Ocular injury in a baby: a suspicious history of trauma involving both anterior and posterior segment that have resulted in some degree of phthisis bulbi
In this chapter, we described the epidemiological and clinical characteristics, hot topics in the current understanding, current consensuses, controversial areas, and treatment of mechanical ocular trauma in children.
6.2 Epidemiological and Clinical Characteristics of Mechanical Ocular Trauma in Children
Ocular trauma may affect children at any age but peak incidence is about 5–9 years . Boys are affected about two or four times more than girls [11, 12]. Ocular trauma generally occurs at home [10, 11, 13]. In our study representing 182 pediatric open globe injuries in Turkish population, 45.1 % of injuries occur at home . Particularly, infants and younger children are at great risk at home without adult supervision. Furthermore, immature motor-mental skills, carelessness, and uncontrolled emotions increase the rate of home injuries in younger children . The incidence rate of outdoor places such as streets and roads and school tends to increase in older children .
6.2.1 Environment and Injury Sources
Ocular injuries are commonly accidental compared to those caused by violent assaults and work-related injuries in adults. In general, injuries occur while the child is playing or in sports activity [1, 14]. Accidental falls and blows, hand or finger nail, or toys are the common injury sources in younger children [15–17]. Injuries due to sports account for 27 % of all pediatric ocular trauma that requires hospital admission, and the rate of these injuries increase in older children . In a study from Taiwan, sharp objects (39.8 %) were the common causes of ocular injury . Incidence of projectile-related eye injuries is increasing in the last years due to lack of eyewear protection or adult supervision. Projectiles such as thrown objects (25.2 %) and toy gun bullets (23.1 %) were the major etiologic agents of severe ocular injuries in Greece . Visual outcomes of projectile-related injuries are poor particularly in paintball or air gun injuries and firework-related injuries [20–22]. Listman reported that 43 % of children had a final visual acuity less than 20/200 after paintball injury . Sternberg et al. reported that 59 % of the cases injured with BB pellets required enucleation or evisceration . About 20 years ago, firework (all kinds of explosive agents)-related ocular injuries were creating a burst incidence during especially at short-term festival-like holidays in Turkish children. Nowadays, this kind of injuries occurs very rare after rigid prohibition of explosives by law. Injuries caused by animal attacks (rooster attack, dog bite) or fish hook are prevalent in rural areas [23–25]. Furthermore, hypodermic needle injuries are surprisingly frequent in children .
6.2.2 Mechanism of Injury
Almost all ocular injuries occur by direct mechanical effect. Other rare causes of ocular injuries are indirect effects of head or body trauma. Terson’s syndrome and shaken baby syndrome are well-known indirect causes of ocular injuries (Fig. 6.2a, b).
(a, b) Bilateral indirect ocular injury in a toddler: an 8-month-old baby had visual loss, nystagmus, vitreous hemorrhage, premacular sub-ILM hemorrhage, and optic atrophy in both eyes after a traffic accident 2 months ago. The baby was hospitalized for intracranial, subarachnoid hemorrhage before referral to the eye department. A successful bilateral vitrectomy and ILM peeling were performed to clean premacular hemorrhage. Although rate of nystagmus was diminished, visual acuity gain was limited after the surgery because of bilateral optic atrophy that may be related to intracranial hemorrhage
Mechanical ocular injuries may be open or closed globe injuries. Closed globe injuries constitute the largest part of the mechanical injuries . Closed globe injuries may be caused by blunt object (contusion), partial laceration with sharp object (lamellar laceration) (Fig. 6.3), and superficial foreign body. Most of the closed globe injuries do not require hospitalization or surgical intervention and have a favorable outcome compared to open globe injuries.
Closed globe injury: sharp object induced lid laceration and lamellar scleral incision
Open globe injuries are encountered 27–48 % of all pediatric ocular injuries [27–31]. Incidence rates increase in hospital-based studies or cases requiring surgical intervention [12, 32]. Open globe injuries constitute of rupture, penetrating injury, perforating injury, and intraocular foreign body according to the Birmingham Eye Trauma Terminology . Penetrating injuries are the most common mechanism in open globe injuries [8, 34]. Anterior and posterior segments are insulted at the same time at almost half of these injuries  (Fig. 6.4). Globe ruptures are encountered 9–17 % of the cases in open globe injuries, but the visual outcomes seem to be poor compared to penetrating injuries [8, 28, 36, 37].
