As a physician in the pediatric emergency department, I see a surge in sports-related injuries with the arrival of summer and baseball season. Baseballs (and sometimes bats!) have a particular affinity for finding the pediatric eyes that make their way to my hospital. The eyes are one of those “black box” organs with their own language and pathology.
Basic Management of Pediatric Eye Trauma
For those working in urgent care, the emergency department, or even a general peds clinic, knowing the basics of managing eye trauma is essential. But how do you do an eye exam on a squirmy, hurting kid with an eye injury? For toddlers under two, you can watch their visual behaviors rather than do a formal exam. For children older than two, you can have them identify figures on a chart and do simple matching games to determine if they can see. After age five, they can start to identify letters to get a formal visual acuity. If an eye is swollen shut, you can improve the odds of getting an exam by providing pain control with a local eye drop anesthetic, like proparacaine 1% drops.
When to Consult an Expert
Certain types of eye injuries, lacerations to the lid margin, or injuries involving the canthus require an oculoplastics expert. Kids with corneal abrasions—commonly due to sandy baseball fields—typically heal within one to three days. During this time, providing ophthalmic antibiotics (hold the steroid combos!) helps prevent infection. For cases not improving after 48 hours or abrasions over the pupil, I send them to an eye specialist.
What to Do in Severe Cases
For more severe scenarios, like a foreign body (for example, sand or a piece of metal) embedded in the cornea, you can try flushing it out with saline. But if you need to “dig,” or if there’s a suspected penetrating injury—indicated by a teardrop-shaped pupil and excruciating pain—do NOT pull it out. Send them STAT to the eye doctor, cover their eye with a hard barrier, and control their pain to avoid extrusion of the globe’s contents (ew!).
If it is a subtle case, a CT might help you make this diagnosis—but beware! There can still be an open globe injury even with a normal-looking CT, so if the mechanism is concerning, don’t be shy to call the eye doctor. If there is still uncertainty, you can do a fluorescein exam to look for a waterfalling of the dye out of the eye, called a positive Seidel's sign.
Innovative Solutions for Young Patients
In the cases of a superficially embedded object that might be irrigated out, and the patient is too young to tolerate the plastic Morgan lenses, nasal cannula oxygen tubing can direct saline into their eyes. Warning: this may impair the budding friendships between you, the clinician, and your youngest patients. They can thank you later.
