Eye injuries in children: causes, symptoms, diagnosis, treatment

Serious eye injuries in children in developed countries occur at a rate of 12 cases per 100,000 population annually.

Usually the injury is unilateral, but in rare circumstances, with a time interval, injury or disease of the fellow eye is possible. Eye injury can cause a pronounced cosmetic defect and limit future professional choice. Traumatic damage to the organ of vision most often occurs at a young age, especially in boys, as well as in socially disadvantaged groups with reduced parental supervision and lack of education.

[ 1 ], [ 2 ], [ 3 ], [ 4 ]

Eyelid trauma

A combination with facial trauma is possible, but an isolated nature is also possible. With dog and other animal bites, concomitant damage to the lacrimal canals often occurs.

Damage to the lacrimal canals requires wound sealing with sutures and drainage of the wound channel with a tubular drain. In case of uncomplicated damage to the lacrimal canals, microsurgical dissection is performed followed by intubation of the nasolacrimal system through the upper and lower lacrimal canals.

Subconjunctival hemorrhages

It is important to remember that subconjunctival hemorrhages may mask underlying penetrating damage or trauma to the scleral capsule of the eyeball. The hemorrhages themselves are not dangerous and quickly resolve without requiring treatment.

Corneal injuries

Corneal abrasions occur when the cornea is damaged by sharp objects such as a knife, rod, etc. Fluorescein drops are used to determine the extent of the damage. If foreign bodies are present, they are removed. An antibiotic ointment is placed in the conjunctival cavity, and analgesics are instilled. Cycloplegia helps to avoid a reaction from the ciliary body.

Ruptures of the eye capsule

As a rule, they are localized in the corneoscleral region or in the anterior parts of the scleral capsule of the eyeball. Such injuries are necessarily accompanied by intraocular damage, except for cases of eye perforation by very small objects, such as a needle.

Research

1. An examination of the fellow eye is performed, including ophthalmoscopy with a dilated pupil.
2. To assess the extent of damage, since parts may be covered by hemorrhages, a slit lamp examination is required.
3. If possible, measure intraocular pressure. In case of penetrating wound of the eyeball, the pressure will be reduced.
4. To assess the involvement of the posterior segment in the process and to exclude the presence of an intraocular foreign body, an ultrasound examination is advisable, especially in the case of hemorrhages in the anterior segment of the eye and cataracts. Computed tomography (CT) helps to exclude the presence of intraocular foreign bodies of the orbit and fractures of its walls, as well as retrobulbar hemorrhages. Magnetic resonance imaging (MRI) is performed if the presence of a metallic foreign body is suspected.

Tactics of management

Almost all young children require pain relief, especially if the injury is penetrating to the eyeball. Depolarizing muscle relaxants should be avoided. The wound is sealed using appropriate absorbable or non-absorbable suture material. Non-absorbable corneal sutures in children are removed as soon as possible, especially when the sutures are loose or come undone. Hyphema is surgically removed simultaneously with the following surgical interventions:

1. the injury is accompanied by damage to the lens with its initial clouding. A lensectomy is performed and, if the posterior capsule of the lens is intact, the surgical intervention is supplemented by primary or secondary implantation of an intraocular lens;
2. The injury is accompanied by hemorrhages into the vitreous body and other damage to the posterior segment of the eyeball. Surgical intervention is supplemented by vitrectomy or retinal surgery.

Penetrating and non-penetrating injuries of the eyeball

The management of these patients is no different from that of other eye injuries, except for cases complicated by the presence of an intraocular or retroocular foreign body. The approach depends on the nature of the foreign body. Most foreign bodies are removed with microsurgical intraocular tweezers. Metallic foreign bodies are removed with a large magnet, but with the introduction of microsurgical techniques this method has become less common. Orbital foreign bodies that are not toxic do not always require removal, and although current guidelines recommend removing any foreign body, small pieces of glass may be left in place.

Blunt trauma to the eye

Blunt trauma can cause a number of intraocular disorders.

1. Hyphema.
2. Dislocation of the lens and cataract.

[ 5 ], [ 6 ], [ 7 ], [ 8 ], [ 9 ], [ 10 ]

Hyphema in childhood

Reasons

• Injury.
• Tumors:
  • juvenile xanthogranuloma;
  • leukemia;
  • Langerhan's histiocytosis;
  • medulloepithelioma;
  • retinoblastoma.
• Rubeosis:
  • retinal dysplasia;
  • persistent hyperplasia of the primary vitreous body (PHV);
  • retinopathy of prematurity (ROP);
  • sickle cell anemia.
• Malformations of the iris vessels.
• Iridoschisis.
• Iritis and rubeosis iridis.
• Blood coagulation disorders, scurvy, purpura.
• PGPS.
• Melanoma of the iris.

Tactics of management

1. Immediately after the appearance of the symptom, concomitant intraocular disorders are established.
2. Subsequently, an examination is carried out as thoroughly as the child’s age allows.
3. Monitor intraocular pressure.
4. Avoid prescribing aspirin or nonsteroidal anti-inflammatory drugs.
5. Hyphema is washed out of the anterior chamber if there is no tendency for resorption within 3 days or if there is a significant increase in intraocular pressure.

