Pediatrics

Ocular Laceration

OVERVIEW: What every practitioner needs to know

Are you sure your patient has a laceration? What are the typical findings for this disease?

Lacerations involving ocular structures (lids, conjunctiva, cornea, and sclera) present with a history of trauma. The physical findings are usually obvious, indicating injury to the eye and/or its surrounding structures. Any injury to the eyelids or globe, even what appears to be a minor or superficial injury, can result in serious disruption or loss of intraocular contents and permanent loss of vision.

History of trauma

Pain—more notable with lid or corneal injury

External laceration of lids (must rule out deeper injury)

Red eye (conjunctival or globe laceration)

Decreased vision (globe laceration, hyphema, retinal or optic nerve injury)

Indications that more extensive or deeper ocular injury has occurred follow:

Extensive conjunctival hemorrhage and edema (full-thickness laceration)

Peaking of the pupil (iris plugging full-thickness laceration)

Fluid leak or iris prolapse (full-thickness corneal or scleral laceration)

Lacerations of the Eyelid and Eye

Every patient with a history of trauma in and around the eye must have a thorough examination to rule out more serious injuries producing penetration and/or perforation of the eyeball itself. Superficial or minor lacerations of the lid and conjunctiva can be managed by the primary care/emergency room physician. Eyelid margin lacerations should be evaluated by an ophthalmologist.

As soon as a deeper penetrating or perforating injury is suspected, the eye should be protected with a shield, with no pressure on the eyelids (not an eye patch), and the child should be emergently examined by an ophthalmologist. During ancillary evaluations such as computed tomography (CT) to rule out a foreign body, the eye shield should remain in place, except for removal if necessary during the evaluation, and personnel should be warned that pressure on the eyelid can result in permanent loss of vision.

Eyelid lacerations are diagnosed from the physical appearance demonstrating disruption of the lid surface or margin (Figure 1). This can be the result of blunt or sharp trauma. Once a lid laceration is recognized, deeper injuries involving the conjunctiva, sclera, and cornea must be suspected and ruled out before treating the lid laceration. Concern or uncertainty regarding the potential for penetrating injury with an intraocular foreign body requires evaluation by CT.

Figure 1.

Laceration of lid. This is a full-thickness laceration involving the tear drainage system.

Conjunctival lacerations are superficial disruptions of the ocular surface. The conjunctival laceration can be isolated or combined with lid and deeper ocular lacerations or injuries. Once a conjunctival laceration is recognized, deeper injuries involving the conjunctiva, sclera, and cornea must be suspected and ruled out before treating the conjunctival laceration. Concern or uncertainty regarding the potential for penetrating injury with an intraocular foreign body requires evaluation by CT.

Corneal lacerations may be partial or full thickness (Figure 2 and Figure 3). The laceration may involve just the cornea or it may extend into the surrounding sclera. Partial-thickness corneal lacerations must be evaluated carefully for depth and extent. Evidence of a full-thickness laceration is confirmed by leakage of fluid (positive Seidel test), flat or very shallow anterior chamber, or peaking of the iris with plugging of the laceration by iris tissue (Figure 4,Figure 5A and Figure 5B).

Figure 2.

Corneal laceration. It is difficult to determine the depth from this photograph. It may be more superficial with corneal edema, or it could be full thickness (it is) involving the iris and lens.

Figure 3.

Full-thickness corneal laceration with hyphema. The laceration goes from the 11:00 position and passes across the superior pupillary axis. The anterior chamber is shallow with a layering of blood.

Figure 4.

Corneal puncture laceration with iris plugging wound. The pupil is distorted and pulled into the wound. The red-brown fleshy material is iris extending through the laceration onto the external corneal surface.

Figure 5a.

Full-thickness corneal laceration with iris plugging the wound. Irregular pupil and early cataract.

Figure 5b.

Laceration after repair in same patient as in Figure 5A.

Once a corneal laceration is recognized, deeper injuries involving the sclera and cornea must be suspected and ruled out before treating the corneal laceration. Concern or uncertainty regarding the potential for penetrating injury with an intraocular foreign body requires evaluation by CT .

Scleral lacerations may be partial or full thickness (Figure 6). The overlying conjunctiva will show corresponding laceration, but secondary edema and hemorrhage may make evaluation of the scleral laceration difficult (Figure 7 and Figure 8). The primary concern is that full-penetration has occurred and the globe has been essentially ruptured. Further damage and potential loss of intraocular contents is high risk, especially if pressure is applied to the globe. Once a corneal laceration is recognized, deeper injuries involving the sclera and cornea must be suspected and ruled out before treating the corneal laceration. Concern or uncertainty regarding the potential for penetrating injury with an intraocular foreign body requires evaluation by CT.

Figure 6.

