Because of its prominence and delicateness, the eye is frequently injured. Eye injuries occur despite a large number of physiologic protective mechanisms and structures, including the eyelids and eyelashes, the tarsal plates, the orbicularis oculi muscles, the lacrimal apparatus, the corneal reflex, and the lid reflexes. Severe injury can lead to significant disability, especially if the injury is bilateral. Evaluating eye injuries in children is often challenging. The clinician’s goal is to identify the type and severity of injury without causing further damage.

Eye patches, which are designed to maintain the eye in a closed position, are to be distinguished from eye guards or shields, which are fenestrated metal guards used to protect the eye. Eye patching may reduce discomfort and promote healing. In contrast, eye guards play an important role in preventing further injury. Proper use of these techniques and appropriate consultation with an ophthalmologist are important in optimizing visual outcome in children with eye injuries.

The most important ocular structures to identify are the conjunctivae (bulbar and palpebral), the cornea, the iris, the ciliary apparatus, and the anterior chamber (see Fig. 45.1). The epithelium of the cornea is directly continuous with the conjunctiva. The cornea is extensively innervated by the ciliary nerves. It is unique in being avascular, having no direct blood supply. Oxygen and nutrients are supplied to the cornea by tears and by their diffusion from the ciliary circulation. Nonetheless, after corneal injuries, healing and re-epithelialization occur rapidly.

Full-thickness lacerations of the cornea or sclera allow extrusion of aqueous or vitreous humor. The underlying iris or choroid often plugs the wound, preventing ongoing leakage. Further trauma or pressure on the globe or physical agitation can disrupt this delicate protective mechanism and cause further extrusion of intraocular contents. Helping the child to be as calm as possible and placing an eye guard protects the ruptured globe from additional injury. Eye patches should be avoided in possible globe injury, since they put pressure on the globe, which can worsen the eye injury.

The goals of eye patching are to provide comfort and facilitate healing. Eye patching can reduce photophobia (light-induced ciliary spasm) and pain associated with blinking by keeping the eyelid closed. Patching may facilitate healing of corneal injuries by preventing the surface abrasion that may occur during eye blinking. Eye patches are contraindicated in (a) patients with possible penetrating eye injury or open globe, (b) patients with glaucoma, (c) patients in whom corticosteroid ophthalmic solutions have been instilled, (d) wearers of extended-wear contact lenses, and (e) patients with chemical eye injuries, whose eyes should remain open to allow residual chemical to drain until thorough irrigation has been completed. Patches also are relatively contraindicated in the treatment of abrasions secondary to contact lens wear (see “Complications”).

Although eye patching is virtually always recommended in the treatment of corneal abrasion, almost no literature demonstrates that patching has advantages over treatment without patching in minor corneal abrasions. In fact, some studies indicate that patients who have not been patched have faster
healing and are more comfortable (1,2). Furthermore, the possibility exists that patching may predispose the eye to infection by creating a warm, moist environment that favors bacterial growth. Placing antibiotic cream into the eye provides a false sense of security because effective antibiotic levels in the eye fall within 6 hours after cream instillation and within 2 hours after instilling antibiotic eye drops. In adolescents and young adults who drive, patching has the additional disadvantage of eliminating stereoscopic vision, which can increase the risk of an automobile crash. Reading is also difficult or impossible with a patch in place. If a child or adolescent who has a simple corneal abrasion will not keep a patch in place or finds a patch too inconvenient or uncomfortable, then he or she should be treated without one.