The history of the injury usually provides a substantial number of details to assist with management decisions when the orbit has been traumatized. The cause of the injury and character of any projectile or blunt object that struck the orbit should be determined, if possible. The extent of injury created by the trauma is directly proportional to the force; the amount of penetration, if any; and the adjacent tissue damage caused by the penetrating object. A sharp object will cause less surrounding damage than a blunt, penetrating object, for example. This information can be used to guide clinical judgment concerning the extent of damage and any treatment required. A vital piece of information to obtain in the history is the status of the vision immediately after the injury. This cannot be overemphasized. Was there vision loss? If so, was the loss gradual or sudden? Was the loss total or incomplete? The pediatric patient’s injuries and age may prevent accurate history taking. However, parents or older siblings are often witnesses to the injury and can provide helpful information.

A brief ocular exam is essential. As a minimum, the exam should attempt to determine the visual acuity, status of the pupils, and ocular motility. A standard visual acuity with an eye chart or near vision card is preferable. A 2009 article found that visually asymptomatic patients do not have ocular injuries requiring emergent evaluation [1]. There is evidence, however, that 50% of pediatric patients with orbital fractures have associated ocular injuries, so it is still necessary to perform as complete an ophthalmic examination as is safely possible in the acute situation [2]. It may be necessary to manually separate the lids to obtain a visual acuity, but if there is any concern regarding globe rupture, extreme caution is wise and may dictate the use of local or general anesthesia. A lid retractor is often helpful for separating the eyelids. A bent paper clip or Desmarres retractor can also be used. In the younger pediatric patient, the ability to fixate on and follow a target is ascertained, if possible. The response of the pupils to light should be determined. The presence of an afferent pupillary defect indicates optic nerve or diffuse retinal damage. The injured child may be unable to cooperate adequately for the determination of an accurate visual acuity. In this circumstance, the pupillary response is the best indicator of the visual status.

An external exam of the lids and adnexa is performed quickly, providing valuable information. The integrity of the eyelids, including the position of the medial and lateral canthal tendons, is determined. Gentle manipulation of the soft tissue with cotton-tipped applicators is usually possible. Lacerations are examined closely. Lacerations penetrating the orbital septum usually have orbital fat in the wound, which should alert the examiner to the possibility of deeper, more severe trauma. This may involve retained foreign bodies deeper in the orbit, penetration of the globe, or even neurosurgical damage with penetration into the anterior cranial fossa via the orbital roof or into the middle cranial fossa via the deep lateral wall of the orbit and superior orbital fissure.

After the lids are separated, a brief assessment of the integrity of the globe can be made. A shallow anterior chamber indicates anterior globe rupture or penetration. A deep anterior chamber indicates a loss of globe integrity posteriorly. The motion of the globe can be quickly assessed if the patient is alert and cooperative. If the child’s level of consciousness does not allow for direct evaluation of globe motility, forced ductions are necessary. In the pediatric patient, it is usually not possible to perform this test in the office, but it can be done if the child is placed under general anesthesia for any reason. Forced ductions are contraindicated if there is suspicion of a ruptured globe. A positive result indicates either severe orbital edema or entrapment of orbital soft tissue.

Imaging the injured orbit is essential to adequately assess the integrity of the globe and surrounding structures. The ready availability of computed topographic (CT) scans has largely replaced plain film x-rays in evaluating orbital trauma [3]. Magnetic resonance imaging (MRI) is also readily available and offers some advantages over CT scans. The orbital soft tissue is shown in much greater detail. Furthermore, nonmagnetic foreign bodies are revealed more easily with MRI scanning [4]. CT scans are still superior for the evaluation of orbital bone damage, localization of magnetic foreign bodies, and localization of nonmetallic but still radio-opaque objects. When evaluating orbital trauma, it is recommended that CT scans be obtained first, to reveal the presence of any fractures. If greater soft tissue details are needed, an MRI scan of the orbit can then be obtained (see Chap. 32). The younger pediatric patient will require some level of sedation to undergo these exams.