Sharp object induced periocular lid laceration and open globe injury in an 8-year-old boy; corneoscleral incision and involvement of anterior segment structures; iris, lens, and ciliary body
Taking a reliable history from a child is difficult because:
Most of the injuries are not witnessed.
Child may not realize visual loss.
Child may be distressed and uncooperative.
Child may feel itself responsible for the accident and may be afraid of parents’ retribution or punishment.
History of the ocular injury should be thorough and preferably taken from the child and includes:
Time of the injury (important for open globe injuries).
Place of the injury.
Mechanism of injury (blunt or sharp object, possibility of retained intraocular foreign body).
Any change of vision.
Any intervention at the time of or after the initial injury.
Past medical and ocular history.
Injury with an animal bite is more common in children and requires tetanus or rabies prophylaxis.
It is very important not to remove superficially observed foreign bodies, those that may be in contact with ocular structures or have ocular penetrations out of operation room. Otherwise, ocular tissues may be damaged while removing foreign body or leaking wound may induce further tissue prolapses.
Eye protection with a sterile eye pad until the surgery is not necessary if there exist large foreign bodies those are superficially exposed as seen in Fig. 6.5.
Open globe injury with visible foreign body: a 12-year-old boy was exposed to ocular injury while working at a car repair facility. A piece of wire was responsible from the injury, and one end of the wire was in the anterior chamber. Luckily the body was transferred to our clinic by the help of two other elderly workers keeping the lids open without touching the foreign body. He was taken to the operating room immediately, and corneal repair and foreign body removal were performed. No other tissue damage was noted during the operation, and the eye had 20/20 vision during the follow-up
Examination should be quick to determine the extent and management planning of the injury.
In noncompliant children, examination may be performed under general anesthesia.
Parents may be asked to assist the examination because the child may be distressed or uncooperative and resist the examination .
Examination starts with a quick inspection of the lids, the adnexa, and the globe for determining wounds, tissue prolapse, chemosis, hemorrhage, and superficial or protruding foreign bodies.
Initial visual acuity:
It is important for the prognosis of injury, but unfortunately in small-aged, noncompliant children, that is frequently not possible. Also in open globe injuries involving the cornea, correct visual acuity examination is rarely possible.
It should be assessed in each eye separately in age-appropriate manner (Snellen or ETDRS chart for school-going children, E charts for preschool children, and fixation and follow for infants).
In the presence of no light perception, electrophysiological tests (ERG/VEP) may be performed in order to evaluate visual integrity. It is also important to remember that negative ERG/VEP responses are not an indication for enucleation or evisceration.
Direct and indirect light reflexes
The presence or absence of relative afferent pupillary defect (important for prognosis, the presence of associated traumatic optic neuropathy or severe retinal injury)
Shape of pupil (any retraction of the pupil may indicate the presence of open globe injury)
Intraocular pressure (IOP):
Low IOP may indicate an underlying open globe injury.
Note: IOP may be normal or elevated especially if the leaking wound is obstructed by the prolapsing intraocular tissues in a case of OGI.
Extent and the length of the wound:
Injuries extending more posterior and wounds greater than 10 mm are associated with poor visual prognosis and high risk of RD development [39, 40] (Fig. 6.6a–c).
(a) Open globe injury with a sharp point kitchen knife in a 4-year-old boy. A corneoscleral wound with deeper penetration involving the iris and lens damage is clearly seen. (b) Measuring posterior scleral extension of the wound is crucial during the operation. (c) Corneoscleral saturation and reforming anterior chamber with air. Postoperative evaluation showed dense vitreous hemorrhage, retina and choroidal cut, and detachment posteriorly
Scleral wound that is not extending more than 5 mm from the limbus does not always indicate survival of the retina. Sharp objects with anteroposterior directional forces frequently touch posterior retina-choroid once it penetrates anterior eyewall in children. Smaller axial length in children may be an additional factor for this situation.
