HISTORY The emergency provider should quickly assess the child’s relevant past history in order to assess the expected baseline visual acuity The mechanism of injury should also be ascertained in order to understand the risk of serious ocular pathology and predict injury patterns Finally, the patient should be asked about current symptoms including pain, decrease in vision, foreign body sensation, photophobia, or tearing Assessment of Prior Eye Pathology and Relevant Medical History It is important to establish the child’s prior ocular history in order to assess the anticipated baseline visual acuity A history of poor vision including use of contact lenses or glasses, amblyopia, or strabismus surgery should be queried If the child is wearing contact lenses, they should be removed if this can be done safely A history of systemic disorders may predispose some children to specific injuries or worse outcomes For example, patients with collagen disorders are more prone to open-globe injuries or intraocular hemorrhage, and patients with sickle cell anemia have a higher incidence of complications from hyphema Assessment of Injury Mechanism Clinicians should assess the exact mechanism of injury as the type of trauma and the nature of the force inflicted may predict injury patterns and prognosis For example, significant blunt impact directly to the globe (e.g., baseballs), projectiles, and sharp objects (e.g., sticks or pencils) have high risk of intraocular damage Severe blunt trauma may cause orbital fractures and can also rupture the globe Projectiles pose great risk to the globe, and globe rupture sustained following gun injury often leads to poor visual outcome Hammering, drilling, filing, and nailing are particularly high-risk behaviors for intraocular foreign bodies, especially if safety eyewear use is suboptimal PHYSICAL EXAMINATION Every attempt should be made to examine the eye with the child in a position of comfort in order to minimize agitation, particularly if the history or gross appearance of the eye suggests the possibility of an open-globe injury If the examination is concerning for an open-globe injury, the physician should stop the examination, shield the eye, and consult an ophthalmologist emergently Pain medications and antiemetics can help reduce common causes of elevated intraocular pressure that can lead to further prolapse of intraocular contents Assess Visual Acuity The first step is to assess the visual acuity of both the injured and the unaffected eye The presence of bilaterally poor vision in a patient with unilateral eye trauma suggests that the cause of the poor vision may be unrelated to the trauma Some patients may be unable to perform this task because of eye pain, noncompliance, inability to open swollen lids, or obtundation from accompanying head trauma Even if the eyelids remain closed, the physician should test for light perception By shining a bright light in the direction of the globe through the closed eyelid, the physician can ask the patient whether he or she perceives the additional light on that side A verbal acknowledgment or a reflex contraction of the lids indicates light perception TABLE 114.1 TRAUMA INDICATIONS FOR EMERGENT CONSULTATION WITH AN OPHTHALMOLOGIST Definitive or suspected open-globe injury Inability to open the eyelids to inspect the eye due to severe ocular trauma or periocular injury Visual disturbance related to ocular trauma Hyphema Extraocular movement disturbance Foreign body not able to be removed Absent red reflex Papilledema Retinal hemorrhages If the patient is able to exhibit a greater degree of compliance, the examiner may ask the patient to count fingers that are held at varying distances The maximum distance at which this task is completed should be noted on the chart (e.g., counting fingers at ft) If the patient is able to comply, the examiner should obtain a visual acuity using a distance chart (see Chapter 123 Ophthalmic Emergencies ) If the patient cannot stand but can identify letters or numbers, a commercially available near visual acuity card, a smart-phone eye chart application, or any other reading material may be used to assess near vision This testing has to be done at the appropriate distance from the patient’s eye; all near vision cards will denote the testing distance for the calibrated visual acuity measures Normal near vision usually indicates that the patient has not sustained a significant ocular injury If a patient demonstrates poor acuity in the traumatized eye, the clinician should suspect that the deficit is injury-related However, one can readily establish whether this deficit is related to the trauma or uncorrected refractive error using the pinhole test When a person looks through a pinhole and experiences improvement in performance on visual acuity testing, he or she may have uncorrected refractive error as the cause of the initially tested poor vision If the visual deficit does not improve through a pinhole and therefore is likely related to the trauma, an ophthalmologist should be consulted The urgency of evaluation will depend on the mechanism of injury and other physical examination findings Inspect the Periorbital Tissues and Eyelids Thoroughly The periorbital tissues and eyelids should be carefully examined for ecchymosis, laceration, deformity, swelling, tenderness, and ptosis Palpation of the orbital bones should be performed to assess for tenderness, deformity, or step-off that may suggest orbital fracture If crepitus is present, it may be indicative of a fracture communicating with a sinus Laceration in the periorbital tissue should be assessed for fat prolapse, which suggests communication with the orbital compartment and need for ophthalmology consultation It should also be assessed for occult foreign bodies that may embed innocuously into the orbital compartment Examine sensation to evaluate for infraorbital or supraorbital nerve injury secondary to laceration, blunt trauma, or orbital fracture For eyelid lacerations, careful attention should be paid to the location of the laceration and the depth of the wound The eyelid should be everted to evaluate for subconjunctival and globe involvement, indicating that the laceration may be a full-thickness, complete perforation Lacerations in close proximity to the medial canthus should prompt ophthalmology consultation for evaluation of the integrity of the lacrimal duct system Open the Eyelids If the patient is unable to open the eyelids voluntarily, the examiner should assist the patient A warm compress may be applied gently to the eyelashes to loosen any crust, blood, or discharge that may be holding the eyelashes together When opening the eyelids, avoid pressure on the globe, which might lead to extrusion of intraocular contents via an underlying open-globe injury The examiner’s thumbs can be placed on the supraorbital and infraorbital ridges while exerting pressure against the underlying bone, and then pulled away from each other such that the eyelids are separated ( Fig 114.1 ) If the globe cannot be readily viewed using these techniques, it is safer to refer the patient for an ophthalmology consultation Risking the use of a speculum or retractor may upset the patient, raise intraocular pressure, and contribute to disruption of intraocular contents if an open-globe injury is present Even the ophthalmologist may choose to avoid such attempts and proceed directly to an examination under anesthesia Check the Red Reflex Absence or asymmetry of the red reflex indicates an abnormality to the path of light into the eye This abnormality may be at the level of the cornea (e.g., a contusion or laceration causing edema and clouding) or anterior chamber or posterior chambers of the eye (e.g., vitreous hemorrhage or inflammation) An abnormal red reflex requires emergent ophthalmology consultation FIGURE 114.1 Opening swollen eyelids manually from the superior and inferior orbital rims