AAO PEDIATRIC OPHTHALMOLOGY OCULAR TRAUMA IN CHILD.pptx

AAO READING 2024

1. Ocular trauma in Childhood Faradhillah A. Suryadi AAO READING SUBDIVISI PO 02-10-2024 Pembimbing : dr. Ratih Natasha Maharani, Sp.M (K), M.Kes

2. Special Considerations in the Management of Pediatric Ocular Trauma

3. Special Considerations in the Management of Pediatric Ocular Trauma Another issue is the potential for the injury to cause amblyopia . In children younger than 5–7 years, deprivation amblyopia associated with traumatic cataract or other media opacity can cause severe, long- term reduction of vision even after appropriate management of the original physical damage. Minimizing the interval between the injury and the restoration of optimal media clarity and optics, including adequate aphakic refractive correction, is thus a high priority. Monocular occlusion following injury should be kept to a minimum ; the expected benefit from an occlusive dressing must be weighed against the risk of disturbing binocular function or inducing amblyopia in a very young child

4. ACCIDENTAL TRAUMA In younger children, most accidental ocular trauma occurs during casual play with other children. Older children and adolescents are most likely to be injured while participating in sports. Fireworks, BB guns, and various projectiles are less frequent causes of pediatric ocular trauma, but they are likely to cause severe injuries. The incidence of severe eye injury is particularly high in children aged 11–15 years compared with that in other age groups. Injured boys outnumber girls by a factor of 3 or 4 to 1. Most serious childhood eye injuries could, in principle, be prevented by appropriate adult supervision and by regular use of protective eyewear during sports activities. These measures are particularly impor tant for the child who already has monocular vision loss

5. CORNEAL ABRASION Corneal abrasion is one of the most common ocular injuries in children and adults. Disruption of the corneal epithelium is usually associated with immediate pain, foreign- body sensation, tearing, and discomfort with blinking . Topical cycloplegic drops and antibiotic ointment may help reduce discomfort and the risk of infection, respectively. Traumatic corneal epithelial defects usually heal within 1–2 days . A pressure patch to keep the eyelids closed is not necessary for most abrasions. Many children find the patch uncomfortable, and patching does not reduce the time required for the abrasion to heal.

6. THERMAL INJURY Cigarette burns of the cornea are the most common thermal injuries to the ocular surface in childhood. Usually, these occur in toddlers and are accidental, not manifestations of abuse. The burns usually result from the child running into a cigarette held at eye level by an adult. Despite the alarming initial white appearance of coagulated corneal epithelium, cigarette burns typically heal in a few days and without scarring. Treatment is the same as treatment of corneal abrasions (discussed in the previous section).

7. CHEMICAL INJURY Chemical burns in childhood are generally caused by organic solvents or soaps in house hold cleaning agents. Even burns involving almost total loss of corneal epithelium are likely to heal in a week or less with or without patching . Acid and alkali burns in children, as in adults, can be much more serious. The initial and most important step in management of all chemical injuries is immediate copious irrigation and meticulous removal of any particulate matter from the conjunctival fornices .

8. CORNEAL FOREIGN BODY Corneal foreign bodies in children can sometimes be dislodged with a forceful stream of irrigating solution. After topical anesthetic is applied, a cotton swab or blunt spatula can often be used to remove the corneal foreign body, with or without a slit lamp; use of sharp instruments should be avoided. If these methods are unsuccessful, the child may require sedation or general anesthesia to facilitate removal of the foreign body.

9. PENETRATING OR PERFORATING INJURY Unless an adult has witnessed the traumatic incident, the history cannot be relied upon to exclude the possibility of penetrating injury to the globe. The anterior segment and fundus must be thoroughly inspected . An examination under anesthesia may be necessary when a penetrating injury is suspected . An area of subconjunctival hemorrhage or chemosis or a small break in the skin of the eyelid may be the only surface manifestation of scleral perforation by a sharp- pointed object, such as a pencil or scissors blade (Fig 27-1). Distortion of the pupil may be the most evident sign of a small corneal or limbal perforatio n. Imaging should be considered if there is any reason to suspect an intraocular or orbital foreign body. Corneoscleral lacerations in children are repaired using the same princi ples employed for these repairs in adults (see BCSC Section 8, External Disease and Cornea). Corneal wounds heal relatively rapidly in very young patients; sutures should be removed correspondingly earlier . Small conjunctival lacerations are often self- sealing . After a penetrating injury to the cornea, fibrin clots may form quickly in the anterior chamber of a child’s eye, and these can simulate the appearance of fluffy cataractous lens cortex. To avoid rendering the eye aphakic unnecessarily (and thereby compromising vision rehabilitation), the clinician should not remove the lens as part of primary wound repair unless absolutely certain that the anterior capsule has been ruptured. Even if lens cortex is exposed, postponing cataract surgery for 1–2 weeks, until severe posttraumatic

