First, a complete account of the accident should be obtained. In some situations parents or baby-sitters have not witnessed the accident and may be unable to give an exact accounting. The child should be questioned and may be able to provide valuable information regarding the accident. Isolating the child from the parents may reveal a more accurate history of the events. From the history, the nature and extent of the injury can be determined, which aids in how extensive an evaluation is needed. Knowing the type of trauma may alert one to look for secondary ocular effects, such as fat emboli from a crush injury. Injuries caused by large blunt objects may produce contusions to the periorbital region and would favor contrecoup retinal problems and blowout fractures of the orbit along with rim fractures. Missiles or sharp objects would raise the suspicion of a perforated globe or retained foreign bodies in soft tissues or the orbit.

Because of the potential for general anesthesia, pertinent past surgical history of the patient and drug allergies are important to obtain along with current immunizations. Although the incidence of tetanus is rare, in the United States booster doses of tetanus toxoid should be received every 5 years to maintain adequate immunity and should be administered in “dirty” cases.¹ A dose of 0.5 ml of tetanus toxoid is appropriate for immunized children. If the child has not been immunized, the tetanus immunization series should be initiated with a 0.5-ml dose of diphtheria-pertussis-tetanus vaccine.

Even in the pediatric age group, a complete medical history is necessary. Although the incidence of transmissible disease is low, the potential exists and one should not hesitate to obtain permission for testing for human immunodeficiency virus and hepatitis. Medical conditions should be considered with particular attention to hematologic and bleeding disorders. Knowing the sickle cell status in black patients is important before general anesthesia is administered.

Examination should be as extensive as the injury permits. If there are other injuries that must be addressed, the examination and treatment may be modified as determined by the severity and extent of those injuries. Recording visual acuity should be attempted on all patients with ocular and periocular trauma. Various methods of evaluating the vision include Snellen letters, random Es, Allen pictures, finger counting, and light perception with or without projection. One must consider the child’s age and the severity of the injury when determining the appropriate visual acuity test. The severity of ocular injury can be assessed by its affect on vision. Initial visual acuity is known to be a prognostic indicator of final outcome.

After all information has been gathered, a definitive plan of action can be considered. If surgery is needed for a rupture, repair must be made as soon as possible. Correction of external problems involving the eyelids and lacrimal system can be delayed for 24 to 48 hours without increased risk of infection.

After a thorough history and examination have been performed, it is important to document all this information to help in the management of the patient and also be available if any legal action regarding the injury is taken.

A detailed history of the trauma may indicate the nature and extent of the injury. The initial questioning should be directed toward the child, with the parents present to corroborate the story. Children may not readily volunteer the exact cause of the accident for fear of parental reprisal. In this case, it is helpful to repeat the questions to the child in a nonthreatening manner away from the parents. This gives the child an opportunity to provide more accurate details about the accident. The history should always probe for the possibility of an intraocular foreign body with the appropriate ancillary test of roentgenography, CT, or ultrasonography. Plain films are of little value except as a screening device. It is important to note whether eyeglasses or contacts were worn at the time of the injury.

It is especially important to know the visual status of both eyes before the injury and whether there is a history of amblyopia or previous ocular surgery. Any medications the child is taking or any hematologic or clotting problems should also be ascertained.²

In our experience, most ruptured globes in children that involve sclera are evident because of severe chemosis and poor vision. These ruptures are often associated with a protruding iris and flat anterior chamber. There may be difficulty in diagnosing a small corneal perforation, which can be self-sealing. As in any ocular injury, the best corrected vision should be determined either with lenses or pin hole testing. Noting whether the pupil is round, eccentric, miotic, or mydriatic or has an altered reaction to light may lead to the realization of a ruptured globe, even if the puncture wound is small.

Motility examination, manipulation of the lids, and intraocular pressure measurements should be avoided in a patient suspected of having a perforation. Shields should be immediately placed on the eye to minimize the possibility of extruding intraocular contents.

Slit-lamp examination can help determine the status of lacerations and hemorrhages of the conjunctiva, corneal defects, foreign bodies, and depth of the anterior chamber. The Seidel test for evaluation of a corneal wound leak is important in determining whether the wound has sealed itself or whether aqueous is being emitted.

Posterior segment examination should be avoided in cases of ruptured globes to prevent possible extrusion of intraocular contents. However, it may be necessary to look for choroidal and retinal ruptures or vitreous foreign bodies.³

Depending on the age and cooperation level of the child, the examiner selects the approach needed to correct the problem. Partial thickness lacerations or small self-sealing corneal lacerations may be managed conservatively with patching, a contact lens, or cyanoacrylate adhesives. These solutions avoid the use of general anesthetics and possible corneal irregularities, which may lead to amblyogenic factors, depending on the age of the child. Admission to the hospital with close observation and antibiotic administration is ideal.

One must consider when faced with the self-sealing wound that a wound leak may develop when the edema from the cornea subsides. The ocular status could also be compromised by the activity of the child.

However, after a surgical decision has been made, it is best to proceed immediately with the repair to avoid possible endophthalmitis. A shield should be worn at all times by the patient to prevent additional complications to the eye. It is also prudent to wait until the laceration is repaired before adding medications to the eye, either in the form of antibiotics or mydriatics, which could prove toxic to the retina.

