Ocular trauma

13.3 Ocular trauma



Jennie Martin




Essentials



1 Anxiety is pronounced in the carer, be calm in your approach.

2 Consider hidden injury.

3 Never apply pressure to an eye that may be ruptured or penetrated.

4 Commence immediate treatment with chemical injury.


Introduction


Injury is the leading cause of visual disability and blindness in children and has the following features


• severe eye injury is not uncommon;

• all age groups may be affected, peak 11–15 years;

• male predominance after infancy;

• usually unintentional, age-related patterns;

• causes include sports activities (balls or clashes); projectiles; plant thorns; pet bites/scratches; elastic/bungee cords; fireworks;

• education is important as up to 90% of injuries are preventable;

• visual impairment results in an emotional, social and economic cost;

• there are unique challenges to obtaining a history and examination in the child.

Trauma to the eye engenders a marked anxiety reaction in the carer who is always concerned about long term visual impairment. Use a careful and calm approach to enable co-operation so a thorough examination may be performed. Ensure the parent/carer is with the child at all times.


Always consider what may lie beneath an injury that appears to be superficial. Even in an unco-operative child, extensive information can be obtained by observation alone. Uncommonly, mild sedation may be required; however, when there are genuine concerns, referral for general anaesthesia to enable adequate examination is preferred. If gentle restraint has not facilitated examination or a particular procedure, repeated and forcible restraint should not be performed.


Begin by taking a careful history. In addition to aspects of history common to all presentations, ask specifically about existing eye disorders, the mechanism of injury and subsequent events.


Often the injury is unwitnessed or the child may be frightened and so the history may be vague or concealed. Have a high index of suspicion for hidden injury. Specifically ask for visual symptoms of reduction or change in vision. Children are prone to the oculocardiac reflex and a history of bradycardia, nausea, somnolence or syncope strongly suggests a significant injury.


Perform the non-invasive aspects of the examination first. Reassure the patient and carer that you will not hurt them. Dim the room lights if possible, keep the ophthalmoscope light to a minimum. Be systematic and touch last. Importantly, know when to stop and refer.


Document the visual acuity in each eye. Visual acuity testing should be adjusted to the age and ability of the child. Fix and follow testing, ability to reach for a small toy with one or the other eye covered, an Allen chart using pictures (allow the child to identify the pictures closely first), a Tumbling E chart (described as table legs pointing in different directions) or a formal Snellen chart. A difference of two or more lines is significant. Remember the child has a low attention span, so do not insist on them reading every line. If acuity is markedly reduced, use finger counting or light perception at close range.


Follow with a visual inspection. If appropriate, relieve pain with topical anaesthesia early to assist examination.


Examine and document:


• the pupillary shape, size and reaction to light;

• ocular movements in all directions of gaze (nystagmus, diplopia, pain or limitation of movement);

• inspect the lids;

• palpate orbital rims for steps or tenderness;

• test for infraorbital nerve sensation;

• the position of the globes (exophthalmos, enophthalmos);

• the conjunctival surface of eye lids (the deep superior fornix requires lid eversion for viewing);

• conjunctiva and sclera for laceration or foreign body;

• red reflex;

• corneal surface (use fluorescein staining where possible);

• examine the anterior chamber depth and clarity.


Trauma



Lid lacerations


A laceration to the eyelid may be partial or full thickness and may involve the lid margins, canthal tendons, levator complex or canalicular system.


Perform a thorough and complete eye examination to exclude an injury to the globe (see ‘ruptured globe’ below). Pressure exerted by attempts at cleaning and repair may apply pressure to a potentially ruptured globe. Children who are unable to co-operate enough to allow accurate assessment of wound depth should be referred for examination under anaesthesia. If a globe injury is suspected, apply a rigid shield, fast the patient and refer immediately.


The mechanism of injury should be determined to assess the risk of a foreign body (e.g. windscreen shattering), whether a bite (human or animal) and whether significant contamination may have occurred.


Indications for emergency ophthalmologic consultation include:


• bites and those with significant contamination requiring debridement;

• lacerations involving the eyelid margin to prevent notching;

• lacerations on the nasal side of the eyelid punctum – due to the risk of injury to the canalicular system;

• lacerations with involvement of the levator aponeurosis of the upper eyelid (which produces ptosis) or the superior rectus muscle.

• exposure of orbital fat – this suggests the orbital septum has been lacerated as there is no subcutaneous fat in the lids themselves;

• lacerations with significant tissue loss.

Wounds requiring referral should be cleaned with normal saline and have foreign material removed as much as possible. Following cleansing, the wound should be covered with a saline soaked dressing, prophylactic antibiotics commenced for bites or significantly contaminated wounds and tetanus status considered.


If the laceration is suitable for repair in the emergency department, the eyebrow should not be shaved as long-term cosmetic alterations may result and the hair direction assists in correct alignment of the wound. Tissue should not be removed, as the good blood supply of the eyelid generally ensures viability. Partial thickness lacerations should be repaired with 6/0 synthetic suture and full thickness lacerations should be repaired in layers. In general, non-absorbable sutures should be removed in 4–7 days. Tissue glue is not advised due to proximity to the lashes and cornea.



Ecchymosis


A black eye is a common injury and may be limited to a minor ecchymosis of the lid or extend to a periorbital haematoma with significant oedema. Always consider a blow-out fracture of the orbit, globe injury and/or base of skull fracture or anterior fossa fracture (suggested by a subconjunctival haemorrhage without posterior limit). Always document the ocular motility. Care must be exercised when opening the lids so that pressure is not exerted on the globe until a ruptured globe is excluded. If the eyelids are markedly swollen, examination of the eye is difficult. Placing one’s thumb on the infra-orbital and supra orbital rims, the swollen eyelids can be separated without placing pressure on the globe. The eyelids should not be forcibly opened. If a strong index of suspicion exists, place a rigid shield and refer. When swelling limits direct visualisation of the eye, ocular ultrasound is used in some centres to allow non-invasive assessment.


After other injury is excluded, the eyelid haematoma requires no specific management. Cold compresses may provide analgesia for the first 24 hours. The eye should be re-examined in 24 hours to ensure an injury has not been missed. Swelling and bruising may appear to extend down the cheek or to the other eye.

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Sep 7, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Ocular trauma

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