Evaluation of vitreous, retina, and choroid.
If posterior segment examination is difficult owing to media opacities, diagnostic tests such as ocular USG may be deferred after primary open globe repair (Fig. 6.7a, b).
(a) Serous choroidal detachment and (b) hemorrhagic choroidal detachment demonstrated by ocular USG. (c) Hemorrhagic choroidal detachment (red stars) demonstrated by orbital CT
At the time of OGI, orbital CT may be sometimes helpful in order to diagnose choroidal detachment before primary open globe repair (Fig. 6.7c).
6.4 Anterior Segment Injuries and Management
In adult population, spontaneous subconjunctival hemorrhage may occur without ocular trauma, and conversely in childhood, spontaneous subconjunctival hemorrhage is extremely rare so that subconjunctival hemorrhage is a strong indicator of ocular trauma in children and helpful especially in cases of poor cooperation (Fig. 6.8).
Traumatic subconjunctival hemorrhage in a child after a needle penetrating nasal sclera
Treatment is not necessary if it is sole.
It may be associated with occult scleral lacerations, and in eyes with occult laceration suspicion (lower IOP, distorted pupil, vitreous hemorrhage, wrinkled lens capsule), surgical exploration is required.
Larger lacerations require saturation.
Corneal foreign body:
Superficial foreign bodies can be removed in the biomicroscope with cotton wool tips or sharp needle (Fig. 6.9).
Corneal metallic foreign body in a 16-year-old child while working at a repair industry
Deep corneal foreign bodies (unless they are not penetrated anterior chamber) should be removed in operating room in noncompliant children.
Erosion is usually characterized with pain, tearing, photophobia, and decreased vision.
Child often keeps the eye closed.
Erosion is detected with fluorescein dye testing (Fig. 6.10).
Corneal erosion that is easily demonstrated by fluorescein dye testing and visualized by blue filter of pen light in a child that cannot be examined by slit lamp microscopy
Corneal laceration is the most common finding in pediatric open globe injuries .
Sports injuries and automobile crashes (airbag injuries) are major causes of globe rupture in older children .
Certain eyes are prone to rupture with minor trauma (Ehlers-Danlos syndrome, osteogenesis imperfecta) .
Ruptures occur generally in the weakest point of the eyewall (behind the insertion of the extraocular muscles).
Subconjunctival hemorrhage, distorted pupil, shallow anterior chamber, wrinkled lens capsule, and lowered intraocular pressure may be the signs of occult penetration.
The Seidel test is used to determine the leakage of aqueous humor.
In some self-sealing corneal wounds, gentle pressure may help to detect the leakage from the wound.
Bandage contact lenses may be sufficient in self-sealing partial-thickness lacerations (suturing may be necessary in noncompliant patients).
In cases with full-thickness laceration, prompt primary globe repair should be performed to restore the structural integrity as well as prevention of infection in children.
Fibrin clots often form quickly in children after primary repair and may simulate lens cortex appearance.
Children under the age of 9 are at risk for amblyopia. Refractive correction with spectacles or contact lens combined with occlusion therapy should start as soon as possible.
In adults, sutures are generally removed after 3 months. But the pediatric cornea is less rigid and sutures are loosened earlier than adults.
Leukoma and anterior synechiae are the common sequelae of corneal laceration .
In extensive corneal opacities, penetrating keratoplasty (PK) may be indicated.
In children reported rate of 1-year graft survival is between 70 and 100 %, but long-term graft survival is not so good [44–47]. Also in cases of PK combined with vitreoretinal surgeries, prognosis is poor [48, 49].
PK is necessary if corneal opacity is obscuring posterior segment visualization in the presence of a serious posterior segment pathology (retinal detachment, choroidal detachment, intraocular foreign body, etc.). In such cases, a temporary keratoprosthesis is used during the operation, and PK is performed at the end of the operation (Fig. 6.11a–d).
(a, b) Removing corneal disk after trephining. (c) Temporary keratoprosthesis and (d) PK completed following posterior segment surgery
Interrupted sutures should be used and removed earlier due to high rate of vascularization in children .
