In this section
Paediatric ocular trauma is a cause of significant
morbidity, with up to 280,000 hospital admissions worldwide per year. 
However, hospital admissions only account for around 5% of total eye injuries –
so it has been estimated that worldwide there are around 6 million episodes of
eye injury in children. Open globe injury (ruptured globe due to
blunt trauma, or laceration due to a penetrating injury) is a severe form,
which, in children, is most commonly caused secondary to penetration with a
sharp object whilst at home.
Children account for between 20 and 59% of all eye injuries. They are more predisposed to eye injury due
to their developing physical coordination, limited ability to detect
environmental risks and a more vulnerable facial morphology. The outcome of paediatric eye injuries is
worse than that of adults due to their visual immaturity, increased years of
visual loss and potential for amblyopia. Most paediatric eye
injuries (66.2%) occur during play – predominantly whilst at home under
supervision of parents / caregivers (47.7%), but often whilst at school /
nursery (24.4%). Sharp
instruments are the most common cause of injury, followed by plants, animals,
toys or sports equipment. In the Australian context, it has been
estimated that sports-related eye injuries make up 11% of all paediatric eye
injuries.  Boys are twice as likely to sustain a significant eye
injury compared to girls.
Features of ocular trauma history and examination (see also RCH Clinical Practice Guideline: Acute eye
injuries in children and RCH Clinical Practice Guideline: Penetrating eye injury)
Serious eye injuries can be under-appreciated when children
present with a painful, blurred vision or an extensive subconjunctival
haemorrhage. In all traumatic eye
injuries consider the following principles: 
Where an open globe injury is suspected it is important to
minimise child distress – as crying can raise ocular pressure leading to
extrusion of intraocular contents.
The key diagnoses to seek and identify are:
If adequate examination is not possible due to either the
child’s age or level of cooperation, specialist assistance should be
sought. Where there is significant
concern for an open globe injury, it is prudent not to overly distress the
child through multiple attempts at examination, as crying can lead to an
increase in intraocular pressure, with the resultant extrusion of intraocular
contents. Early referral to ophthalmology
is appropriate in these cases – along with administration of appropriate
systemic and topical analgesia and anti-emetics. Ondansetron is an appropriate option, as it
has a lower risk of causing a dystonic reaction. Opiate analgesia may lead to nausea and
vomiting which can increase intra-ocular pressure – so consider pre-treating
with anti-emetics if you think strong analgesia is required.
Even when open globe injury is not suspected, appropriate
analgesia, oral or intranasal analgesia as well as topical (single drop of
preservative free local anaesthetic – eg amethocaine 1%) should be given to
reduce pain and aid the child’s ability to tolerate examination. However, it is worth noting that local
anaesthetic is itself a direct epithelial toxin, so it shouldn’t be used
repeatedly (and patients should not be discharged with topical local
anaesthetic). A child life specialist
(play therapist) may also assist in helping the child relax during an
examination. Be aware that when a child
has suffered a monocular injury, occluding the good eye may increase their
distress (as they will no longer be able to see).
Where a burn is suspected, first aid should take precedence
over a complete examination. This
consists of copious irrigation (after local anaesthetic and systemic analgesia
given). In some cases the patient may
need to be sedated to facilitate first aid treatment.
A complete examination of the eyes requires examination of:
1.Visual acuity in both the injured and uninjured
A difference of more than 2 lines on an eye
chart is likely to be significant. If unable to read a chart, check the patient can
count fingers or confirm light perception
5.Lids, conjunctiva and sclera
6.Cornea, Anterior Chamber and Iris
8.Palpate the orbital rim
9.Consider assessing intraocular pressure
Open globe injury refers to a full-thickness mechanical
injury to the cornea and/or sclera. The
two broad types are:
Penetrating injuries are the most common, followed by
intraocular foreign body injuries, then rupture, with perforating injuries
being the least common. The most common
location for injury is at home – especially for pre-school children. Older
children are increasingly likely to sustain an open globe injury outside of the
home. A common cause of injury is
kitchen items, followed by sticks, pencils, metallic and elastic objects. Older children may suffer projectile injuries
through hammering or the use of paintball guns / air rifles.
penetrating eye injury is suspected:
Anterior signs: peaked or irregular pupil, iris
prolapse, corneal laceration, hyphaema, extensive subconjunctival haemorrhage and chemosis (conjunctival swelling).
Posterior signs: poor red reflex (vitreous
haemorrhage), decreased vision, uveal prolapse,
These occur following high
energy blunt traumas (e.g. hit with ball, bat or fist) that create an increase in intra-orbital pressure.
These include pain and diplopia (especially on vertical movement), tenderness, eyelid
swelling. Nausea +/- vomiting and pain on eye movement may occur if there is entrapped
Ptosis, tenderness, restricted eye movements (especially on vertical
movement), crepitus of lower lid. The globe may appear "enopthlamic" (recessed into the orbit) or displaced downwards. There may also have associated ocular injuries secondary to blunt trauma – (see above). Infraorbital nerve involvement leads to reduced sensation
to cheek, upper teeth and gums of affected side.
causes are a common and significant cause of ocular trauma in paediatrics.
fundoscopy by an ophthalmologist is required in all cases of suspected NAI, and
should be considered in all cases of head injury of infants and young children.
pathological findings include: Extensive multilayered (retinal, pre-retinal and
subretinal) haemorrhages in all four quadrants with possible vitreous
and alkaline solutions that come into contact with the eye surface can cause
considerable damage and are a true ophthalmic emergency. Immediate
irrigation prior to arrival in ED is ideal, if this hasn’t occurred it should
be performed on arrival to ED
facilitate irrigate of the eye:
chemical burns should be assessed by ophthalmology after wash-out.
burns are especially damaging as the base solution will denature proteins, lyse
cell membranes which enhances penetration into the eye and increases further
solutions also cause severe damage, however acid solutions largely precipitate
proteins which can limit the area and depth of necrosis.
One of the most common paediatric ocular presentations to
eyelid laceration should be treated as a potential penetrating injury until
proven otherwise. Superficial
laceration away from the lid margin, may be safely closed by standard suture
techniques. However any laceration that
involves the eyelid margin should be repaired by an ophthalmologist given the
complex lid anatomy (tarsus, grey line, medial and lateral longitudinal tendons
even minor, to the medial canthus may involve the canaliculus and thus should