Pediatric Ocular Trauma: Recognition and Management

Pediatric Ocular Trauma: Recognition and Management (Trauma CME and Pharmacology CME)

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Table of Contents

About This Issue

Traumatic ocular injuries in pediatric patients are common reasons for emergency department visits. A thorough systematic evaluation will reduce morbidity and improve vision outcomes. This issue provides guidance for recognizing the most serious kinds of injuries, using appropriate techniques for examining a patient based on their age, and determining when to an emergent ophthalmology consult is needed. In this issue, you will learn:

Ocular trauma classification and standardized terminology that will facilitate accurate communication with an ophthalmologist

Recommendations for age-appropriate visual acuity screening and eye examinations

A systematic anatomical approach to eye examination

Bedside modalities that can help diagnose certain injuries

Treatment recommendations for common conditions

Which cases need an emergent ophthalmology consultation

Table of Contents
  1. About This Issue
  2. Abstract
  3. Case Presentations
  4. Introduction
  5. Critical Appraisal of the Literature
  6. Etiology and Pathophysiology
    1. Ocular Trauma Classification
  7. Differential Diagnosis
  8. Prehospital Care
  9. Emergency Department Evaluation
    1. History
    2. Physical Examination
    3. Visual Acuity Screening
    4. Eye Examination
      1. Newborns and Young Infants (Ages 0 to 6 Months)
        • Red Reflex
        • External Inspection and Globe Examination
        • Pupillary Examination
      2. Infants, Toddlers, and Preschool Children (Ages 6 Months to 5 Years)
        • Fix and Follow
        • Corneal Light Reflex
        • Cover/Uncover Test
      3. Systematic Eye Examination
        • Eyelids
        • Orbital Skeleton and Extraocular Muscles
        • Conjunctiva
        • Sclera
        • Cornea
        • Anterior Chamber
        • Iris and Pupils
        • Lens
        • Retina
    5. Slit Lamp Examination
  10. Diagnostic Studies
    1. Bedside Modalities
      1. Fluorescein
      2. pH
      3. Ocular Pressures
    2. Imaging Studies
      1. Ultrasound
      2. Computed Tomography
      3. Magnetic Resonance Imaging
  11. Treatment of Common Conditions
    1. Lid Lacerations
    2. Orbital Fractures
    3. Corneal Abrasion
    4. Corneal Foreign Body
    5. Chemical and Thermal Burns
    6. Traumatic Hyphema
    7. Traumatic Iritis
    8. Open Globe Injuries
    9. Retrobulbar Hemorrhage
    10. Consulting Ophthalmology
  12. Special Populations
    1. Patients With Coagulation Disorders
    2. Patients With Sickle Cell Trait/Disease
    3. Neonates and Infants
    4. Patients With Contact Lenses
  13. Controversies and Cutting Edge
    1. Ketamine for Sedation
    2. Tetanus Prophylaxis
    3. Topical Nonsteroidal Anti-Inflammatory Drugs
    4. Topical Anesthetics for Corneal Abrasions
    5. Visual Acuity Apps
  14. Disposition
  15. Summary
  16. 5 Things That Will Change Your Practice
  17. Risk Management Pitfalls for Pediatric Ocular Trauma
  18. Cost-Effective Strategies
  19. Case Conclusions
  20. Clinical Pathways
    1. Clinical Pathway for Management of Pediatric Ocular Trauma
    2. Clinical Pathway for Management of Isolated Post-Traumatic Hyphema
  21. Tables and Figures
  22. References


Ocular injuries are the most common cause of preventable blindness in children. A detailed and systematic evaluation of patients with ocular trauma will reduce morbidity and improve long-term vision outcomes. This issue reviews the critical aspects of the pediatric ocular examination for accurate diagnosis of vision-threatening injuries. It also provides recommendations for immediate emergency department treatment, and indications for urgent versus emergent ophthalmology referral.