Hyphema occurs due to tearing of iris vessels after blunt trauma or direct insult of the eye by penetrating object (Fig. 6.12).
Total hyphema with scleral rupture
Child abuse should be considered. Furthermore, intraocular tumors (retinoblastoma) or bleeding diathesis should be kept in mind.
Complications are secondary hemorrhage, increased IOP, optic atrophy, peripheral anterior synechiae, and corneal staining (Fig. 6.13).
Corneal staining by hemosiderin
Children with clotting problems are prone to secondary hemorrhage.
Due to the difficulty of detecting early corneal blood staining and measuring the IOP in younger children, early surgical intervention may be advocated in total hyphema that persists for 4 or 5 days (Fig. 6.12).
Inpatient or outpatient management is controversial.
Parents should be warned for activity limitation, medication use, and follow-up examinations in outpatient management .
Hospitalization is indicated if parents are not able to supervise the child for strict bed rest, large hyphema exists, or the child has sickle cell disease.
Traumatic cataracts account for 29 % of all childhood cataract and may occur after both open and closed globe injuries  (Fig. 6.14).
Traumatic cataract formation in a case of open globe injury
An abnormal red reflex or leukocoria may indicate the presence of cataract in preverbal children.
Partial cataracts may not require surgical intervention in older children by determining visual acuity with the Snellen chart.
Iridodialysis may result in monocular diplopia, photophobia in larger defects, and cosmetic problems. Iridodialysis can be fixed surgically (Fig. 6.15a, b).
(a) A 16-year-old boy: iridodialysis, traumatic cataract, and retinal detachment after a traffic accident. (b) Same patient after combined surgery including iridodialysis repair
6.4.2 Total Aniridia
Partial or total iris defects (Fig. 6.16) also cause photophobia, visual impairment, and cosmetic problems. Artificial iris implantations, aniridia contact lenses, or sclerally fixated aniridia lenses (Fig. 6.17) are frequently used treatment options.
Total traumatic aniridia
This is another case of combined anterior and posterior segment trauma. He was 7 years old at the time of trauma. Corneoscleral penetration, total aniridia, traumatic cataract, and retinal detachment were prominent findings. After successful repair of retinal detachment, anterior segment reconstruction was done secondarily. He was complaining about photophobia. Ophtec aniridia lens was the choice for the correction of aniridia and aphakia together. This picture is 7 years after the surgery
6.5 Posterior Segment Injuries and Management
Management of posterior segment injuries requires special attention in children due to:
Different anatomical structures:
Distance of pars plana from the limbus is closer when compared to adults so corneoscleral lacerations may be related with anterior retinal damages.
Remember surgical sclerotomy sites from the limbus:
<6 months: 1.5 mm
6–12 months: 2 mm
1–2 years: 2.5 mm
2–6 years: 3 mm
Shorter axial length: Penetrating injuries may involve posterior segment structures with relatively shorter penetrations compared to adult age.
More adherence of vitreous to the retina (difficulty of inducing posterior vitreous detachment (PVD) during surgery) and lens capsule
Amblyopia risk under age of 9 years .
Unlike in adults (PVD or diabetic retinopathy), trauma is the main cause of vitreous hemorrhage in children (73.1 %) .
Vitreous hemorrhage may occur after blunt or penetrating injuries, shaken baby syndrome, trivial trauma in children with blood dyscrasia, or Terson’s syndrome which is exclusively related with traumatic subdural hemorrhage in children (Fig. 6.2a, b).
Younger children do not complain decreased visual acuity, floaters, or pain; they present with strabismus, abnormal red reflex, or nystagmus.
Vitreous hemorrhage may obscure the accompanying retinal pathologies that can lead to retinal detachment. Furthermore, it precipitates the fibroblastic intraocular proliferation more prominently and acts as a scaffold for intraocular proliferation [55, 56].
Vitreous hemorrhage is a major risk factor in the development of proliferative vitreoretinopathy .
Severe vitreous hemorrhage following ocular trauma has a low rate of spontaneous clearing .
