• Trauma

    Epidemiology

    Eye trauma is a complex field to which every ophthalmologist will be exposed. The sudden nature of injury and the risk of sight loss make eye trauma one of the most feared and potentially handicapping medical problems. Children are particularly susceptible to eye trauma; 52% of all eye trauma affects pediatric patients1 and trauma is the leading cause of monocular blindness in children.2 The incidence hovers at about 15 per 100,000 per year, but this number seems to increase in developing countries and lower socioeconomic status. Children younger than 5 years seem to be more affected, although other series indicate ages 11–15 years are at higher risk due to sport-related trauma. Male preponderance is the rule, but not as much as in the adult population.3 Home is the most common place for trauma to happen, but this depends highly on the activities in which a child engages. In economically developed countries, sports are the main cause of trauma, whereas in developing countries, domestic activities have a more significant role in injury occurrence.4,5

    According to the United States Eye Injury Registry (USEIR), the world's largest database of serious eye injuries, male-to-female ratio in the pediatric population is 3.4:1, becoming higher with age. The place of injury tends to change according to age as well. Younger children tend to suffer accidents at home, whereas older children are more prone to experience trauma while practicing sports. Work-related accidents tend to be rare in developed countries, but are fairly common in developing countries where children work at a younger age or are bystanders.6 Certain activities — fireworks, air- and spring-propelled projectiles (paint-balls, pellets, BB guns, arrows) — deserve special attention because of the energy delivered, often causing severe and permanent visual loss. According to one series, 32% lost an eye, and 53% lost light perception.7

    Prevention

    Prevention is the only way of avoiding ocular trauma and decreasing its morbidity. However, compulsory measures for eye protection have not been very popular. A few exceptions highlight the effectiveness of such measures, as exemplified by the obligatory use of face-mask protection in minor league hockey and baseball, which has decreased eye trauma to nearly zero.8,9 Total banning of an activity or compulsory protection seem to work much better than adult supervision, which is often unreliable. Ophthalmologists and other eye-care personnel have an unequaled opportunity to advise and educate patients on the proper prescription and use of protective eyewear according to their activities.

    Proper child seat and seatbelt use have also decreased automobile-accident death and morbidity rates significantly. Although airbag-related eye trauma occurs, the consequences of not having air bags would probably be much more serious. Air bags have been redesigned on several occasions to try to minimize these injuries.10

    Air rifles and guns are often given to children as toys or presents. Children also fashion their own weapons using elastic cords, balloons, and rubber bands to construct slingshots and other types of projectile-launching artifacts. These are not toys, and adults should be instructed on the dangers of such devices and proper eye protection when their use is unavoidable. Parental supervision is usually not enough to prevent these injuries.

    Why Is the Child Eye Different?

    There are several circumstances that make eye trauma different in a child than in an adult. As mentioned previously, eye trauma is much more frequent during childhood. This might be explained by the following:

    • Lack of experience and foresight, hindering the ability to predict dangerous situations that can lead to injury
    • Immature motor skills and the tendency to copy adult behavior
    • Curiosity and peer pressure to assume risk-prone activities
    • Increased level of male hormones in adolescent boys, pushing them to undertake risky behavior11

    These facts point to the need for adult supervision and the design of preventive measures to curtail trauma at home, at school, and during sports.

    Once an injury has occurred, a series of natural mechanisms is set in motion to combat infection, remove necrotic tissue, and heal the wounded tissues. Although there is no confirming experimental data, inflammatory and scarring responses seem to be more aggressive in children. Increased fibrosis can hamper visual recovery by producing dense corneal opacities, pupillary and cyclitic membranes, and proliferative vitreoretinopathy. The judicious use of anti-inflammatory medication is of paramount importance in this population.

    Any ocular or orbital trauma that impedes adequate vision in a young patient carries the risk of producing amblyopia. The younger the patient, the higher the risk. Pathologic entities that can be relatively innocuous in the adult such as hyphema, vitreous hemorrhage, or even chronic lid abnormalities can have severe visual implications in a young child. Attention to prompt visual rehabilitation is vital in avoiding permanent visual loss due to amblyopia.

