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Pediatric Ocular Trauma — Globe & Anterior Segment
Traumatic Hyphema
A hyphema is blood layering in the anterior chamber, and it is one of the most common consequences of blunt pediatric ocular trauma. Management is driven far more by the risk of rebleeding than by the initial bleed itself. The recommended position is head-of-bed elevation at 30–45 degrees rather than flat supine rest: gravity settles the blood inferiorly, keeps the visual axis clear, and limits corneal blood staining and the intraocular pressure spikes that come from blood clogging the trabecular meshwork.
Rebleeding peaks 2 to 5 days after the injury, as the original clot retracts and the still-healing vessels tear open again, a window distinct from both the acute presentation and the weeks that follow. A rebleed is often worse than the original hyphema, with a greater risk of pressure elevation and corneal blood staining, which is why follow-up is concentrated there.
Traumatic Mydriasis & Rosette Cataract
Blunt trauma can tear the iris sphincter muscle directly, producing traumatic mydriasis: an irregular, poorly reactive pupil with radial sphincter tears visible on slit-lamp exam. This is a mechanical injury to the iris itself, not a neurologic finding, and should not be confused with a tonic (Adie's) pupil or a relative afferent pupillary defect.
The same blunt force can disrupt the lens capsule and cortex, producing a traumatic cataract: a petal-shaped or feathery opacity along the lens suture lines, known as a rosette (or stellate) cataract. It can be partial and slowly progressive rather than dense from the outset, but any post-traumatic lens opacity in a child carries the same deprivation-amblyopia risk as a congenital cataract and needs the same close monitoring.
Multilayered retinal hemorrhages extending out to the ora serrata, in an infant with no history of significant trauma, are a hallmark of abusive head trauma (shaken baby syndrome, non-accidental trauma). Acceleration-deceleration and rotational shaking forces produce this extensive, multilayered pattern, far beyond what accidental injury typically leaves behind. The retinal exam is often one of the earliest and most objective findings pointing toward abuse, sometimes preceding every other recognized sign. Any ophthalmologist examining a young child with an unexplained or inconsistent trauma history and extensive peripheral retinal hemorrhage is obligated to consider abuse and report it through the appropriate child-protection channel, not treat it as an isolated eye finding.
Open Globe Injury: Classification, Diagnosis & Emergency Management
Open globe injuries are classified by the Birmingham Eye Trauma Terminology (BETT) system, based on the number and nature of full-thickness wounds. A perforating injury has two full-thickness wounds, an entry and an exit, from the same object; a penetrating injury has only a single entrance wound with no exit. The full BETT system, covering rupture, penetrating, perforating, and intraocular-foreign-body injuries, is detailed on the Ocular Trauma topic's open globe classification page. Children are frequently poor historians who may minimize or hide how an injury happened, so a low threshold for suspecting an open globe, and a careful, complete exam, matters more in this age group than in adults.
A positive Seidel test confirms an open globe. Concentrated fluorescein is applied under cobalt blue light; a stream of lighter, diluted dye flowing away from the wound means aqueous humor is leaking and washing it out.
Once an open globe is suspected, management means a rigid protective shield placed without pressure on the eye, and nothing that could extrude intraocular contents through the wound: no ocular massage, no forcing the lids open to instill drops, no bedside irrigation of embedded debris. Any of that manipulation risks worsening the injury. Definitive exploration and repair belongs in the operating room, not at the bedside.
When an intraocular metallic foreign body is suspected, MRI is contraindicated: its magnetic field can move the fragment and worsen the damage. Thin-cut, non-contrast CT of the orbit is the imaging study of choice instead.
Post-Traumatic Endophthalmitis Risk
In children, open globe injuries frequently come from sticks, thorns, and other organic material encountered during play. Contamination with organic plant matter at the wound site is the single greatest risk factor for post-traumatic endophthalmitis: it carries a far higher fungal and bacterial load than a metallic or glass foreign body, and a wooden-object injury needs broader-spectrum prophylactic antibiotics than a typical open globe injury from a cleaner mechanism.
- Hyphema: head-of-bed elevation (30–45°); rebleeding risk peaks 2–5 days post-injury, not immediately and not weeks later.
- Perforating = entry and exit wound from the same object; penetrating = entry wound only, no exit (BETT classification).
- Suspected open globe: rigid shield, no drops, no massage, no irrigation; go straight to the operating room.
- Organic material (wood, plant matter) at an open globe wound site is the leading risk factor for post-traumatic endophthalmitis.
- Extensive, multilayered retinal hemorrhage to the ora serrata with an inconsistent trauma history = consider abusive head trauma and involve child protection.
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