Pediatric Ocular Trauma

Intro & Assessment - Tiny Trauma Terrors

• Pediatric Uniqueness: ↑Globe elasticity, ↓scleral rigidity. Higher risk of amblyopia post-trauma. Communication challenges.
• Common Causes: Accidental (falls, sports, sharp objects), Non-Accidental Injury (NAI).
• Initial Approach:
  • History: Mechanism, timing, symptoms. AMPLE history.
  • Visual Acuity (VA): Age-appropriate (Fix & Follow, CSM, Lea, HOTV, Snellen).
  • Examination:
    • External: Lids, orbit.
    • Anterior Segment: Cornea (fluorescein, Seidel test), AC, iris, lens.
    • Posterior Segment: Fundoscopy (vitreous, retina).
    • Intraocular Pressure (IOP).
  • Consider Examination Under Anesthesia (EUA) if uncooperative.

⭐ Always consider Non-Accidental Injury (NAI) in children with unexplained or inconsistent ocular trauma, especially bilateral retinal hemorrhages in infants or injuries not matching the given history.

Closed Globe Injuries - Bruises, Burns & Bumps

• Contusions (Blunt Trauma):
  • Lid/Conjunctiva: Ecchymosis ("black eye"), subconjunctival hemorrhage.
  • Cornea: Abrasion, edema.
  • Anterior Chamber: Hyphema; risk of rebleed (days 3-5), secondary glaucoma. Graded I-IV.
  • Iris: Traumatic mydriasis/miosis, iritis.
  • Lens: Vossius ring, cataract, subluxation.
  • Posterior: Commotio retinae (Berlin's edema), vitreous hemorrhage, choroidal rupture.
• Burns:
  • Chemical: ⚠️ Alkali (e.g., lime $Ca(OH)_2$) worse than acid. Immediate copious irrigation vital. Roper-Hall classification.
  • Thermal: Eyelids commonly affected; corneal injury possible.
  • Photokeratitis (UV): Painful superficial punctate keratitis.
• Superficial Foreign Bodies (SFB):
  • Corneal/conjunctival: Pain, FB sensation. Remove; manage rust ring. Prophylactic antibiotics.

⭐ Alkali burns cause liquefactive necrosis (deeper penetration, severe damage) vs. acid burns (coagulative necrosis).

Open Globe & Fractures - Piercing Perils & Bones

• Open Globe Injury (OGI): Full-thickness scleral/corneal defect.

  • Types: Rupture (blunt), Laceration (sharp: penetrating, perforating, IOFB).
  • Signs: Peaked pupil, uveal prolapse, ↓IOP, (+) Seidel, 360° BSCH.
  • Rx: Shield eye, IV Abx (Cipro+Clinda), TT, Antiemetics. Surgery <24h.
  • Imaging: CT scan (NO MRI if ?metallic IOFB).

• Intraocular Foreign Body (IOFB):

  • Localization: CT (gold), B-scan.
  • Material: Inert (glass), Reactive (Fe-siderosis, Cu-chalcosis).

• Orbital Fractures:

  • Blowout (floor > medial): Diplopia, enophthalmos, infraorbital anesthesia, "teardrop" sign.
    • 📌 "I Forgot My Eyeglasses" (Inferior rectus, Floor, Medial wall, Entrapment).
  • Repair if: Enophthalmos >2mm, persistent diplopia, entrapment.

⭐ Most common site for orbital blowout fracture: posterior medial orbital floor.

NAI & Prevention - Hidden Harms & Safe Sight

• Non-Accidental Injury (NAI):
  • High index of suspicion with bilateral, unexplained, or recurrent ocular trauma.
  • Shaken Baby Syndrome (SBS) is a key consideration.
    • Classic triad: Retinal hemorrhages (RH), subdural hematoma, encephalopathy.
    • RH: Often bilateral, numerous, multilayered, extending to periphery.
  • Other signs: Periorbital ecchymosis, hyphema, lens dislocation, vitreous hemorrhage.
  • Differentiate from: Accidental trauma, birth trauma, coagulopathies, CPR artifacts.
• Sympathetic Ophthalmia:
  • Rare bilateral granulomatous uveitis after penetrating trauma to one eye.
  • Prevention: Prompt wound closure; consider enucleation/evisceration of a severely traumatized, blind eye, ideally within 2 weeks of injury.
• Prevention of Ocular Trauma:
  • Parental education: Safe toys, hazard-free home environment, adequate supervision.
  • Protective eyewear: Polycarbonate lenses for sports and high-risk activities.
  • Avoidance of projectile toys (e.g., air guns, fireworks).

⭐ Extensive, bilateral, multi-layered retinal hemorrhages, especially those extending to the ora serrata, are highly suggestive of Non-Accidental Injury / Shaken Baby Syndrome in infants and young children.

High-Yield Points - ⚡ Biggest Takeaways

• Hyphema is common; 8-ball hyphema signifies a poor prognosis.
• Shaken Baby Syndrome often presents with bilateral, multilayered retinal hemorrhages.
• Orbital floor fractures can cause diplopia and inferior rectus muscle entrapment.
• Chemical injuries necessitate immediate, copious irrigation with saline or water.
• Always consider Non-Accidental Injury (NAI) with inconsistent history or unusual injury patterns.
• Open globe injuries are surgical emergencies; avoid any pressure on the globe.
• Sympathetic ophthalmia is a rare, bilateral granulomatous uveitis post-penetrating trauma to one eye.