Fig. 25.1
Types of trauma . An example of the often unusual types of trauma that can be encountered in the pediatric patient population. A screen door handle impaled this 9 year old as he chased his brother into the house
Blows to the ocular area from falling or absorbing a blow, as well as the impact of projectiles like rocks and toys, account for a substantial portion of injuries. In a 1990 study, accidental blows or falls were associated with 37% of ocular trauma, while 27% of injuries occurred during play time and sports activity. Other causes of eye injuries included motor vehicle accidents (11%) and burns (9%) [4]. In another review of 238 children, a Norwegian group found the most common source of injuries were projectiles (22%), toys like balls and arrows (18%), sticks/pencils (10%), and falls (10%) [5].
Trauma to the eyelids and adnexal injury can cause contusions, crush injuries, abrasions, lacerations, puncture wounds, avulsions, or burns. It is not unusual for some combination of these tissue responses to be present. For example, a single dog bite can lead to a puncture wound, a hematoma, a laceration, and an abrasion. In the United States, 44,000 facial injuries occur annually from dog bites, and the majority of the victims are children [6]. Furthermore, dog bites are commonly a source of canalicular laceration in the children, most of whom are boys under 10 years of age [7].
Blunt trauma to the lids and ocular adnexa most commonly result in contusions and hematomas. Because of the fascial planes in the periocular area associated with the loose connections in the subcutaneous tissue, hematomas in the eyelids often remain localized and can expand to an impressive size (Fig. 25.2). It is always important to evaluate the orbit and globe for more serious injuries when large hematomas are present in the lid (Fig. 25.3).
Fig. 25.2
Lid hematomas secondary to blunt trauma . Lid hematomas from blunt trauma can remain localized and expand in size; they can also obscure significant injury to the globe
Fig. 25.3
Lid hematoma in a 4-year-old child. The pressure of the hematoma is causing superior displacement of her globe
The shearing force and compressive nature of blunt trauma can often cause avulsions . These types of lacerations are usually irregular, deep, and often have pieces of tissue that bridge the defect. Furthermore, lacerations from crush injuries can be more extensive in the deeper tissue planes in association with extensive edema and contusion. A review of 222 patients with ocular injuries by LaRoche et al. found that 3% also had lid lacerations [8].
When evaluating a lid laceration , it is important to inspect for damage to the lacrimal drainage system which can modify the treatment plan. Sharp trauma from knives, for example, will lead to smooth, well-defined lacerations (Fig. 25.4). Also, the amount of surrounding edema and hematoma is much less when compared to a laceration induced by a blunt, crushing injury. Puncture wounds are another form of sharp injury. Again, these wounds can often look very superficial and harmless since there is usually little edema or bleeding. The presence of a retained foreign body or deep tissue damage needs to be considered in any puncture wound (Fig. 25.5). Careful exploration and irrigation of these wounds are required. When a patient is examined a few hours after an injury, a wound has had time to stick together due to fibrin and clotting. Thus it is critical when examining a patient to apply a wet compress over the wound and mildly manipulate the tissue. Sometimes an eyelid that appears apposed is actually covering a large laceration. If this is not tolerated, a sedated exam in the emergency room or under general anesthesia is warranted. Before any manipulated of the ocular adnexa, however, a penetrating or perforating ocular injury must be ruled out. A low threshold must be held to examine a patient under anesthesia to rule out an ocular injury.
Fig. 25.4
A seemingly minor eyelid laceration with ptosis. Surgical exploration confirmed involvement of the levator muscle in the laceration
Fig. 25.5
Foreign body in lacrimal sac . (a) Eight-year-old patient with hemophilia and no history of trauma developed epiphora over preceding year. (b) Exploration of lacrimal sac reveals graphite foreign body. Family later recalls puncture wound from a pencil several years before. Appropriate hematologic factors were given preoperatively and successfully controlled hemorrhage during surgery
Projectiles are a common source of eyelid and ocular injury. Rocks, slingshots, arrows, bungee cords, toys, and balls are some of the many objects that can cause trauma when hurled. The impact of the object can cause lacerations, hematomas, and severe injury to the globe. This illustrates that a full eye exam is imperative in every trauma patient (Fig. 25.6).
Fig. 25.6
Example of blunt trauma (rock) causing both a lid laceration and rupture of the globe
Air guns that shoot pellets and BBs are another dangerous source of eyelid and ocular projectile trauma . A study done at Johns Hopkins University revealed that 91% of air gun shooters were male as were 89% of the victims. On average, the victims were 13 years old. An interesting point of this study was that 45% of the victims were the intended target, while 26% of those injured were hurt because of a ricochet [9]. Almost all of the injuries were caused by an acquaintance.
