Trauma to the eye can take many forms. Physical trauma to the eye and surrounding structures may be blunt or sharp. Trauma can also result from radiation (thermal and electromagnetic) and chemical agents.

Foreign bodies

Foreign bodies on the surface present with a painful, watery eye. If a foreign body or corneal ulcer is suspected, instil 1 drop of local anaesthetic to ease the pain and facilitate examination. Suitable local anaesthetics are proxymetacaine 0.5%, amethocaine 0.5 or 1%, or benoxinate 0.4%. Do not use local anaesthetics for the continuing treatment of ocular pain under any circumstance.

Conjunctival foreign bodies are common and often found on the posterior surface of the upper lid. Therefore, eversion of the lid is essential. Most foreign bodies are easily removed with a moist cotton wool swab. If they are embedded and/or difficult to remove, refer the child to an ophthalmologist. Beware of an iris naevus (small pigmented lesion on the iris that can be mistaken for a corneal foreign body) or iris prolapse through a perforating injury of the cornea mimicking a corneal foreign body.

Intraocular foreign bodies are generally the result of high-velocity fragments. Suspect them if the history involves an explosion, metal(s) striking on metal, or any other situation that involves high-speed objects (e.g. power tools or a lawn mower). If the history is at all suggestive, even in the absence of local signs, radiography of the orbit (AP and lateral) is necessary. If an intraocular foreign body is demonstrated or suspected, immediate referral to an ophthalmologist is mandatory.

Eyelid injuries

All eyelid lacerations except the most minor should be repaired under general anaesthesia. Refer to an ophthalmologist if lacerations involve the lid margin or the medial aspect of the eyelids (canalicular injury is likely).

Hyphaema (blood in the anterior chamber)

This is the result of blunt trauma to the eye and all cases require referral to an ophthalmologist. The potential complications include other eye injuries, secondary haemorrhage and vision loss. Minor hyphaemas can be managed as an outpatient. More significant hyphaemas require admission and bed rest.

Fracture of the orbital bones

A blowout fracture through the wall of the orbit is suspected if ≥1 of the following three cardinal signs are present:

• Restricted movement of the eye, particularly in a vertical plane, with double vision.
  
• Infra-orbital nerve anaesthesia.
  
• Enophthalmos – this may be difficult to assess initially because of eyelid haematoma.

Diagnosis is usually clinical. Refer to an ophthalmologist before organising a CT scan. A CT scan is used to demonstrate the fracture of the orbital wall and entrapped orbital tissue (the classic sign is a tear-drop ‘polyp’ hanging from the roof of the maxillary antrum).

Penetrating injury (including intraocular foreign body)

This should always be considered in patients with lacerations involving the eyelids, particularly after motor vehicle accidents. Clinical clues include distortion of the pupil, prolapse of the iris through the cornea, or presence of pigmented tissue over the sclera. If suspected, protect the eye with a cone or shield that does not place pressure on the eyelids or eye and admit. Prevent vomiting with an antiemetic, as this may cause extrusion of eye contents. Refer to an ophthalmologist immediately.

Chemical burns

Irrigate the eye with saline or water copiously for 15 min using an i.v. giving set under local anaesthesia. Continue this until the fluid is neutral on pH testing. Refer all chemical burns to an ophthalmologist.

Thermal burns

The ocular surface is rarely involved. Check for ulceration with fluorescein staining. Butesin picrate ointment is suitable for use on lid burns. Secondary lid swelling may result in corneal exposure and should be treated with ocular lubricants.

Non-accidental injury

The presence of retinal haemorrhages in cases of unexplained head injury raises the possibility of non-accidental injury. Appropriate investigation of the circumstances of the injury should be initiated. The retinal haemorrhages must be assessed by an ophthalmologist (refer to chapter 17, Child abuse)

Both periorbital and orbital cellulitis present with erythematous, swollen lids in a febrile child. Orbital cellulitis is differentiated by the presence of proptosis and ophthalmoplegia. Hence the lids must be separated (a Desmarres lid retractor may be used) to enable a thorough examination.

Periorbital (preseptal) cellulitis

Periorbital (preseptal) cellulitis refers to infection in the soft tissues of the eyelids. This may arise from purulent conjunctivitis, dacryocystitis, or gain entry via local trauma or insect bite.

• Distinguish this from a periorbital allergic reaction. A well child, who has eyelid swelling with minimal or no erythema, fever, tenderness nor local warmth, is quite likely to have an allergic reaction to an allergen that has been blown or rubbed into the eye, or secondary to an insect bite. In this case no specific radiological imaging is required. An oral antihistamine may be used. The child should be reviewed if the swelling does not settle in the next 24 h or if signs of inflammation develop (fever, pain or unwell child).

Recommended antibiotics

Watery eyes are common in children and are the result of either poor tear drainage or overproduction. The latter is usually the result of eye irritation and causes include foreign bodies (see p. 327), corneal ulcer (see p. 331), conjunctivitis (see p. 328) and infantile glaucoma (see p. 334).

Nasolacrimal duct obstruction is the most common cause of watery eyes and discharge that persist after the first 2 weeks of life. The discharge is worse on waking and the conjunctiva is not inflamed. It usually resolves spontaneously, due to an opening of the lower end of the nasolacrimal duct. Local eye cleaning is usually the only treatment indicated. If the eye is red and inflamed, topical framycetin sulfate eye drops may be given (avoid repeated courses of chloramphenicol). If the discharge and watering have not settled by 12 months of age, refer to an ophthalmologist for probing.

Refer all children with squint or suspected squint to an ophthalmologist. This will allow early detection (and possibly prevention) of amblyopia and detection of any underlying pathology such as retinoblastoma or cataract. Examine the red reflex of all children suspected to have a squint; if the reflex is abnormal (very dull or white) urgent referral to an ophthalmologist is required to exclude cataract or retinoblastoma.

A child does not ‘grow out of’ a squint. However, in the first few months of life, babies may have an intermittent squint, especially when feeding. A child of any age with a constant large-angle squint or a child over 6 months with any squint (constant or intermittent) should be referred to an ophthalmologist. All children with a first-degree relative with a squint should be seen by an ophthalmologist at about 3–3.5 years of age, even if there is no squint, as they may have a refractive error alone.

• Styes are acute bacterial infections of an eyelash follicle. They occur at the eyelid margin and are red and tender. Removing the lash directly related to the stye will often result in discharge of pus and hasten its resolution. Local antibiotics are sometimes indicated. Systemic antibiotics are rarely needed.
  
• A chalazion is an obstructed tarsal (or meibomian) gland. These glands are situated within the substance of the eyelid and thus a chalazion will present as a lump within the eyelid. There may be no associated symptoms. Redness associated with a chalazion is usually the result of sterile inflammation due to leakage of the contents, rather than a bacterial infection. Thus local or systemic antibiotics seldom influence the natural history of these lesions. Warm compresses may hasten resolution. If the chalazion is persistent (>6 months), large or causes discomfort, incision and drainage under general anaesthesia may be indicated.
  
• Ptosis is a droopy or lowered upper eyelid. In children it is usually the result of a minor and isolated anomaly in the development of the levator muscle. It may be unilateral or bilateral, and is sometimes inherited in a dominant manner. If the lowered eyelid obstructs the pupil in a young child, visual loss will occur secondary to amblyopia. Urgent referral to an ophthalmologist is appropriate in such cases. In more minor degrees of ptosis, surgical intervention is for cosmesis and is less urgent.