discuss other patients with Ophthalmology prior to discharge.
• Start topical antibiotics and arrange for follow-up. 

Acute eye injuries in children-flow chart

For obvious penetrating eye injury see Penetrating Eye injury guideline

Download the PDF version of this chart