Pediatric Trauma: Preoperative Considerations
Erin O. Schotthoefer, MD
Pediatric ocular trauma occurs at a rate of 3.3-5.7 million children annually.1
Boys are more likely to injure their eyes than girls, and different mechanisms of injury occur more commonly in different age groups.1
High-risk activities include those that involve projectiles such as air-powered guns or sharp projectiles such as darts. Injuries can also occur at a higher rate during sporting events, related to bungee cord use or secondary to airbag deployment.1 However, the majority of pediatric open globe injuries occur at home.2
Determine the mechanism of injury by history, if possible, to guide examination and treatment considerations. Pediatric trauma is unique because children may not be reliable historians and the injury may be unwitnessed.
In addition to the accidental mechanisms of injury listed above, children are also at risk for nonaccidental trauma inflicted by another person.
Check recognition visual acuity if possible or fixation behavior in preverbal children.
Defer measurement of intraocular pressure until globe rupture has been ruled out.
Evaluate with slit lamp (portable slit lamp, if needed) for conjunctival and corneal injury, traumatic iritis, hyphema, and traumatic cataract.
Hemorrhagic chemosis can be a sign of a full-thickness scleral injury.
A flat anterior chamber or a peaked pupil is concerning for a corneal or scleral laceration.
Perform Seidel testing on suspected penetrating injuries if possible.
Consider CT scan if intraocular foreign body is suspected.
B scan should be performed with caution if there is concern for open globe injury.
Concussive injuries: evaluate for orbital fractures. Evaluate sensory testing of the fifth cranial nerve. Perform full motility testing to evaluate for entrapment. Be suspicious if there is vomiting or vasovagal response with eye movements in children. Even in the absence of globe trauma or significant ecchymosis, pediatric patients’ orbital bones are more flexible and a small fracture of the orbital floor can entrap the inferior rectus or surrounding tissues (the “white-eyed blow out fracture”).3
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