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Eye injuries may be more serious than they look. (Specialists Are Not Always Available).

PALM SPRINGS, CALIF. -- Although many pediatricians think of eye injuries as problems to refer to specialists, there are times when pediatricians must deal with these conditions on their own.

That's why it's important to have a working knowledge of some of the common eye injuries that afflict children, Dr. Ann Stout said at a meeting sponsored by California Chapter 2 of the American Academy of Pediatrics.

"There are times when you can't reach a specialist," said Dr. Stout of Oregon Health Sciences University Portland. "And there are times when you could be dealing with injuries known as occult, which are more serious than they look. Unless your index of suspicion is high, you'll miss these conditions."

The most frequent cause of eye injuries in children is sports accidents. These injuries occur from the impact of a ball or when one player pokes another. Motor vehicle accidents and falls also can cause many eye injuries.

But the most serious eye injuries in children are likely to result from projectiles fired from BB or air guns. "Unfortunately these cases often have poor visual outcomes," Dr. Stout said at the meeting, also sponsored by the AAP and the Los Angeles Pediatric Society

Severe vision loss (less than 20/200) occurs in 50% of knife injuries, 23% of BB injuries, and 10% of other projectile injuries.

There are four types of eye injuries: blunt trauma, penetrating injuries, perforations, and occult injuries.

Blunt trauma can have low morbidity causing such problems as abrasions, soft tissue lacerations, and retinal edema. These injuries also can cause more serious conditions such as hyphema, a dislocated lens, and vitreous hemorrhage.

Penetrating injuries occur when a small object--such as a tiny piece of metal or glass--goes into the eye but doesn't exit. These injuries are often resolved, but at their worst they can cause such problems as a delayed cataract.

In perforating injuries, the foreign body enters and exits the eye. In these cases, physicians should check for any retained remnants that could cause future problems. Metal left in the eye can cause long-term toxicity for instance.

Occult injuries are those that seem superficial but are actually hiding a more serious injury, such as a ruptured globe, retinal edema, hemorrhage, or choroidal rupture. One sign of these injuries is vision loss that seems out of proportion to the trauma, Dr. Stout said.

Diagnosing children with even mild injuries such as abrasions can be tricky. Apply an anesthetic to facilitate an exam in looking for abrasions. The eye also should be stained with fluorescein and inspected carefully for a foreign body she said.

Always be on guard for occult injuries. "You always need to be thinking: Could this be a deeper injury than it appears on the first exam?" Dr. Stout said.

Topical antibiotic drops can be used to treat abrasions, and cycloplegia (paralysis of the ciliary muscle) or topical nonsteroidal anti-inflammatory drops are good choices for pain control.

Pediatricians also are likely to see a variety of cases involving blunt trauma to the eye. They result in conditions such as papillary mydriasis, miosis, and iridocycitis (an inflammatory reaction associated with aching and photosensitivity). Iridocyclitis is treated with cycloplegia and steroid drops.

More serious problems can include lens subluxation with secondary astigmatism or late-onset glaucoma resulting from damage to the drainage structures in the eye.

Hyphema is one troubling problem that often results from blunt trauma.

The major dangers of hyphemas are rebleeds, which occur from 2 to 5 days after the injury because of clot retraction.

"Rebleeds are worse than the initial bleed," Dr. Stout said. They can cause corneal blood staining and glaucoma with severe loss of vision. African American children are at higher risk for rebleeds than are children of other races.

Hyphemas should be treated with bed rest, and the patient's head should be elevated. Hospital admission should be considered for hyphemas that involve more than one-third of the anterior chamber depth, because more than 60% of these patients will experience a rebleed. Sickle cell patients also should be hospitalized as they are at increased risk for glaucoma.

The treatments for hyphemas include cycloplegia, topical or low-dose systemic steroids, and oral agents to prevent rebleeding. Surgery is indicated for persistent glaucoma, corneal blood staining, or a total "eight-ball" hyphema.

"Tragically total eight-ball hyphemas are often overlooked in dark-eyed people. Once the cornea is stained, the only solution is a transplant or time--often a year or more," Dr. Stout said.
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Author:Boughton, Barbara
Publication:Pediatric News
Geographic Code:1USA
Date:Jun 1, 2002
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