    Examining a Child with Eye Trauma and Counseling Parents

    Obtaining an accurate history is paramount in dealing with eye trauma. Unfortunately, children are generally poor historians, especially when in pain or frightened. The ophthalmologist’s clinical skills are of the utmost importance in getting as accurate a history as possible as quickly as possible. Children more than 3–4 years of age can generally contribute significantly to learning the circumstances around the traumatic event. Address the child's version of the events prior to the accompanying adult's. This gives a child a sense of importance and control and establishes a bond of trust. In taking the history, concentrate on finding the facts pertaining to the trauma, not on whom to blame, which can make the child defensive and uncooperative. Obtain prior treatment, eye health, and allergy and immunization history.

    Start the examination with external inspection, touching the child as little as possible. At each step, explain what is being done to allay fears of pain or discomfort and to strengthen the doctor-patient bond. Note visual acuity in each eye as faithfully as possible. Note any asymmetry in lid or globe position. Note lid and periorbital lesions regardless of size or apparent inconsequence because even small injuries can suggest an intraorbital foreign body or be associated with infection. Use as much magnification as possible, with the ideal being a slit-lamp exam when the child is cooperative enough. The best cooperation can be elicited by explaining the exam, reassuring the patient that there will be no pain, and keeping direct contact to a minimum. The main point is to find whether the globe is open or there is enough evidence to suggest this possibility (subconjunctival hemorrhage, hypotension, a deep anterior chamber, etc.). Physically restraining a pediatric patient during the exam is advisable only if an open globe has been ruled out. Otherwise, a struggle has a high risk of further damage and tissue extrusion. If an open globe cannot be ruled out, exam under anesthesia (EUA) is warranted. If an EUA is necessary, obtain consent for injury repair beforehand so the procedure can be done under the same anesthetic. If there is any possibility of a foreign body or orbital fracture, obtain a CT scan prior to EUA.

    Once the evaluation has been completed, an assessment needs to be made of the involved tissues, the extent of the damage, and what steps need to be taken for the repair or treatment to obtain the best results, both functional and cosmetic. Discuss the available treatment options with the responsible parties (parents, guardians) in an honest, compassionate manner to address the risks, benefits, and best alternatives. Make sure they understand the possibility of complications, the likely need for future additional procedures and long-term follow-up, and that the prognosis is reserved. How much of this information is shared with the child is up to the parents, but an informed child (according to age and understanding) is usually a more cooperative child.

    Ocular Manifestations of Head and Body Injuries

    Trauma in other parts of the body can have severe consequences regarding vision. Child abuse is a very important cause of ocular injuries. Up to 40% of battered children present with eye injuries.12 The ophthalmologist plays a crucial role in identifying these patients. Suspect child abuse in all cases of pediatric eye trauma. Suspect child battering if the history does not match the clinical picture or if there is no clear explanation for the injuries. These children often have been seen on multiple occasions in different hospitals. They might present with bruises in different stages of resolution, fractures, and/or skin burns, and are often malnourished and dehydrated. Eye findings can run the gamut of blunt ocular injuries and they can be associated with findings suggesting intracranial trauma.

    One of the most severe forms of abuse is nonaccidental trauma, or shaken baby syndrome, which is responsible for 1,200 deaths per year in the United States. This condition usually affects infants younger than 6 months of age, but can present in older children as well. An infant is light enough to be carried and shaken vigorously and does not have the neck-muscle strength to hold a proportionally large head and to avoid a whiplash-type injury to the brain. The history is often incompatible with clinical findings. Common findings include lethargy, irritability, and vomiting (due to brain edema and intracranial hypertension) with intraocular and retinal hemorrhages, subdural hematomas, seizures, bruises, and rib and long-bone fractures. Other signs of abuse might be noted: skin burn marks, scars, and bruises and fractures in different stages of healing. Additional ocular findings include choroidal hemorrhage, retinal detachment, perineural optic-nerve hemorrhage, and macular folds. The prognosis is not good overall. The mortality rate is 20–30% and only 20% of patients recover fully.13 Visual impairment can be due to retinal detachment or folds, optic nerve atrophy, deprivation amblyopia, or cortical blindness. Most will develop variable degrees of cerebral damage. Ophthalmologists, pediatricians, and social workers have a very important role in identifying these patients and protecting them from further harm.