The traumatized orbit is best imaged with thin axial and direct coronal CT scans through the orbit [5]. The spiral CT scan is rapid enough that it may not be necessary to sedate the pediatric patient [6]. These patients are frequently immobilized for C-spine safety, however, and it is often not possible to obtain direct coronal views. It has been suggested that the best protocol is to obtain thin-section axial CT scans, 0.625–1.25 mm. A multiplanar reformation can then provide different views. A three-dimensional reformation is a useful tool when an orbital fracture is present [5].

Close communication between the physician managing orbital trauma and the radiologist is essential. Routine scans of the brain, face, or sinuses do not provide enough data to enable the physician to make proper clinical decisions when managing orbital trauma. The physician should insist that the proper views and scans, as described above, be obtained as the initial study. In this way, unnecessary returns to the CT scanning suite and delays in initiating therapy can be avoided.

Penetration of the orbital soft tissues with a foreign body has very serious potential complications. Not only is the integrity of the globe threatened, but it is also possible to penetrate the cranial vault through the orbit. It is, therefore, safest to assume that an intracranial injury is present with all penetrating orbital injuries until proven otherwise. The energy and size of the penetrating object will determine the severity of the damage [7]. A sharp object or a minute particle, such as a sliver of metal generated by metal-on-metal pounding, may penetrate the orbit and globe with minimal disruption of the immediately surrounding tissue, thus creating little collateral damage and leaving a reasonable possibility of repair with preservation of vision. In contrast, blunt objects or high-velocity projectiles, such as a bullet, can blind the eye without directly contacting the globe.

Dividing penetrating orbital trauma into low-energy trauma versus high-energy trauma is a clinically useful concept. Since not all penetrating objects are associated with significant collateral damage, therapeutic options and expectations are different. Penetrating objects that are small in size or of relatively slow speed cause less surrounding damage. In this category would be most projectiles propelled by the human hand, BBs, pellet gun projectiles, and particles small enough to lack sufficient energy to visibly disrupt the globe (Fig. 42.2). Injuries in this category are also unlikely to result in significant orbital fractures. There may be bony defects at the site of penetration, but significant displacement of the orbital bones is unlikely to occur. The orbital bones may deflect or block further penetration of the foreign body. A small chip fracture may be present at this point. The damage suffered by orbital soft tissue structures will be from direct injury by the projectile. This may involve cutting or tearing of the extraocular muscles, severing of the motor nerve(s) with subsequent deficits in the activity of one or more extraocular muscles, orbital hemorrhage from severing an artery within the orbit, globe penetration with possible intraocular hemorrhage or retinal damage, or any combination of the above. Seemingly innocuous and well-tolerated penetration can result in sudden and complete blindness if the optic nerve is impaled or severed by the penetrating object.

On the other hand, orbital trauma caused by high energy can be devastating. Examples of such trauma include gunshot wounds, blunt trauma from a fall or accident, assault with a club of some kind, and concussion from a blast injury. With this mechanism of injury, the damage is caused not only by the actual penetration but by the shock wave as well. Such a blow can disrupt orbital structures and easily cause rupture of the globe. The injury can be far more extensive than is initially apparent, based solely on the location of the penetration. High-energy trauma is far more likely to penetrate the cranial vault, creating injuries with neurosurgical consequences.

Creating a distinction between high- and low-energy penetrating trauma is not intended to minimize the potential consequence to the visual system of globe penetration with a small fragment. A small metal fragment that would represent a mere nuisance anywhere else in the body can be blinding if it strikes and penetrates the eye (Fig. 42.3). Appropriate and timely intervention by an ophthalmologist experienced in posterior segment trauma can maximize the potential outcome.

