Ocular Trauma in Children and in Elderly Patients

Ferenc Kuhn

2.16.1 Introduction

Injuries occurring to children and elderly people1 have some unique features that deserve special attention. A brief overview of these distinctive features are provided below; otherwise, see the relevant chapters for more information.

2.16.2 Pediatric Injuries2 General

• The younger the child, the more different the injury's characteristics are from those occurring in the adult population. This is compounded by the eye's different anatomy (see Sect.

Children are at a higher risk of an eye injury than adults due to:

• Immature motor skills, paired with a tendency to imitate adult behavior

• Reduced "common sense" control over behavior and emotions

• Strong motivation from peer pressure and natural curiosity to "just do it"

1 In this chapter, children are defined as those under 19 and elderly as those 60 years of age or older.

2 The author is greatly indebted to JM Rohrbach, Tübingen, Germany for his invaluable contributions to this chapter.

• Increased levels of male hormones in adolescent boys.

• The child usually has a long life expectancy; permanent visual loss therefore represents a greater burden for individual, family, and society.

• Amblyopia is a major concern in the appropriate age group;3 every effort should be made to restore the normal anatomy and the eye's refractive power as early as possible, and to instigate anti-amblyopia (orthoptic) treatment as necessary. The threat of amblyopia is somewhat smaller in children who are myopic since they have relatively preserved near vision.

• Posttraumatic stress disorder is common in children and may require professional help to treat [50]. History

With regard to history:

• Wearing a white coat during the examination may be frightful to the child; wearing "civilian" clothes is recommended instead.

• Explaining what is going to happen and that the examination will be painless is much more important in children than in adults.

• The child may refuse to cooperate with the ophthalmologist's efforts to elicit exactly how the injury occurred. The child may be afraid of the parent's4 retribution (e.g., because abuse has occurred; see Chap. 3.3) or of punishment for an illegal activity5. To escape responsibility or accountability, the child may give no information, false information, or even fabricated information [40]. The reliability of history is greatly enhanced if a witness can be identified.6

• Injuries that rarely occur in adults, such as an animal bite to the face and eyes (Fig. 1.1.5), are much more common in children. Such injuries have systemic implications,7 which must not be neglected.

3 Typically, under 7 years.

4 Throughout this chapter, the "parent" may be a legal guardian or a caretaker.

5 i.e., fighting with a sibling.

6 Unless, of course, the witness is the adult responsible for the injury.

7 e.g., tetanus or rabies prophylaxis. Epidemiology8 and Prevention

With regard to epidemiology and prevention:

• Children suffer 27-52% of all ocular trauma [18, 26, 39], a disproportionate rate. One-quarter of open globe injuries occurred in children in one study [16].

• Up to a third of persons hospitalized for trauma in the U.S. are children [30, 46, 59], with a hospitalization rate of 9 per 100,000 persons per year among those aged 20 years or less [8].

• Injury is the leading cause of monocular blindness in children [28].

• In a population-based report from the U.S., the estimated incidence rate of ocular trauma for those under 16 years of age was 15 per 100,000 persons per year [53].

• The risk of eye injury is measurably increased for children from a socio-economically challenged population [13].

• Injuries to children (and to the elderly) are especially common at the home (39% and 59% in the USEIR, respectively). In one study, 15 cases of eye injury caused by pointed door handles were treated at a single facility over a 2-year period [10]. The trauma was very severe: the rate of optic nerve evulsion reached 93%.

• In developing countries, children are disproportionally represented among those injured. An unpublished study9 from Mali found that 40% of all eye injury cases involved children. The most common activity was play.10 One-third of the injured children did not arrive at the ER within 24 h.

• Needle injury is surprisingly frequent among children: in one study 1% of all pediatric cataracts undergoing surgery were caused by a needle [42]. Of the 42 eyes, 29% developed endophthalmitis; the rate reached 50% if the object was a hypodermic needle.

8 The data are from the USEIR unless otherwise indicated.

9 KF Sylla, Bamako, Mali

10 Included using sharp needles that women use to plait their hair.

• Trauma sustained during play in general and playing sports in particular is predominant. Using proper protective eyewear during sports is effective and should be encouraged [1, 14].

• The average age of the victim of air-gun-related ocular trauma was 11 years in one study, and 51% of the victims were shot by a friend or sibling [7]. The rate of injury is 14% among children but only 0.8% among adults. A third of the injured eyes were enucleated, another half remained NLP [48].

• Paintball, with the popularity of nonorganized (unofficial) games where the wearing of full facemasks is not enforced, represents an increasingly common source. In a 4-year survey from New Jersey, 75% of the 79 injuries involved children [56]. The outcome is poor: in one study only 43% of eyes had 20/40 or greater final visual acuity [37].

• The rate of children among those injured by fireworks is very high: 75% in Sweden [54], 49% in Austria [43], and 69% in the USEIR, with a bystander being injured in 67% [34].

• Abuse to children is of major importance; this is discussed in Chap. 3.3 (shaken baby syndrome). Evaluation

With regard to evaluation:

• The child may physically resist the examination, and may have to be restrained. Having the parent/guardian to assist in this is very helpful [32].

• To characterize visual performance in children aged 8 years and above, the use of a standardized reading text11, rather than charts measuring distance vision (i.e., Snellen, EDTRS), may be preferable [57].

• If impacted by a blunt object, a young child's orbital bones fracture but also bend, with a decreased tendency to shatter. As a result, muscle entrapment is much more common than in adults [17]; examining the ocular motility is therefore crucial.

11 MNREAD chart, available in English, Japanese, and Italian.

• Gentle palpation is often able to identify subcutaneous foreign bodies and crepitus as well as finding bone dislocation (see Chap. 1.9). Counseling

For most parents, having their child sustain an eye injury has major psychological implications, and the parents' sensitivity must be appreciated by the ophthalmologist. It is entirely different to discuss "the case" with the very same person if he is the patient vs the parent. In addition, based on the injured child's age (and maturity),12 it is the parent, rather than the injured child, who must give consent to the procedure(s) to be performed.13 Occasionally, the ophthalmologist must initiate legal proceedings to save the child's sight, should the parent be negligent or deny consent. Surgical Decision-Making and Surgical Tips Anatomical Differences and Their Management Implications

In addition to differences already mentioned, the following must be kept in mind:

• The eye continues to grow after birth, well past age 10 years/4

• The younger the child, the less convenient it is to operate on the eye/5

• The younger the child, the more difficult it is to predict the correct power of the IOL.

• The cornea is less rigid in children; sutures therefore may become loose much faster than in adults.

• The anterior lens capsule is thinner and more elastic, making capsu-lorhexis more difficult to perform.

12 The country's legal requirements must also be respected.

13 Nevertheless, it is also important to engage the child and gain his confidence. This, as already discussed, helps overcome the child's initial resistance.

14 The growth is especially strong in the first 4 years.

15 This is true both for physical access to the eye through a narrow palpebral fissure and the room available for intraocular manipulations.

Table 2.16.1 The recommended distance from the limbus of the sclerotomy in children


Distance (mm)

<6 months

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