10. PENETRATING OR PERFORATING INJURY inflammation has resolved , may result in a smoother postoperative recovery and reduced risk of complications without significantly worsening the visual prognosis Full- thickness eyelid lacerations , especially those involving a canaliculus, should be repaired meticulously; sedation or general anesthesia may be required, even in older children. Working near the eyes with sharp instruments and draping the face to create a sterile field are likely to frighten an awake child and add to the difficulty of the repair. Clearly superficial wounds can be repaired in the emergency department. For superficial wounds, use of an absorbable suture is acceptable if the physician wishes to avoid the need to remove nonabsorbable sutures.

11. BLUNT INJURY - HYPHEMA As with all forms of pediatric trauma, the precise occurrence that lead to the hyphema may be difficult to determine. The possibility of abuse must be considered , as must the possibility of a nontraumatic etiology: retinoblastoma, juvenile xanthogranuloma of the iris, and bleeding diathesis resulting from leukemia or other blood dyscrasia are relatively rare but important causes of spontaneous hyphema during the early years of life. When the findings are suspicious and the iris and fundus cannot be adequately seen, ultrasonography or magnetic resonance imaging should be performed to rule out intraocular tumor . If a bleeding disorder is suspected, a complete blood count and coagulation studies should be performed.

12. BLUNT INJURY - HYPHEMA Intraocular pressure (IOP), an important factor in therapeutic decision making for patients with traumatic hyphema , is often difficult to monitor in the pediatric patient . The risks of inaccurate measurements and of further traumatizing the injured eye may outweigh the potential value of obtaining measurements in uncooperative children . With small hyphemas (Fig 27-2), concern about pressure is greatest in patients with sickle cell trait or disease. Sickling may develop in the anterior chamber, elevating IOP and retarding resorption of blood, or in the retinal circulation, causing vascular occlusion . All African American children with traumatic hyphema require sickle cell screening to evaluate for these conditions.

13. BLUNT INJURY - HYPHEMA As in adults, medical management of hyphema in children remains controversial. Care must be taken to minimize the risk of rebleeding, which usually occurs between 3 and 7 days postinjury as a result of clot lysis and retraction. Outpatient management with activity restriction and close follow-up is generally accepted. However, if parental cooperation is questionable or if the patient has sickle trait, hospitalization for several days after injury, when the risk of rebleeding is greatest, remains justifiable. Many ophthalmologists routinely use cycloplegic and corticosteroid drops to facilitate fundus examination, improve comfort, and reduce the risk of inflammatory complications and rebleeding. The value of these topical agents is unproven, and some clinicians prefer to use them selectively for control of pain or obvious inflammation, or to avoid them altogether to minimize manipulation of the eye. Pressure- lowering medi cation is appropriate for eyes known or strongly suspected to have elevated IOP. Aspirin- containing compounds and nonsteroidal anti- inflammatory drugs can increase the risk of rebleeding and should be avoided.

14. BLUNT INJURY - HYPHEMA Many treatments have been proposed to prevent rebleeding in traumatic hyphema , although none is universally accepted. The difficulty of detecting early corneal blood staining in a child and the risk that staining may cause severe deprivation amblyopia, coupled with the problems of accurately measuring IOP, justify early surgical intervention whenever a total hyphema persists for 4–5 days . In children with sickle cell trait or disease, it may be necessary to perform surgery even earlier if elevated pressures (>25 mm Hg for over 24 hours) occur. Late glaucoma is a potential complication of traumatic hyphema in children, as in adults, and may occur with no symptoms. Gonioscopy can be performed after the eye has healed and the child is able to cooperate . Annual follow-up should be continued in children with a history of traumatic hyphema , in light of the potential late complications of cataract, retinal detachment, and glaucoma .

15. ORBITAL FRACTURES - ORBITAL FLOOR FRACTURE Blunt facial trauma is the usual cause of orbital floor fractures . The term blowout fracture is used when the rim remains intact. Orbital floor fracture is thought to be due to either of the following: an acute increase in intraorbital pressure, which occurs when a direct impact occludes the orbital entrance; or compression of the rim, which results in buckling of the floor. Orbital floor fracture can be part of more extensive fractures of the orbit and midface. In some cases, the mechanism causing floor fractures extends to include the medial wall as well. Periorbital ecchymosis and diplopia are common in the immediate posttrauma period. Injury to the inferior rectus muscle or to its nerve, with resultant weakness, may be caused by hemorrhage or ischemia, in addition to restriction. This injury can occur either at the time of the fracture or during its repair. Injury to the inferior rectus muscle can manifest as either limited elevation or depression. Hypoesthesia in the cutaneous distribution of the infraorbital nerve can also occur.