Explosion injuries in children are almost always from fireworks. An article published in a 1996 study found that 29% of firework injuries were noted to involve the eye and 18% involved other areas of the face. Almost all the injuries occurred in a 3-week period around the July 4 US Independence Day celebration. The victims averaged 8.5 years in age and about three quarters were male. The most common type of injury was a burn (72%), and firecrackers were the most common type of firework device involved (42%) [10].
Evaluation
Since pediatric trauma is often unusual , an accurate history is imperative. If the injury was due to a fall, the height of the fall and the impact surface should be determined. If the child was struck with an object, the type of object (wood, metal, rock, glass, etc.) and an estimate of the speed of the object (thrown, shot, etc.) should be determined. Knowledge of the mechanism and severity of trauma will help to guide the physician in the initial diagnosis and management of the damage. If the object causing the trauma is available, it should be inspected. A pencil, for example, should be examined to rule out the loss of its tip or any fragments. This would necessitate orbital imaging.
The level of consciousness of the child immediately following and subsequent to the injury should be determined if at all possible. A patient must be cleared by the emergency room or primary trauma team to be examined. Even the ophthalmologist should remember the value of assessing for airway, breathing, and circulation (the trauma A-B-C’s) before examining the eyes and eyelids. It is also important to obtain the immunization status of the child and a past medical history including current medications being used and any known allergies.
As with any form of ophthalmic trauma , the first concern after insuring the integrity of the airway, respiratory, and circulatory systems is the status of the visual system. When the patient’s age and type of trauma allow the practitioner to obtain a visual acuity, it should always be documented. A near vision card is usually quite satisfactory for this purpose. In younger children, the ability to fixate on an object with the opposite eye covered is an excellent indication of an intact visual system.
The pupillary response to light stimulation also provides invaluable information. When the visual acuity cannot be obtained, the pupil response may be the only evidence of an intact visual system. The presence of an afferent pupillary defect (Marcus Gunn pupil) may be the only evidence of optic nerve damage in the presence of severe trauma.
Once the integrity of the vision has been established, attention turns to the visible trauma. In many cases, all of the damage from the trauma is readily visible. Four major concerns should be addressed during this secondary survey. First, are there any retained foreign bodies? The mechanism of trauma will help guide this concern, but it is safest to assume the presence of retained foreign bodies with any projectile-type injury until determined otherwise. Second, is there any missing tissue? Although it is very unusual for even the most severe trauma to result in significant loss of tissue, first appearances can be very deceiving (Fig. 25.7). With large lacerations, tissue will contract and give the appearance of a gap secondary to tissue loss. In most instances, however, all tissue is present and can be repositioned. Third, what is the status of the lacrimal system? With many types of lid trauma, the lacrimal system can be damaged, if not directly, then as a result of the force of the trauma. A 2008 article demonstrated that 66% of eyelid lacerations involved the canalicular system [11].
Fig. 25.7
A lid margin laceration that was difficult to see until the lid was everted
Structurally, the lid medial to the punctum is the weakest and, therefore, the most likely to tear with blunt force [12]. Involvement of the lacrimal drainage channels should be assumed with any avulsion or laceration extending into this area. The canaliculi lie between the anterior and posterior arm of the medial canthal tendon (Fig. 25.8). The canaliculi and both arms of the tendon are usually damaged as a unit. Finally, what damage could be present that is not readily visible? A high level of suspicion is helpful. Is there traumatic optic neuropathy? Is there a fracture? Is the globe damaged? Could there be intracranial damage? A detailed, systematic approach should allow the practitioner to determine all of the above.
Fig. 25.8
Medial canthal anatomy . Artistic rendition of the medial canthal anatomy. Note the lacrimal drainage channels lying between the anterior and posterior arms of the medial canthal tendon. The anterior arm attaches to the anterior lacrimal crest. The posterior arm attaches to the posterior lacrimal crest
Ancillary testing is an important part of the diagnostic process. Any suspicion of fractures or metallic foreign bodies should be further evaluated by the use of narrow-cut computer tomography (CT) scans (see Chaps. 32 and 42). Magnetic resonance imaging is far superior to CT scans in the evaluation of soft tissue, however, has not place in the setting of trauma before the presence of a retained metallic foreign body has been ruled out the presence of deep hemorrhage is readily seen and not distorted by bone. Retained foreign bodies often appear as a low-intensity signal or relative void in the soft tissue on MRI scans, both confirming their presence and providing guidance for removal [13, 14]. High-resolution Doppler ultrasound may also have a roll in the diagnosis and localization of retained foreign bodies, particularly when there is a high level of suspicion and the answer is not evident using the conventional methods of imaging [15].