Penetrating injuries mandate an imaging study. An orbital CT scan is the most appropriate first choice. This will usually localize any radio-opaque intraorbital or intraocular foreign body [8]. It is not foolproof, however. A foreign body lodged immediately adjacent to the sclera may present a confusing picture (Fig. 42.4). The distinction between intraocular and extraocular location can be difficult. Communication with the radiologist is very helpful in this situation. The gain and contrast on the CT can be manipulated to minimize scatter from metallic foreign bodies. This will also enhance one’s ability to determine the exact location with respect to the globe. Clinical correlation may be necessary. As stated earlier, an MRI offers advantages over CT scans when the penetrating object is a plant foreign matter of some kind (Fig. 42.5). Although plain film x-rays are often suggested as a screening tool, they do not localize foreign bodies within the orbit with the same precision afforded by CT scanning and will not image foreign bodies that are not opaque to x-rays.

The initial management consists of the diagnosis of the injury, extent of the penetration, assessment of damage to the bones and soft tissue, as well as determining if there is a retained foreign body, as discussed above. Nonsurgical management consists of preventing infection and reducing inflammation. The child’s inoculation history should be obtained to insure that the tetanus immunization is up to date. Parenteral antibiotics should be started. At a minimum, a single dose of a broad-spectrum antibiotic such as ceftriaxone should be given. Ceftriaxone has the advantage of a long half-life and can be administered once daily. The duration of antibiotic therapy must be determined by the type of injury. For example, retained foreign bodies that are potentially contaminated, such as wood or plant material, require prolonged therapy because of the high potential for infection. If a longer course of antibiotics is considered necessary, a home health agency may be of assistance, to avoid unnecessary hospitalization. If a purulent discharge does develop, cultures must be obtained to guide accurate antibiotic selection. Topical therapy of intraocular injury should be initiated, if appropriate. Pain medication should not be neglected. Liquid preparations that include codeine are available for the pediatric age group and should be used if appropriate.

Surgical removal of retained orbital foreign bodies is indicated for the following reasons:

It is not mandatory to remove all orbital foreign bodies; clinical judgment is certainly necessary. If removing the foreign body will do more harm than leaving it in place, then removal is not indicated. Removal of small foreign bodies from the orbit is never as easy as it may appear clinically or on a scan. Foreign bodies that can be left in place are usually small and relatively inert, such as glass or small fragments of metal. The composition of the metal fragment may assume importance if it can degenerate and be absorbed with potential systemic consequences (e.g., copper) [8]. It has also been shown that loss of vision is almost always the result of the initial trauma rather than the subsequent management [8].

One of the more common foreign bodies in the pediatric age group is the BB or pellet from a CO₂-powered pellet gun. These pellets are usually composed of metal alloy, which may include copper. If left alone, they will quickly become encapsulated by scar tissue. This sequesters the foreign body from the systemic circulation. Despite containing some copper, the authors are not aware of any harm done by leaving these foreign bodies in place. The initial penetration causes the problem in these instances, and this type of foreign body can be left in place without long-term sequelae (Fig. 42.8).

If the foreign body is one that requires removal, the surgeon should insure that the preoperative localization of the foreign body is quantified as accurately as possible. This requires imaging tests as described above. The surgical approach to the orbit will be dictated by the location of the foreign body. The anterior orbit can be entered easily by utilizing the lid crease incision in the upper lid or the fornix in the lower lid (see Chap. 37). This will minimize postoperative scarring. The lateral orbit can be approached with a lateral orbitotomy. Depending on the location of the foreign body and the damage that has occurred, it may be necessary to enlist the assistance of those in other disciplines, such as the otolaryngologist for concomitant sinus damage or the neurosurgeon for deep posterior foreign bodies which require a transcranial approach (Fig. 42.9). Once it has been decided to remove the foreign body, it is critical to remove the entire object, if at all possible (Fig. 42.10). This can be a clinical challenge with multiple small foreign bodies. Plant material, such as a tree branch, that penetrates the orbit is also difficult to remove in its entirety. Wood or other plant material that is retained will usually develop into chronic orbital-cutaneous fistula. The development of a chronic draining fistula following blunt orbital trauma is a sensitive sign indicating retained orbital foreign material. It may even be unsuspected prior to the development of the fistula (Fig. 42.11).