16. ORBITAL FRACTURES - ORBITAL FLOOR FRACTURE In a patient with limited elevation, a positive forced duction test indicates the presence of restriction . Bradycardia, heart block, nausea, or syncope can occur as a vagal response to entrapment. When the entrapment involves the more anterior portion of the orbital floor or when there is associated injury to the inferior rectus muscle or its nerve, there can also be limited depression. Reduced saccadic velocity and force generation on attempted downgaze suggest weak muscle action. Orbital computed tomography and high- resolution , multipositional magnetic resonance imaging are useful for revealing the presence and extent of the injury. A special presentation, the white- eyed blowout fracture, is characterized by marked restriction (in both directions) of vertical ocular motility despite minimal signs of softtissue injury . This restriction is due to entrapment of the inferior rectus muscle or orbital tissue either beneath a trapdoor fracture or, unique to children, in a linear opening caused by flexion deformity of the floor. In this condition, early surgery, rather than observation, is required in order to minimize permanent muscle and nerve damage.

17. MANAGEMENT There are several approaches to the management of orbital floor fractures. Some clinicians advocate surgical exploration in all cases , irrespective of the results of forced duction testing . The justification for this approach is that, especially with large bony defects, progressive herniation of orbital contents into the adjacent maxillary sinus can occur, resulting in disfiguring enophthalmos . Others recommend waiting for a few days to 2 weeks to allow periorbital ecchymosis to subside. For these surgeons, the main indication to operate is evidence of restriction with unresolved diplopia in primary position. Diplopia immediately after the injury is common and is not necessarily an indication for urgent intervention.

18. ORBITAL ROOF FRACTURES Though rare in older patients, orbital roof fractures are common in children younger than 10 years . Isolated roof fractures typically result from impact to the brow region in a fall, often from a height of only a few feet. The principal external manifestation is upper eyelid hematoma (Fig 27-3). These fractures often heal without treatment

19. TRAUMATIC OPTIC NEUROPATHY The optic nerve may be damaged by trauma to the head, orbit, or globe . Vision loss is usually immediate and severe with a relative afferent pupillary defect present. Initially, the optic nerve appears normal, but it becomes atrophic within 1–2 months of injury. Management is controversial and may include high- dose intravenous ste roids and optic canal decompress

20. NONACCIDENTAL TRAUMA Although most eye injuries in childhood are accidental or innocently caused by other children , a significant number of them result from physical abuse by adults . The terms used for intentional physical abuse of a child include nonaccidental trauma and child abuse. Child abuse includes emotional abuse, sexual abuse, and neglect as well as physical abuse. It is a pervasive problem, with an estimated 750,000 cases per year in the United States. A reliable history is often difficult to obtain when nonaccidental trauma has occurred . Suspicion of nonaccidental trauma should be aroused when repeated accounts of the circumstances of injur y or histories obtained from different individuals are inconsistent or when the events described do not correlate with the injuries ( eg , bruises on multiple aspects of the head after “a fall”) or with the child’s developmental level ( eg , a 1- month- old “rolling off a bed” or a 4- month- old “climbing out of a high chair”). Any physician who suspects child abuse is required by law in every US state and Canadian province to report the incident to a designated governmental agency. Once this obligation has been discharged, full investigation of the situation by appropriate specialists and authorities is usually performed. Physicians should be familiar with the regulations in their own country. If possible, ocular abnormalities should be documented photographically or with a detailed drawing to use as evidence in court

21. Abusive Head Trauma A unique complex of ocular, intracranial, and sometimes other injuries occurs in infants who have been abused by violent shaking. This is recognized as one of the most important manifestations of child abuse. Although the term shaken baby syndrome is still occasionally used , it has largely been replaced with the terms abusive head trauma (AHT) and inflicted childhood neurotrauma because these infants may sustain impact injury as well as shaking injury involving the head . Patients with AHT are usually younger than 5 years and most often younger than 12 months. When a reliable history is available, it typically involves a parent or other caregiver who shook an inconsolable crying baby in anger or frustration . Often, however, the only information provided is that the child’s mental status deteriorated or that a seizure or respiratory difficulty developed.

