Paediatrics: Trauma

Trauma

Chemical injury (alkali/acids/solvents detergents / irritants)

Start treatment immediately, unless penetrating eye injury is suspected.

•   Instill topical anaesthesia (Proxymetacaine 0.5% if available).

•   Irrigate with copious saline for 30min.

•   Wait 5–10min—ascertain nature of chemical.

•   Check pH using litmus paper inside bottom lid.

•   Continue irrigation until pH is 7.

•   Sweep conjunctival fornices with moistened cotton bud.

•   Refer if severe injury and alkali involved otherwise give chloramphenicol ointment tds 2–3 days and SOS appointment.

Corneal abrasion and foreign bodies

Symptoms include sharp, stabbing pain, photophobia, and discomfort on blinking.

•   Instill topical anaesthetic to facilitate examination.

•   Test visual acuity.

•   Examine with ophthalmoscope set on +20 or slit lamp.

•   Instill fluorescein and examine with blue light: if linear/vertical abrasions are present a sub-tarsal FB is likely.

•   Ask the child to look down, but not close the eyes; evert the upper lid using a cotton bud placed on the upper lid crease as a pivot point.

•   Use cotton bud to sweep away FB if present.

Large central corneal abrasions should be referred. Central corneal scar-ring can cause amblyopia to develop in a young child. Otherwise give chlo-ramphenicol ointment tds 1wk with SOS appointment.

Blunt trauma

Blunt trauma is common in older children (especially boys) due to their propensity of throwing things at each other! The child usually complains of achy pain and blurred vision.

•   Instill anaesthetic to facilitate examination.

•   Check visual acuity.

•   Compare pupil size: traumatic mydriasis may be seen.

•   Examine with ophthalmoscope on +20 for hyphaema (blood in anterior chamber).

•   Check red reflex.

Refer to ophthalmologist if hyphaema/traumatic mydriasis is present.

Penetrating trauma

Suspect penetrating trauma if there is a history of the child falling onto a sharp object (e.g. pencil) or history of high velocity missile, e.g. air gun pel-let. The severity of pain and reduction of vision is variable.

·Instill anaesthetic if child is in pain.

·Check visual acuity.

• Examine pupil reactions and look for symmetry.

• Signs of perforation/penetration include:

•   sub-conjunctival haemorrhage;

•   dark pigment on surface or under conjunctiva;

•   distorted pupil and hyphaema.

• Refer immediately, protect eye with hard eye shield and keep nil by mouth.

Inflicted head injury (NAI)

Severe shaking and shaking/impact injury in infants causes retinal haemor-rhages. Haemorrhages are typically multi-layered: deep retina haemorrhag-es (blots and white centered haemorrhages), superficial retinal haemor-rhages (flame shaped haemorrhages) and sub-hyaloid haemorrhages (often associated with a fluid level) occur together. Superficial haemorrhages can disappear within days, but the deeper and sub-hyaloid haemorrhages can take months to resolve. Vitreous traction on the retina may result in peri-macular folds in severe cases and papilloedema may be present secondary to sub-dural haemorrhage.

If NAI is considered, a senior ophthalmologist should be requested to document and, if possible, take photographs of the retinal appearance. Often the visual prognosis in such cases is poor, not because of the retinal injury, but because of the associated brain injury.