Case Presentations

EMS is bringing in a previously healthy 3-year-old girl with a pencil lodged in her left eye...
  • The EMS provider does not report other injuries. He tells you the girl is awake, alert, and crying.
  • Her vital signs include a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, respiratory rate of 20 breaths/min, and oxygen saturation of 99% on room air. The EMS provider tells you that there are no focal neurological findings.
  • The EMS provider asks you whether they should attempt removal of the pencil and if you have any other recommendations.
A previously healthy 16-year-old boy presents to the ED after blunt eye trauma...
  • The boy was punched in the face by his brother. There was no loss of consciousness, vomiting, or other injuries. The patient complains of left eye swelling and blurry vision.
  • The physical examination is significant for left upper and lower eyelid edema and ecchymosis, and subconjunctival hemorrhage on the medial left globe. Extraocular movements are intact, his pupils are round and reactive to light, no hyphema is noted, and a nasal and oral examination is normal.
  • Your order a CT orbit that shows orbital wall fracture without entrapment.
  • You wonder whether you should consult ophthalmology for evaluation in the ED.
A healthy immunized 2-year-old girl presents to the ED after she spilled a bottle of household bleach on herself…
  • The mother noticed that the girl’s eyes were red and she was crying. The mother called poison control, who told her to rinse the girl’s eyes with water before going to the ED.
  • The child’s physical examination is unremarkable except for mild conjunctival injection bilaterally.
  • You wonder whether you should use a topical anesthetic. Should you re-irrigate the eyes? If so, what should the end-point of irrigation be?

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathways

Clinical Pathway for Management of Pediatric Ocular Trauma

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Tables and Figures

Table 3. Differential Diagnosis of Ocular Trauma

Table 1. Anatomical Classification of Ocular Trauma
Table 2. Standardized Terminology for Ocular Trauma
Table 4. History Questions for Pediatric Ocular Trauma
Table 5. Visual Acuity Screening, by Age

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

9. * Messman AM. Ocular injuries: new strategies in emergency department management. Emerg Med Pract. 2015;17(11):1-21. (Review)

27. * Kuckelkorn R, Schrage N, Keller G, et al. Emergency treatment of chemical and thermal eye burns. Acta Ophthalmol Scand. 2002;80(1):4-10. (Review) DOI: 10.1034/j.1600-0420.2002.800102.x

35. * Donahue SP, Baker CN, Committee on Practice and Ambulatory Medicine, American Academy of Pediatrics, et al. Procedures for the evaluation of the visual system by pediatricians. Pediatrics. 2016;137(1):e20153597. (Clinical report) DOI: 10.1542/peds.2015-3597

45. * Trief D, Adebona OT, Turalba AV, et al. The pediatric traumatic hyphema. Int Ophthalmol Clin. 2013;53(4):43-57. (Review) DOI: 10.1097/IIO.0b013e3182a129fd

108. *SooHoo JR, Davies BW, Braverman RS, et al. Pediatric traumatic hyphema: a review of 138 consecutive cases. J AAPOS. 2013;17(6):565-567. (Retrospective cohort; 138 patients) DOI: 10.1016/j.jaapos.2013.07.007

123. Doan A. Tear drop pupil. EyeRounds Online Atlas of Ophthalmology. Accessed August 1, 2022. (Online textbook)

124. Caccamise WC Sr. Iridodialysis. EyeRounds Online Atlas of Ophthalmology. Accessed August 1, 2022. (Online textbook)

132. Raman P. Retrobulbar hemorrhage in a child an ophthalmic emergency. MSO Meeting 2014. Accessed on August 1, 2022. (Case report)

Subscribe to get the full list of 162 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.

Keywords: ocular trauma, ocular injuries, eye trauma, eye injuries, closed globe injury, open globe injury, laceration, lid laceration, abrasion, corneal abrasion, orbital wall fracture, orbital fracture, orbital blowout fracture, muscle entrapment, ocular compartment syndrome, foreign body, iritis, hyphema, chemical burn, chemical exposure, retrobulbar hemorrhage, iridodialysis, ocular ultrasound, ocular computed tomography, visual acuity testing, eye examination, fluorescein, ice-rink sign, Seidel sign, ophthalmology referral, ophthalmology consultation, nonaccidental trauma, visual acuity apps

Publication Information

Ami P. Shah, MD, MPH; Don Walker, MD

Peer Reviewed By

Tyler Ayalin, MD; Asha Tharayil, MD, FAAP

Publication Date

September 1, 2022

CME Expiration Date

September 1, 2025    CME Information

CME Credits

4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits.
Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME and 0.25 Pharmacology CME credits.

Pub Med ID: 35998253

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