Globe perforation with loss of contents. There is blood in the anterior chamber with iris through the wound at the 12:00 position.

Figure 7.

Globe perforation with loss of contents and typical conjunctival hemorrhage. Iris is seen through the wound at midcornea and at the 5:00 position.

Figure 8.

Globe perforation. the extensive conjunctival disruption is a sign that the globe integrity has been compromised.

What caused this disease to develop at this time?

Lacerations of the lid and eye result from trauma. Young boys are more likely to experience this type of injury.

Would imaging studies be helpful? Af so, which ones?

The diagnosis of lid, conjunctival, corneal, or scleral laceration is made by visual examination. Suspicion of an intraocular foreign body requires examination by CT. Once a full-thickness laceration of the cornea or sclera is suspected, no further physical examination should be performed. The eye should be protected with a noncontact eye shield (not an eye patch).

If you are able to confirm that the patient has an ocular laceration, what treatment should be initiated?

If there is suspicion for full-thickness corneal or scleral laceration, the eye should immediately be protected with a noncontact eye shield. An eye patch is not adequate because it does not protect the globe from pressure. At this point, an emergent ophthalmic consultation must be obtained. No further manipulation of the eyelids or eyeball should be performed because there is a risk for extrusion of intraocular contents and permanent loss of vision. Further evaluation and surgical treatment should be conducted by the ophthalmologist using general anesthesia .

Concern for an intraocular foreign body, either by history of high-velocity projectile injury or unobserved pediatric trauma with significant ocular injury, mandates further evaluation by CT to rule out a foreign body. The eye must be adequately protected with a noncontact eye shield to prevent inadvertent trauma from pressure to the globe. This evaluation may require the child to be sedated.

Minor or superficial lid lacerations may be treated by the primary care or emergency room physician. More extensive lid laceration, especially that involving the lid margin or nasolacrimal drainage system should be referred to an ophthalmologist for appropriate reconstruction. Dog bite injuries are a special subclass because they often involve laceration of the canalicular region.

Lid laceration repair requires local anesthesia and may require sedation or general anesthesia for the pediatric patient. After repair, topical antibiotics are adequate for minor clean lacerations. Contaminated lacerations (dog bite injuries, foreign body contamination) require systemic antibiotics. Tetanus prophylaxis should be investigated. Animal bites may require rabies prophylaxis.

Conjunctival lacerations, once confirmed to be superficial and limited to the conjunctiva, may be treated by the primary care or emergency room physician. Most conjunctival lacerations will heal without surgical repair. Larger conjunctival lacerations can be repaired primarily and followed by a course of topical antibiotics. Examination and repair may require sedation or general anesthesia in the pediatric patient.

Definitive determination of the extent of the conjunctival laceration may be difficult because of edema and hemorrhage. If there is any concern of deeper penetration or intraocular foreign body, the eye should be protected from further injury with a noncontact eye shield and an emergent ophthalmic consultation obtained. Concern for an intraocular foreign body should follow the guidelines noted above.

What are the possible outcomes of ocular laceration?

Lid laceration outcomes are related to the extent of injury and associated structures involved, such as the nasolacrimal drainage system. Nasolacrimal drainage system damage may produce epiphora and secondary infection. Lacerations can result in permanent difficulty closing the eye, with exposure of the cornea, or abnormal lid margin changes, with exposure or trichiasis. Lid lacerations may lead to ptosis, with amblyopia concerns in pediatric patients.

Conjunctival lacerations are usually self-limited. Extensive disruption or severe scarring can produce chronic irritation, interference with ocular motility, and disruption of the normal tear film and lid closure mechanism.

Corneal lacerations frequently result in permanent scarring and the potential for additional vision loss if the scar is near the visual axis. There may be induced astigmatism resulting in a blurred image for that eye. Both of these results present significant risk for amblyopia in a child.

Full-thickness lacerations of the cornea and/or sclera result in loss of intraocular contents and significant risk for permanent visual impairment. The loss of vision can result from scar formation, anterior segment disruption or cataract, secondary glaucoma, and retinal and optic nerve injuries such as contusion and retinal detachment.

What causes this disease and how frequent is it?

Trauma is the principal cause of lid and ocular lacerations.

How can this disease be prevented?

Many, and probably most, injuries of the lid, conjunctiva, cornea, and sclera can be prevented by protective eyewear. This is especially true for sporting and work activities.

What is the evidence?

Ehlers, JP, Chirag, PS, Fenton, GL. "The Wills Eye Manual: Office and emergency room diagnosis and treatment of eye disease". Lippincott, Williams & Wilkins. 2008.

(This is the "on-the-job" reference source for management of eye injuries, basic and advanced diagnostic considerations, and treatment recommendations. This an updated synopsis of clinical practice, providing recognized methods for therapy with rare comment on less-established therapies.)
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