Penetrating or Perforating Injury
Unless an adult has witnessed the traumatic incident, the history cannot be relied upon to exclude the possibility of penetrating injury to the globe. The anterior segment and fundus must be thoroughly inspected. An examination under anesthesia may be necessary when a penetrating injury is suspected. An area of subconjunctival hemorrhage or chemosis or a small break in the skin of the eyelid may be the only surface manifestation of scleral perforation by a sharp-pointed object, such as a pencil or scissors blade (Fig 27-1). Distortion of the pupil may be the most evident sign of a small corneal or limbal perforation. Imaging should be considered if there is any reason to suspect an intraocular or orbital foreign body.
A, Small skin entry wound, right brow region, in a 7-year-old boy. The wound was created by a thrown dart. B, Conjunctival exit wound indicates complete perforation of the eyelid. C, Extensive injury to the anterior segment of the same eye.
Corneoscleral lacerations in children are repaired using the same principles employed for these repairs in adults (see BCSC Section 8, External Disease and Cornea). Corneal wounds heal relatively rapidly in very young patients; sutures should be removed correspondingly earlier. Small conjunctival lacerations are often self-sealing.
After a penetrating injury to the cornea, fibrin clots may form quickly in the anterior chamber of a child’s eye, and these can simulate the appearance of fluffy cataractous lens cortex. To avoid rendering the eye aphakic unnecessarily (and thereby compromising vision rehabilitation), the clinician should not remove the lens as part of primary wound repair unless absolutely certain that the anterior capsule has been ruptured. Even if lens cortex is exposed, postponing cataract surgery for 1–2 weeks, until severe posttraumatic inflammation has resolved, may result in a smoother postoperative recovery and reduced risk of complications without significantly worsening the visual prognosis. See also BCSC Section 11, Lens and Cataract.
Full-thickness eyelid lacerations, especially those involving a canaliculus, should be repaired meticulously; sedation or general anesthesia may be required, even in older children. Working near the eyes with sharp instruments and draping the face to create a sterile field are likely to frighten an awake child and add to the difficulty of the repair. Clearly superficial wounds can be repaired in the emergency department. For superficial wounds, use of an absorbable suture is acceptable if the physician wishes to avoid the need to remove nonabsorbable sutures.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.