Long-term management tactics

Possible recession of the anterior chamber angle, lens dislocation, and damage to the posterior segment are detected. In the presence of angle recession, long-term (sometimes lifelong) observation is necessary due to the possibility of developing glaucoma.

1. Iris damage and anterior chamber angle recession.
2. Retinal detachment.
3. retinal contusion:
   • silvery sheen of the retina due to its swelling;
   • when the macular region is involved in the process, vision is reduced;
   • overall the prognosis is good;
   • sometimes long-term vision loss occurs;
   • There may be a rupture in the layers or throughout the entire thickness of the retina.
4. Rupture of the choroid (see below)
5. Purtscher's disease:
   • trauma is combined with increased pressure in the central retinal vein;
   • manifestations resemble air or fat embolism of the retina;
   • widespread retinal ischemia and hemorrhage;
   • The visual prognosis is unclear.
6. Retinal hemorrhages:
   • can be located in any layer, with predominant epiretinal localization;
   • combined with other intraocular injuries;
   • are combined with retinal tears.
7. Retinal detachment - possible in combination with retinal tears.

Penetrating wound of the outer shell of the eyeball

Penetrating injuries occur when the sclera is delaminated due to non-penetrating trauma. These injuries are often localized around the optic disc. The traumatic agents for scleral ruptures can be a variety of objects - ball bals, sticks, and even a fist.

• With any blunt trauma there is a risk of rupture.
• Intraocular pressure decreases.
• Ultrasound examination reveals hemorrhages in the vitreous body and sometimes deformation of the scleral capsule in the posterior segment.
• A rupture of the sclera may be accompanied by a burst fracture (or, as it is also called, a blow-out fracture).

In case of scleral ruptures in the anterior segment, as well as other penetrating wounds of the eye capsule, surgical intervention is indicated. Technically, surgical treatment of scleral ruptures in the posterior segment is extremely difficult.

Prevention of eye trauma

• Increased supervision by parents, schools and child care institutions.
• Conversations between parents and children about the dangers of eye trauma and the circumstances that accompany it.
• Use of protective glasses, especially for persons with only one eye, in situations where there is a risk of eye injury - during sports games
  that involve small balls, and when working with metal or stone.

Orbital trauma

Blunt trauma to the orbital walls causes fractures with or without displacement of bone fragments. Displaced fractures usually require reduction, while non-displaced fractures do not require treatment.

Complications

• Brown syndrome.
• Severe bone defects in the posterior orbit can cause enophthalmos.

Explosive fracture

Rarely seen in childhood;

A burst fracture is characterized by

1. fracture of the inferior or medial wall with infringement of the orbital contents;
2. enophthalmos;
3. deviation from the primary position;
4. disorder of vertical movements of the eyeball, especially upward;
5. associated intraocular damage;

Treatment:

• in mild burst fractures, treatment is not required, except in cases of severe enophthalmos and significant limitation of eyeball mobility;
• In case of damage to the orbital floor, it is advisable to use synthetic implants.

Cranial Nerve Injuries

Damage to the III, IV and VI pairs of cranial nerves is common in head injuries. Usually, improvement occurs without the use of special treatment. Sometimes, especially in paralysis and paresis of the VI pair of cranial nerves, botulinum toxin is successfully used in the acute phase of the disease. In case of double vision, occlusions and prismatic glasses are recommended and left for at least 6 months after stabilization of strabismus, before any surgical intervention. Occlusion of the undamaged eye is performed, trying to preserve eye movements in the presence of paresis and, thus, avoid subsequent contracture of the rectus muscles.

Traumatic optic neuropathy

May be caused by avulsion of the optic nerve from the eyeball, optic nerve injury due to orbital fractures, ischemic injury due to vascular disorder, or hemorrhage into the optic nerve sheath. Diagnosis is based on ultrasound or imaging of neurologic examinations, pupillary symptoms, and fundus examination. High-dose steroid therapy and optic canal decompression may be effective.

Domestic injury involving violence

• It is becoming more and more common.
• Most often observed in very young children.
• It occurs due to a variety of reasons, often from concussions.
• Bad psychological background - young parents - stressful social or work situation - child abuse, for example by spouses, violence, etc.

[ 11 ], [ 12 ]

Retinal hemorrhages

Retinal hemorrhages are not a pathognomonic symptom of domestic violence, but in terms of the extent and severity of the clinical course they often exceed hemorrhages that occur with ordinary injuries. There are two mechanisms for the formation of hemorrhages:

1. increased intravenous and intraocular pressure;
2. intense shaking followed by braking.

Hemorrhages of any type are encountered:

• vitreous hemorrhages with preretinal localization;
• epiretinal hemorrhages;
• hemorrhages of varying duration;
• perimacular folds with retinal hemorrhages, appearing as raised folds of the retina and choroid in the shape of an arc (a symptom characteristic of trauma involving violence);
• hemorrhages in any layer of the retina.

Other injuries to the eyeball

• Periocular hematoma.
• Cataract.
• Dislocation of the lens.
• Traumatic mydriasis.
• Cigarette burns on the cheeks or eyelids (usually multiple).
• Retinal detachment.
• Retinoschisis in the retinal layers.