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“You’re going to shoot your eye out!” Common ocular trauma in children Desinee Drakulich OD Disclaimer • I have no affiliation, nor do I received financial compensation from any of the companies or brands used in this presentation. Two Studies • Eye injuries in children: the current picture (Europe, 1998) • Pediatric Eye Injury - Related Hospitalizations in the United States (2000) Current Picture • Eye Injuries in children (MacEwen) • 415 patients • Leading cause of non-congenital unilateral blindness in children 0 - 14 years old. Common Dangers • • • • • • • • Sports balls Darts BB guns Projectile toys Broken toys Finger/fist Pencils/Scissors Rubber bands Mechanism of Injury 70% 60% 50% 40% Blunt Penetrating IOFB 30% 20% 10% 0% 0-4 y.o. 5 - 14 y.o. Total Place of Injury 80% 70% 60% 50% Home School Leisure Other 40% 30% 20% 10% 0% 0-4 y.o. 5-14 y.o. Total Cause of Injury 30% 25% Sports Assult Toys Missile Stick Airgun Chemical Other 20% 15% 10% 5% 0% 0-4 y.o. 5-14 y.o. Total Final Visual Acuity 90% 80% 70% 60% 20/40 20/60 - 20/200 <20/200 50% 40% 30% 20% 10% 0% 0-14 y.o. Pediatric Eye Injury • 3834 eye injuries evaluated from 7527 eye injuries reported in patients under 20 y.o. • Estimated 2.4 million eye injuries/year • 35% of injuries are patient under 17 y.o. • Average cost per year - 88 million • Leading cause of monocular visual disability and non-congenital unilateral blindness in children. Age & Gender 25 20 15 Male Female 10 5 0 0-2 y.o. 3-5 y.o. 6-8 y.o. 9-11 y.o. 12-24 y.o. 15-17 y.o. 18-20 y.o. Mechanism of Injury 35 30 25 20 Male Female 15 10 5 0 Ope n Obital Ope n Contus ionSupe rfical Wound to Fracture Wound to Adne xa Eye Bur n Cause of Injury 30 25 20 15 Percent 10 5 0 Motor Vehicle Struck by Cut or pierce Clinical Symptoms • Pain • Watery discharge • Double Vision • Decreased Vision • Sharp, sectoral, dull, photophobic • Entrapment, Nerve damage, Hemorrhage • Damage, Hemorrhage Clinical Signs • • • • • • • • Acuity EOMs Lids Globe Conjunctiva Cornea Anterior chamber Anterior Uveitis • • • • • • • • Hyphema Iris Lens Vitreous Retina Choroid Optic Nerve Avulsion Lids Lids • Signs Ecchymosis, swelling, lacerations • Treatment Suture • Oral Antibiotic Dicloxacillin 250 mg QID, 5-7 days • Topical Antibiotic Polytrim, Bacitricin Ice • 48 hrs Warm • 5-7 days Orbit Orbit • Signs Blow-out fracture Orbital prolapse Diplopia (vertical) EOM entrapment Crepitus • Treatment Orbital CT Surgical Consult Avoid blowing nose Nasal decongstant • Afrin BID, 10 days Ice • 48 hrs Oral Antibiotics • Augmentin 250 mg po TID, 10 days Globe Globe • Full thickness lacerations/Intraocular Foreign Bodies Aching Pain Photophobia Decreased VA Diplopia Chemosis Cell/Flare High or Low IOP • Treatment Advise patient to consume NO food or water. Shield eye Transport to nearest ocular surgeon • Seidel may be checked in office. Conjunctiva Conjunctiva • Laceration Hemorrhage Direct observation of sclera • Treatment Antibiotic ointment • Tobramycin, Polymyxin B Cycloplegia • Homatropine 5% Pressure patch 24 hrs Monitor for infection Conjunctiva Conjunctiva • Subconjunctival Hemorrhage Red eye Usually no visually distrubance Usually no pain • Treatment Patient Reassurance Artifical Tears Cornea Cornea • Partial Thickness Laceration Pain Decreased VA Photophobia Increased tearing • Treatment Same as conjunctival laceration Tight fitting bandage CL Fluoroquinolone Cycloplegic Oral analgesic Cornea Cornea • Abrasion Pain FBS Tearing Photophobia NaFl staining Mild AC reaction • Treatment Cycloplegic QID Zymar QID Bandage CL Topical NSAID Oral Analgesic Traumatic Uveitis Traumatic Uveitis • Signs/Symptoms Pain Photophobia Tearing Decreased VA Cells/Flare Iridodialysis • Treatment Subclinical • Cycloplegic Grade 1, 2 • Cycloplegics QID • Pred Forte 1%, QID Grade 3, 4 • Cycloplegics • Pred Forte q5min - q2h • B-blocker (timolol) Hyphema Hyphema • Microhyphema Bedrest Head Elevation Avoid NSAIDs/Aspirin Protective shield Pred Forte 1% QID Cycloplegic Monitor IOP • Severe Hyphema Hospitalization - especially young children Antifibrinolytic agent • Aminocaproic Acid (50 mg/kg q4h) Risk of amblyopia in young children Lens Lens • Subluxation Increased IOP Pain Decreased VA Diplopia • Treatment Cyloplegic B-blocker or oral pressure lowering or agent Refer for repositioning or removal Lens Lens • Traumatic Cataract Reduced VA Diplopia Elevated IOP Stellate or Rosette opacity Vossius Ring • Treatment B-blocker CE/PC IOL Vitreous Vitreous • PVD Block Spot or Weiss Ring • Traumatic Hemorrhage Reduced VA Cloudy or curtained vision • Treatment Monitor • Treatment Sleep with head elevated Avoid NSAIDs/ Aspirin Vitrectomy Retina Retina • Detachment • Traumatic Macular Hole • Commotio Retinae • Refer to Retinal Specialist • Vitrectomy with peeling of cortical vitreous • Monitor Choroid Choroidal Rupture • Signs/Symptoms Reduced VA Metamorphopsia Similar to RD • Treatment No specific Tx Monitor for CNVM Refer to Retinal Specialist for FA Optic Nerve Optic Nerve • Traumatic Optic Neuropathy Relatively Rare Nerve appears normal Functional defect • • • • Decreased VA APD Color defect Visual Field defect • Treatment Refer IV steroids Surgical decompression No Tx for avulsion Conclusion • Accidental eye injuries are the leading cause of monocular visual disability and non-congenital unilateral blindness in children. • 90% of eye injuries could have been prevented or decreased in severity with better education, appropriate use of safety eyewear, and removal of common and dangerous risk factors. References • Brophy M, Sinclair S, Hostetler G and Xiang H. Pediatric Eye Injury-Related Hospitalizations in the United States. Pediatrics 2006;117;1263-1271. • MacEwen C, Baines P and Desai P. Eye injuries in children: the current picture. Br. J. Ophthalmol. 1999;83;933-936. • Mulrooney B. Cataract, Traumatic. E-medicine.com. 2006. • Onofrey B, Skorin L, Holdeman N. Ocular Therapeutics Handbook: A Clinical Manual. Second Edition 2005.