    Purtscher retinopathy refers to the whitening of the retina associated with retinal hemorrhages typically described after compressive thoracic or head trauma. Whitening of the retina is due to ischemia manifested by widespread cotton-wool spots.14,15 Several mechanisms have been described including venous reflux and vasospasm following increased pressure in the superior vena cava system as well as air and fat embolism, among others. Visual acuity can be severely compromised, and if asymmetrical, can produce an afferent pupillary defect. No treatment has proven efficacious and vision rarely recovers, but there is anecdotal evidence of high-dose systemic steroids being useful.15

    Terson syndrome refers to the simultaneous appearance of intracranial (usually subarachnoid) and vitreous, subinternal limiting membrane or subhyaloid hemorrhage. The intracranial hemorrhage can be of any etiology, including trauma. This intracranial bleeding is thought to cause an increase in orbital venous pressure with rupture of papillary and superficial retinal capillaries. Care of the neurologic problem is paramount and urgent. Vitrectomy should be considered if the vitreous hemorrhage precludes vision and does not clear spontaneously, especially in a child at risk for amblyopia.

    Preventing and treating amblyopia:

    • Maintain a clear visual axis, e.g., remove a traumatic cataract, vitreous hemorrhage, etc.
    • Correct any refractive error.
    • Patch the uninjured eye.

    References

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    2. Jandeck C, Kellner U, Bornfeld N, Foerster MH. Open globe injuries in children. Graefes Arch Clin Exp Ophthalmol. 2000;238(5):420-426.
    3. Strahlman E, Elman M, Daub E, Baker S. Causes of pediatric eye injuries. A population-based study. Arch Ophthalmol (Chicago, Ill 1960). 1990;108(4):603-606.
    4. Oiticica-Barbosa MM, Kasahara N. Eye trauma in children and adolescents: Perspectives from a developing country and validation of the ocular trauma score. J Trop Pediatr. March 2015. doi:10.1093/tropej/fmv010.
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    6. Umeh RE, Umeh OC. Causes and visual outcome of childhood eye injuries in Nigeria. Eye (Lond). 1997;11 ( Pt 4):489-495. doi:10.1038/eye.1997.132.
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    8. Vinger PF. A practical guide for sports eye protection. Phys Sportsmed. 2000;28(6):49-69. doi:10.3810/psm.2000.06.961.
    9. Vinger PF. Sports medicine and the eye care professional. J Am Optom Assoc. 1998;69(6):395-413.
    10. Lehto KS, Sulander PO, Tervo TMT. Do motor vehicle airbags increase risk of ocular injuries in adults? Ophthalmology. 2003;110(6):1082-1088. doi:10.1016/S0161-6420(03)00244-6.
    11. Kuhn F. Ocular Traumatology. Berlin, Heidelberg: Springer Berlin Heidelberg; 2008. doi:10.1007/978-3-540-33825-3.
    12. Tongue AC. The ophthalmologist's role in diagnosing child abuse. Ophthalmology. 1991;98(7):1009-1010.
    13. Kivlin JD, Simons KB, Lazoritz S, Ruttum MS. Shaken baby syndrome. Ophthalmology. 2000;107(7):1246-1254.
    14. Joshi C, Shuckett P, Stockl F. A picture worth remembering: posttraumatic Purtscher's retinopathy in a child. J Child Neurol. 2008;23(3):353-355. doi:10.1177/0883073807308700.
    15. Tachfouti S, Karmane A, El Moussaif H, Boutimzine N. [Purtscher's retinopathy with a favorable outcome after corticosteroids: case report]. Bull Soc Belge Ophtalmol. 2005;(298):45-50.