Retinal detachment is characterized with late diagnosis that is associated with more frequent macula-off status, extensive multiple-quadrant retinal detachment, and higher rates of PVR development in children [62, 64–66].
Due to retinal torn on the impact site.
Due to retinal breaks: retinal dialysis (Fig. 6.18), flap tears (Fig. 6.19), giant tears, necrotic tears, or retinal incarceration.
Retinal detachment with retinal dialysis
Retinal detachment with retinal flap tears
Commonly, initiation of an intraocular fibrocellular proliferation from the wound site through the vitreous gel and the retinal surface with membrane formation and contraction of these membranes leads to tractional retinal detachment (Fig. 6.20) .
Retinal detachment with intraocular fibrocellular proliferation
Delayed surgical intervention and increased fibroblastic activity in children higher than adults account for high frequency of PVR development (up to 64 %) in pediatric population .
PVR is the main cause of surgical failure following RD repair (two thirds of cases) .
Surgical treatment is vitrectomy, scleral buckle, or a combination of these procedures.
It is used to support the vitreous base and relief the anteroposterior traction.
Its use in children is unique aspects because:
Sclera is thinner and thinner suture materials should be used.
<2 years a 2 mm, >2 years a 2.5 mm encircling band is used.
Scleral buckle should be cut if the retina has stable reattachment following surgery due to complications such as extraocular muscle instability and refractive amblyopia caused by myopia.
Vitrectomy is preferred in eyes with:
Rupture or perforating injuries
Traumatic cataract with posterior capsule injury
Tractional or hemorrhagic retinal detachment
Giant retinal tear
While performing vitrectomy, tenting of the retina indicates very strong vitreoretinal adherence .
Vitrectomy should be complete to prevent proliferative vitreoretinopathy development and surgical failure [60, 61, 67].
Visual outcomes (final visual acuity > 20/200) of traumatic retinal detachment are between 0 and 69 % [8, 15]. Poor visual outcome is associated with younger age, the presence of PVR, preoperative macular detachment, poor initial visual acuity, and eyes requiring vitrectomy [64, 68].
Vitrectomy performed in eyes has poor visual acuity compared to scleral buckling, but it is related with the severity of the injury in vitrectomized eyes rather than the surgical technique .
Traumatic macular hole:
Generally occurs after a blunt trauma .
Spontaneous closure rate is higher in children than adults (50 % vs 28 %) .
Strong vitreoretinal adhesions in children challenge to create PVD which is important for surgical success.
Autologous plasmin is used to facilitate PVD formation in children .
Silicone oil may be the choice as endotamponade in noncompliant younger children.
In children, endophthalmitis following open globe injuries is encountered higher than adults (54.2 %)  (Fig. 6.21).
Endophthalmitis following open globe injury
Higher incidence of traumatic endophthalmitis may be related with high rate of delay in diagnosis and treatment in children .
Causative microbial agent is different in children from adults. In children, streptococcus species and in adults staphylococcus species are the predominant microbial agents [77, 78].
Risk factors for endophthalmitis after open globe injury:
In children, lens capsule rupture is not determined as a risk factor for posttraumatic endophthalmitis [76, 81].
Immediate vitrectomy combined with intravitreal injection of 1 mg/0.1 mL vancomycin and 2.24 mg/0.1 mL ceftazidime is the treatment of acute posttraumatic endophthalmitis .
6.5.1 Current Consensuses for the Timing of Cataract Removal and IOL Implantation
In cases with anterior lens capsule tear which can cause rapid IOP elevation to high levels in children or anterior lens dislocation which can cause a pupillary block, primary lensectomy should be combined to primary wound repair in open globe injuries. In closed globe injuries, cataract extraction is generally combined with IOL implantation in children older than 2 years old at the time of trauma or hospital admission. In open globe injuries, generally, a delayed cataract extraction and primary IOL implantation are preferred after primary wound repair older than 2 years old unless posterior segment involvement is present. In combined anterior and posterior segment injuries, simultaneous cataract extraction and vitreoretinal surgery may be performed, and IOL implantation may be planned when the posterior segment, particularly the retina, is stabilized .
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