22. Abusive Head Trauma The involved caregiver may relate that an episode of relatively minor trauma occurred, such as a fall from a bed. Even without a supporting history, the diagnosis of AHT can still be made with confidence on the basis of characteristic clinical findings . It must be kept in mind, however, that answers to important questions concerning the timing and circumstances of injury and the identity of the perpetrator frequently cannot be inferred from medical evidence alone Intracranial injury in AHT frequently includes subdural hematoma (typically bilateral over the cerebral convexities or in the interhemispheric fissure) and subarachnoid hemorrhage. Displacement of the brain in relation to the skull and dura mater ruptures bridging vessels, and compression against the cranial bones produces further damage. Neuroimaging may also show intracranial edema, ischemia, or contusion in the acute stage and atrophy in later stages. These findings are thought to result from repetitive, abrupt accelerationdeceleration of the child’s head as it whiplashes back and forth during the shaking episode. Some authorities, citing the frequency with which patients with AHT also show evidence of having received blows to the head, think that impact is an essential component, although in many cases no sign of impact is found.

23. OCULAR INVOLVEMENT The most common ocular manifestation of AHT, present in approximately 80% of cases, is retinal hemorrhage . These hemorrhages can be seen in all layers of the ret ina and may be unilateral or bilateral. They are found most commonly in the posterior pole but often extend to the periphery (Fig 27-4). Vitreous hemorrhage may also develop, usually as a secondary phenomenon resulting from migration of blood from a preretinal hemorrhage into the vitreous. Occasionally, the vitreous becomes almost completely opacified by dispersed hemorrhage within a few days of injury. Retinal hemorrhages in shaken infants cannot be dated with precision and usually resolve over a period of weeks to months. Vitrectomy should be considered if there is a risk of amblyopia due to persistent vitreous hemorrhage . Some eyes show evidence of retinal tissue disruption in addition to hemorrhage. Fullthickness perimacular folds in the neurosensory retina, typically with circumferential orientation around the macula that creates a craterlike appearance , are highly characteristic.

24. OCULAR INVOLVEMENT Splitting of the retina (traumatic retinoschisis), either deep to the nerve fiber layer or superficial (involving only the internal limiting membrane), may create cavities of considerable extent that are partially filled with blood , also usually in the macular region (Fig 27-5). Full- thickness retinal breaks and detachment are rare. Retinal folds usually flatten out within a few weeks of injury, but schisis cavities can persist indefinitely . A striking feature of AHT is the typical lack of external evidence of trauma. The ocular adnexa and anterior segment may appear entirely normal. Occasionally, the trunk or extremities show bruises representing the imprint of the perpetrator’s hands. In a minority of cases, broken ribs or characteristic metaphyseal fractures of the long bones result from forces generated during shaking. It must be kept in mind, however, that these patients may have been subjected to other forms of abuse .

25. OCULAR INVOLVEMENT When extensive retinal hemorrhage accompanied by perimacular folds and schisis cavities is found in association with intracranial hemorrhage or other evidence of trauma to the brain in an infant, AHT can usually be diagnosed with confidence regardless of other circumstances. Severe accidental head trauma ( eg , sustained in a fall from a second- story level or in a motor vehicle collision) is not frequently accompanied by retinal hemorrhage , and hemorrhage is not extensive when present. Retinal hemorrhage is rare and has never been documented to be extensive following cardiopulmonary resuscitation by trained personnel. Severe, fatal, acute head- crush injury rarely causes hemorrhagic retinopathy with perimacular folds, which can be differentiated from AHT by the associated injuries . Extensive retinal hemorrhage without other ocular findings strongly suggests that intracranial injury has been caused by AHT , but alternative possibilities such as a coagulation disorder must be considered as well. Retinal hemorrhages resulting from birth trauma are common in newborns, but they seldom persist beyond the age of 1 month. Other possible causes of retinal hemorrhage in children include anemia, hypertension, acutely increased intracranial pressure, leukemia, meningitis, glutaricaciduria , and retinopathy of prematurity.

26. PROGNOSIS In one large study, 29% of children with AHT died of their injuries. Poor visual and pupillary responses were correlated with a higher risk of mortality. Survivors often had permanent impairment ranging from mild learning disability and motor disturbances to severe cognitive impairment and quadriparesis. The most common cause of vision loss is cortical injury followed by optic atrophy. Dense vitreous hemorrhage, usually associated with deep traumatic retinoschisis, carries a poor prognosis for both vision and life.

27. OCULAR INJURY SECONDARY TO NONACCIDENTAL TRAUMA The presenting sign of child abuse involves the eye in approximately 5% of cases. Blunt trauma inflicted with fingers, fists, or implements such as belts or straps is the usual mechanism of nonaccidental injury to the ocular adnexa or anterior segment. Periorbital ecchymosis, subconjunctival hemorrhage, and hyphema should raise suspicion of recent abuse if the explanation provided is implausible. Cataract and lens dislocation may be a sign of repeated injury or trauma inflicted earlier. Child abuse should also be suspected with rhegmatogenous reti nal detachment in a child without a history of injury or an apparent predisposing factor, such as high myopia.

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