Eye trauma in children: causes, symptoms, diagnosis, treatment

Serious eye injuries in children in developed countries occur with a frequency of 12 cases per 100 000 population annually.

Usually, the trauma is one-sided, but in rare circumstances, with an interval in time, a traumatism or a disease of the twin eye is possible. Injury to the eye can cause a pronounced cosmetic defect and limit future professional choice. Traumatic damage to the organ of vision occurs more often at a young age, especially in boys, as well as in socially disadvantaged groups with a decrease in supervision by parents and a lack of education.

[1], [2], [3], [4]

Injury to the eyelids

Perhaps a combination with a trauma to the face, but an isolated character is also possible. When bites of dogs and other animals often occur concomitant damage to lacrimal ducts.

Damage to lacrimal ducts requires sealing the wound with sutures and draining the wound channel with tubular drainage. With uncomplicated damage to lacrimal canals, microsurgical dissection is performed followed by intubation of the nasolacrimal system through the upper and lower lacrimal canals.

Subconjunctival hemorrhage

It must be remembered that subconjunctival hemorrhages can mask the subject of penetrating damage or injury to the scleral capsule of the eyeball. By themselves, hemorrhages are not dangerous and quickly resolve, without requiring treatment.

Injuries to the cornea

Corneal abrasions occur when it is damaged by sharp objects, such as a knife, rod, etc. Fluorescein drops are used to determine the size of the lesions. In the presence of foreign bodies they are removed. An ointment containing an antibiotic is placed in the conjunctival cavity, and analgesics are buried. Cycloplegia helps to avoid reaction from the ciliary body.

Tears of the capsule of the eyeball

As a rule, they are localized in the corneoscleral region or in the anterior parts of the scleral capsule of the eyeball. Such injuries are necessarily accompanied by intraocular lesions, except for cases of perforation of the eye with very small objects, such as a needle.

Research

1. Conduct an examination of the paired eye, including ophthalmoscopy with dilated pupils.
2. To assess the prevalence of damage, since parts can be covered with hemorrhages, inspection on a slit lamp is mandatory.
3. If possible, the intraocular pressure is measured. With penetrating through injury of the eyeball, the pressure will be reduced.
4. To assess the involvement in the process of the posterior segment and to exclude the presence of an intraocular foreign body, it is advisable to perform an ultrasound examination, especially for hemorrhages in the anterior part of the eye and for cataracts. Computer tomography (CT) helps to exclude the presence of intraocular foreign bodies of the orbit and fractures of its walls, as well as retrobulbar hemorrhages. Magnetic resonance imaging (MRI) is performed when there is a suspicion of a metallic foreign body.

Tactics of reference

Virtually all young children require anesthesia, especially if it is a penetrating wound of the eyeball. In doing so, try to avoid the use of depolarizing muscle relaxants. The wound is sealed using an appropriate absorbable or non-absorbable suture. Non-absorbable corneal sutures in children are removed as early as possible, especially when the seams are sagging or untied. Hyphemus is surgically removed at the same time with the following surgical interventions:

1. injury is accompanied by damage to the lens with its initial turbidity. Lensectomy is performed and, if the posterior capsule of the lens is preserved, supplement the surgical intervention with primary or secondary implantation of the intraocular lens;
2. injury is accompanied by hemorrhages in the vitreous body and other injuries of the posterior segment of the eyeball. Surgical intervention is complemented by vitrectomy or retinal surgery.

Penetrating and non-penetrating injuries of the eyeball

The management of these patients does not differ from that of other eye injuries, except for cases complicated by the presence of an intraocular or foreign body located behind the eyeball. The approach depends on the nature of the foreign body. Most foreign bodies are removed by microsurgical intraocular forceps. Metal foreign bodies are extracted with a large magnet, but with the introduction of microsurgical techniques this method was used less often. Foreign orbit bodies that do not have a toxic effect do not always need to be removed and, although by the existing rules, it is better to remove any foreign body, small pieces of glass can be left.

Dull eye trauma

Blunt trauma can be the cause of a number of intraocular disorders.

1. Hyphema.
2. Lens dislocation and cataract.

[5], [6], [7], [8], [9], [10]

Hyphema in childhood

Causes

• Injury.
• Tumors:
  • juvenile xanthogranulema;
  • leukemia;
  • histocytosis of Langerhan;
  • medulloepithelioma;
  • retinoblastoma.
• Rubeoz:
  • retinal dysplasia;
  • persistent hyperplasia of the primary vitreous body (PGPS);
  • retinopathy of prematurity (RN);
  • sickle-cell anemia.
• Vascular malformation of the iris.
• Iridoschism.
• Irit and ruby iris.
• Disorders of the blood coagulation system, scurvy, purpura.
• CGPP.
• Melanoma of the iris.

Tactics of reference

1. Immediately after the onset of the symptom, concomitant intraocular disorders are established.
2. In the future, carry out as deep a survey as the child's age permits.
3. Control of intraocular pressure.
4. Avoid the appointment of aspirin or non-steroidal anti-inflammatory drugs.
5. The hyphema from the anterior chamber is washed away, in the absence of a tendency to resorption for 3 days or with a significant increase in intraocular pressure.

