OCULAR INJURIES
Ocular injuries are one of the commonest causes of blindness in children, accounting for ~1 / 3rd of all cases. These injuries are more common in adolescent boys (4:1) and often preventable, caused by sport-accidents, foreign body, fire-works and occasionally child-abuse.
Although spectrum of ocular injuries is diverse (Table 26.13), important ones are discussed here.TABLE 26.13: Common eye injuries in children
• Foreign body
• Blunt trauma
- External: Lid injuries, subconjunctival hemorrhage
- Deep: Hyphema, retinal detachment
- Orbital injuries and fractures
• Penetrating injuries
• Chemical injuries and burns
Foreign bodies are commonest cause of ocular injuries, usually lodged over conjunctiva and cornea and may be floating or embedded.
Sudden development of unilateral red-eye, irritation and epiphora strongly suggests presence of an ocular foreign body, though visualization may be difficult in a struggling child. Conjunctival foreign bodies tend to lodge behind the upper tarsal plate that should always be examined after lid-eversion, while corneal bodies are best seen on slit-lamp examination.
Preliminary management of ocular foreign bodies include gentle removal with a wet cotton bud (if visible and floating) and/or irrigation of eye with plenty of water (if not localized), followed by instillation of antibiotic eye drops. Embedded/occult foreign bodies need ophthalmic referral for removal under slit-lamp. Corneal abrasion/ulceration is the most important complication in these cases, which may be prevented by restraining the child against eye rubbing.
Blunt ocular injuries are often ignored in early stages of head injury and range from self-resolving periorbital or subconjunctival hematoma (black/red eye) to serious orbital fractures.
Possibility of orbital fracture should be suspected in a trauma case with—(a) limitation of upward gaze, (b) lower lid ecchymosis, (c) epistaxis, and (d) ipsilateral facial hyperasthesia due to infraorbital nerve injury as it traverses through orbital floor.
Even in absence of significant vision impairment, all cases of blunt eye injury should be examined for hyphema (blood in anterior chamber) and retinal detachment.Penetrating eye injuries are less common but more serious, usually associated with injury to multiple ocular structures. Firework-accidents are common cause of penetrating eye injuries during festive or wedding seasons in India, usually associated with superficial ocular burns or foreign bodies.
As severe hemorrhage, vision loss and superadded infections are common, these cases should be promptly referred to ophthalmologist after padding the eye.
Chemical eye injuries are usually caused by exposure to domestic or industrial acids or alkali, later being more severe due to saponification of eye-fat that allows further penetration of alkali. Corneal involvement and consequent scarring is the major concern in these cases.
Emergency management of chemical ocular burns include—(a) immediate irrigation with water or saline,
(b) removal of foreign particles during irrigation, if visible, (c) topical antibiotic instillation, and (d) immediate referral to ophthalmologist.
26.3