Blast injuries can occur in the pediatric age group. These are usually related to exploding fireworks. They can be devastating, destroying the globe and lids. Milder injuries that result in retained corneal or intraocular foreign bodies are more commonly seen. Timing of removal depends on the material retained and surrounding damage. A safe general rule is to remove foreign bodies from the globe as soon as the patient can tolerate the procedure. Lid foreign bodies should be removed at the time of repair of the lid damage.

Acute intraorbital hemorrhage that causes decreased visual acuity, acute proptosis, and increased intraocular pressure is a true ophthalmic emergency requiring immediate intervention. The buildup of orbital pressure may be faster than the globe and optic nerve can tolerate, leading to a pressure higher than that in the central retinal artery. This can cause an occlusion of this vascular structure. A brief occlusion may be tolerated by the retina without long-term sequelae, but occlusions lasting longer than 90 min in animal models have demonstrated permanent ischemic necrosis of the inner layer of the retina and permanent loss of visual function [9]. Blunt or penetrating trauma of any type can cause a severe orbital hemorrhage. Children with hemophilia, bone marrow disorders, and severe malnutrition with its associated vitamin deficiencies are predisposed to the development of orbital hemorrhage with even trivial trauma.

Orbital hemorrhage may produce severe proptosis compromising coverage of the cornea, optic nerve dysfunction accompanied by an afferent pupillary defect caused by stretching or compression, or vascular compromise caused by the buildup of orbital pressure. Orbital imaging, either CT or MRI, will confirm the presence of orbital hemorrhage as well as pinpoint its location. Treatment of the hemorrhage is indicated whenever visual function is threatened.

If treatment is indicated, the progression of surgical intervention is as follows:

The canthotomy and cantholysis may be performed in an emergency room setting, even in a pediatric patient. Local infiltration of anesthesia is followed immediately by the procedure. Canthotomy with cantholysis is usually effective in relieving the pressure of the hemorrhage [10]. If this is ineffective, however, then a limbal peritomy or deeper orbital exploration must be performed. This requires general anesthesia in children and the use of operating room facilities.

All procedures for the relief of orbital hemorrhage require that the patient be watched closely to insure that the vision does not decrease. If this does occur, the orbit should be examined immediately, utilizing CT scanning with narrow axial cuts to insure that anterior movement of the globe has not placed the optic nerve on stretch. Release of the lids, on rare occasion, has allowed for enough anterior displacement of the globe to stretch and compromise the optic nerve. Should this happen, an emergent orbital decompression is then indicated.

Blunt trauma may also cause an orbital hemorrhage in a subperiosteal location (Fig. 42.13). This type of hemorrhage will tend to be more localized and less likely to cause severe proptosis. This is obviously not accessible to the limbal approach for emergent drainage. The subperiosteal hemorrhage must be drained when it is considered responsible for visual compromise. This will be determined by the clinical exam, based on visual function, and the results of orbital imaging, defining the size and location of the hemorrhage. Subperiosteal hemorrhages are usually located superiorly or nasally. Either location may be approached through the lid crease.

A question that frequently arises is why the release of orbital pressure itself does not cause more hemorrhaging to occur, thus worsening the clinical situation. The most likely explanation, in our opinion, is that by the time the patient has been brought to the emergency room or physician’s office and the proper diagnosis made, blood clots have already sealed the site of the hemorrhage. Treatment of the hemorrhage, then, releases the pressure without inducing further bleeding. Severe proptosis caused by the lateral canthal tendon release is an indication of the severe orbital pressure elevation that has been present and only rarely indicates continued hemorrhage.