Long-term management tactics

Identify a possible recession of the anterior chamber angle, lens dislocation, damage to the posterior segment. In the presence of recession of the angle, a long (sometimes lifelong) observation is necessary because of the possibility of developing glaucoma.

1. Damage to the iris and recession of the angle of the anterior chamber.
2. Retinal disinsertion.
3. retinal bruise:
   • silvery gleam of the retina due to its edema;
   • when the macular area is involved in the process, vision is reduced;
   • overall the forecast is good;
   • sometimes there is a long-term loss of vision;
   • there may be a break in the layers or the entire thickness of the retina.
4. The rupture of the choroid (see below)
5. Purcher's Disease:
   • trauma is combined with increased pressure in the central vein of the retina;
   • manifestations resemble aerial or fatty embolism of the retina;
   • widespread retinal ischemia and hemorrhage;
   • the visual forecast is ambiguous.
6. Hemorrhages in the retina:
   • can be located in any layer, with predominant epiretinal localization;
   • combined with other intraocular lesions;
   • combined with gaps in the retina.
7. Retinal detachment is possible in combination with retinal ruptures.

Perforated wound of the outer shell of the eyeball

Perforated wounds are found when the sclera is stratified, due to non-penetrating trauma. These lesions are often localized around the optic nerve disc. Traumatizing agents in ruptures of the sclera can be a variety of objects - playing balls, sticks, and also a fist.

• With any blunt injury, there is a risk of rupture.
• Intraocular pressure decreases.
• Ultrasound examination reveals haemorrhages in the vitreous humor and sometimes deformation of the scleral capsule in the posterior segment.
• Accompany the rupture of the sclera can an explosive fracture (or, as it is also called, a blow-out type fracture).

When the sclera ruptures in the anterior segment, as well as with other perforating wounds of the eye capsule, surgical intervention is indicated. Technically, surgical treatment of sclera ruptures in the posterior segment is extremely difficult.

Prevention of eye trauma

• Increased supervision by parents, schools and children's institutions.
• Conversations of parents with children about the danger of eye traumatism and the circumstances accompanying it.
• Use of goggles, especially for people with a single eye in situations fraught with eye injury - in sports games
  in which small balls are used, and also when working on metal and stone.

Injury of the orbit

Blunt injuries to the walls of the orbit are the cause of fractures with or without displacement of bone fragments. Fractures with displacement usually require repositioning, and with fractures without bias in treatment, there is no need.

Complications

• Brown Syndrome (Brown).
• Pronounced bone defects in the posterior part of the orbit can provoke enophthalmos.

Explosive fracture

Rarely found in childhood;

Explosive fracture is characterized

1. fracture of the lower or medial wall with infringement of orbit contents;
2. enophthalmos;
3. deviation from the primary position;
4. upset of vertical movements of the eyeball, especially upwards;
5. concomitant intraocular lesions;

Treatment:

• at light degrees of explosive fractures of treatment it is not required, except for cases of pronounced enophthalmus and a significant limitation of mobility of the eyeball;
• When the bottom of the orbit is damaged, the use of synthetic implants is advisable.

Traumas of cranial nerves

Damage to III, IV and VI pairs of cranial nerves is often found in head injuries. Usually, improvement occurs without the use of special treatment. Sometimes, especially with paralysis and paresis of the VI pair of cranial nerves, in the acute phase of the disease, botulinum toxin is successfully used. When doubling, occlusion and prismatic glasses are recommended and leave them for at least 6 months after strabismus stabilization, before any surgical intervention. The occlusion of the intact eye is performed, trying to keep the eye movements in the presence of the paresis and, thus, avoid the subsequent contracture of the rectus muscles.

Traumatic optic neuropathy

It can be caused by detachment of the optic nerve from the eyeball, optic nerve damage in fractures of the orbit, ischemic damage associated with blood flow disorder or hemorrhage into the optic nerve shell. Diagnosis is based on ultrasound or visualization of neurological examinations, pupillary symptoms and examination of the fundus. Steroid therapy in high doses and decompression of the optic nerve can be effective.

Domestic Trauma Violent

• It occurs more often.
• Often observed in very young children.
• It arises from a variety of causes, often from concussions.
• Poor psychological background - young parents - a stressful social or work situation - poor treatment of the child, for example, by the spouses, violence, etc.

[11], [12]

Hemorrhages in the retina

Hemorrhages in the retina are not a pathognomonic symptom of domestic trauma with the use of violence, but the vastness and severity of the clinical course often surpasses the hemorrhage that occurs with ordinary injuries. There are two mechanisms of hemorrhage formation:

1. increased intravenous and intraocular pressure;
2. intensive shaking followed by inhibition.

There are hemorrhages of any type:

• vitreous hemorrhage with preretinal localization;
• epiretinal hemorrhages;
• hemorrhages of different prescription;
• perimacular folds with hemorrhages in the retina, having the appearance of elevated folds of the retina and a vascular envelope in the form of an arc (a symptom characteristic of trauma with the use of violence);
• hemorrhage in any layer of the retina.

Other damage to the eyeball

• Periocular hematoma.
• Cataract.
• Dislocation of the lens.
• Traumatic mydriasis.
• Burns from cigarettes on the cheeks or eyelids (often multiple).
• Retinal disinsertion.
• Retinoschisis in the layers of the retina.