Every open globe should be treated as a potentially infected case until cultures, which should be taken at the time of surgery, are proven negative and no clinical signs of infection are present. Ideally, antibiotics should not be given until cultures are taken. If there is a delay in taking the child to the operating room, one must use clinical judgment. Broad-spectrum parenteral antibiotics should be initiated either before or during surgery as a precaution against endophthalmitis. Intravenous antibiotics should be continued for 2 to 3 days and then oral antibiotics continued for another 7 days. Cefazolin at a dosage of 50 to 100 mg/kg/day intravenously divided every 8 hours would provide broad spectrum coverage until culture results are available. There are many other choices for broadspectrum coverage. With time and availability of culture results, an antibiotic can be selectively targeted to the specific pathogen found.

The extent of the wound should first be explored so the surgeon understands the complete limits of the laceration. The operating microscope has facilitated this end and when possible it should be used at the time of surgery. The goal is a watertight globe with the lacerated tissues restored to as closely as possible to the original anatomy to help regain normal function.⁴

We have found that most prolapsed tissue can be repositioned within the first 48 hours. Repositioning of uveal tissue is contraindicated when tissues appear necrotic or infected; when this occurs they should be excised. Although a theoretical risk exists, it has not been documented that the risk of infection is greater if prolonged exposed tissue is repositioned so long as there is no evidence of necrosis or infection.⁵

Wound closure should begin by identifying landmarks that can be approximated. Lacerations through the sclera and cornea should first be closed at the anatomic limbus, thus securing normal apposition of the wound and preventing sliding and malapposition of the anatomy. Exposed uveal tissue can be repositioned with an iris or cyclodialysis spatula along with the use of viscoelastics. A close-as-you-go technique for long scleral-corneal lacerations is acceptable as well as halving techniques, in which you approximate the midline of the wound and approximate the two halves. This helps prevent “dog-ears” at the end of the wound.

Nonabsorbable suture (8-0 silk or 9-0 nylon) is preferable at the limbus. The suture of choice for corneal wounds is 10-0 nylon. The knots should be buried when possible. It is preferable to use longer suture bites at the limbus with smaller suture bites closer to the center of the cornea. This aids in preserving normal corneal architecture and prevents severe flattening, which can occur with longer central suture bites.

Vitreous prolapse through a scleral or corneal wound can occur. It is best excised at the lips of the wound using cellulose sponges and scissors. Tugging of the vitreous should be kept to a minimum to prevent retinal complications. As the vitreous is removed, the uveal structure can be repositioned. The use of a viscoelastic may assist in hydraulically repositioning uveal tissue.

Two suture techniques can be used to close the corneal wound. The round circular bite is probably the best but is the hardest to achieve. It is recommended that the box suture be used, which is a through-and-through suture with even bites on either side of the wound. A running suture technique should be avoided in these situations because it may distort the ends of the wounds.

Determining the status of the lens is important. If the lens capsule has been lacerated, the surgeon must decide whether to remove the lens now or later. Removal of the lens can only be attempted after watertight closure has been achieved. A severe corneal laceration may prevent good visualization or stabilization of the wound. Under such circumstances, it may be advisable to wait until the wound has had a chance to heal and can withstand the intraocular pressure generated during lens aspiration. Once the lens appears cataractous, it is best to remove it as early as possible because of the difficulties associated with a hard calcified lens that occur when cortex is exposed to aqueous, as well as the associated risk of amblyopia. Fibrinous precipitation can occur on the anterior lens capsule and masquerade as a cataract. This can be difficult to differentiate from a lens capsule rupture. A lens should only be removed at the time of the initial wound repair if there is evidence of anterior capsule rupture. It is best to wait until a cataract is definitely confirmed in the postoperative period (Fig. 2). Children older than 1 year who have a cataract and corneal laceration that precludes fitting with a contact lens are candidates for intraocular lenses. Only a surgeon with experience in treating pediatric cataracts with intraocular lenses should consider this. A safer situation occurs when the child is older than 3 years of age and will cooperate with a slit-lamp examination. If a lens needs to be removed, it is best to leave the posterior capsule intact for a secondary posterior chamber intraocular lens. If a cataract is mild and there is no capsule rupture, it is best to wait to perform the cataract extraction with intraocular lens insertion until a later date. This allows the posttraumatic inflammation to quiet as well as to decrease the risk of postoperative complications. Extreme care must be taken when removing a traumatic cataract in that there may be an associated zonular weakness increasing the possibility of nuclear loss into the vitreous.

Cefazolin (0.2 ml of 50-mg/ml concentration) should be injected under the conjunctiva at the end of the surgical procedure. Aminoglycosides should be avoided because of the risk of retinal toxicity.⁶ Subconjunctival injection of corticosteroids should be avoided until the surgeon is certain that no infection is present. Atropine ointment (0.5% for children younger than age 1 year and % for children older than 1 year) should be placed to ensure maximal cycloplegia.

Control of postoperative inflammation with restoration of vision in the pediatric age range is critical. Many successful procedures have been performed but have resulted in poor vision because of irregular astigmatism and secondary amblyopia. In visually immature children (younger than 8 years old), plans must be made for visual rehabilitation as soon as the situation permits. This includes the use of contact lenses, patching of the normal eye, and a possible keratoplasty procedure to clear the pupillary space.⁷ Patching the injured eye for more than 24 hours following injury should also be avoided to prevent the risk of iatrogenic amblyopia. Corticosteroids, both topical and systemic, can be used early in the course of treatment. Treating severe inflammation and returning the child to a comfortable condition is paramount.

Children seem to heal much sooner than adults. It has been our experience that corneal sutures can be removed as early as 2 to 4 weeks after trauma. One should monitor signs of healing, such as suture loosening and early vascularization along the corneal wound. Clearing the visual axis and correcting any abnormal refractive errors are essential for a good visual outcome.