A final note concerning the evaluation of lid and adnexal trauma in the pediatric patient population is necessary. It is an unfortunate reality that children can be the victims of abuse or non-accidental trauma (NAT or Suspected Child Abuse and Neglect, SCAN). While the vast majority of children evaluated for trauma in this area are not the unfortunate recipients of accidental trauma, the possibility of NAT (or SCAN) cannot be ignored. Child abuse is a serious problem with grave ramifications for the child and caregiver. It is important, therefore, to look specifically for signs that may help to identify victims of abuse. A dilated fundus exam can be performed, looking for retinal hemorrhages to assist in the diagnosis. If the history does not fit the physical findings or if the trauma is repetitive, NAT (or SCAN) must be considered and appropriate social agencies consulted.
Management
The first priority in lid and adnexal management is the overall health of the patient. Facial trauma is often associated with other, possibly more severe trauma. Life-threatening injuries must be managed first. Injuries to the visual system should be managed next.
Most often, management of pediatric lid trauma will require the use of general anesthesia. While repair is urgent, a surgeon can safely wait until the patient has not eaten for 6–8 h, allowing the stomach to empty so that general anesthesia can be more safely employed. This will give the practitioner time to administer tetanus toxoid and consult with other physicians, if necessary. During this time, the injured areas can be coated with an antibiotic ointment and covered with sterile gauze. An exception to this is the presence of an open globe. Repair should be performed as soon as possible in this situation. While not desirable, delayed repair of lid trauma can be safely performed. Lid lacerations can be closed primarily as late as 1–2 days after injury because of the excellent blood supply present in facial soft tissue [16]. Copious irrigation of the wounds during surgery helps to reduce the incidence of postoperative infections. If the wound is from a dog bite or appears infected, antibiotics are started too.
Repair of wounds that do not involve the lid margin are usually straightforward but can be misleading and may involve more damage than is apparent at first glance. This is especially true with penetrating injuries, which can involve the levator complex in the upper lid or even involve the globe. The presence of visible preaponeurotic fat indicates penetration of the orbital septum and possible levator damage. After the wound is cleaned, deep layers are approximated with care taken to insure that appropriate anatomic relationships are maintained. Only the eyelid retractors and conjunctiva should be sutured and never the orbital septum as direct closure of the latter can result in lagophthalmos. For brow and non-marginal lid lacerations , the authors prefer to use a 4-0, 5-0, or 6-0 polyglycolic acid (Vicryl) suture to repair the deep layers (Fig. 25.9). The thinnest suture that supports the wound tension should be utilized. The skin is closed with a 6-0 plain or fast-absorbing gut. For linear sub- or supra-brow lacerations , skin closure with a 5-0 nylon or Prolene suture is also an effective option if the child will tolerate suture removal 5–7 days later. These sutures can be secured as a looped knot at each end to help facilitate suture removal. An application of a cyanoacrylate glue for additional skin closure support can also be an added step that may be useful in many pediatric situations to maintain good closure. The deep sutures provides the structural integrity to the wound during healing while the gut or running subcuticular suture approximates the skin edges if more security for wound tension is required. The use of absorbable sutures on the skin is a particular advantage in the pediatric population. The trauma and difficulty of suture removal is eliminated, and the final scar at the site of the injury is usually quite acceptable.
Fig. 25.9
Deep brow laceration . (a) Laceration before surgical closure with retracted tissues. (b) Laceration 1 week after multilayer closure
Trauma involving the lid margin is more involved. Proper closure of the margin is imperative to avoid notching, rotation, or lash deformities. Also, the degree of injury may not be suspected at the time of exam. The key to a good result is accurate approximation of the gray line of the lid margin [17]. If this suture is properly placed, the remainder of the repair will fall into place (Fig. 25.10). Typically, three marginal sutures are placed. The first passes through the gray line. Using a 6-0 chromic gut or Vicryl suture, the needle is introduced into the lid approximately 1 mm from the edge of the wound. It arcs more widely before exiting into the wound 2–3 mm below the lid margin. It is then introduced into the soft tissue on the other side of the wound at the same depth, mirroring the track of the suture on the first side. The suture is brought together and used to place traction on the lid margin. The wound edges and lid margins are examined. If the alignment is not satisfactory, the suture is withdrawn and repositioned. If the alignment is correct, then additional 6-0 sutures are placed through the lash line at the anterior edge of the lid margin and the mucocutaneous junction on the posterior edge of the lid margin (Fig. 25.11). Alignment is checked with each suture placement. An alternative option for younger patients is to place a vertical mattress suture through the gray line with a 5-0 Vicryl on a P-2 needle with the knot buried in the margin and then a single vertical mattress 6-0 Vicryl anterior to this in the lash line with the knot buried in the same fashion. This has the advantage of not having to remove sutures and removes the risk of the child grabbing at the eyelid sutures and ripping them out.
