|
 |
| CASE REPORT |
|
| Year : 2014 | Volume
: 7
| Issue : 1 | Page : 88-90 |
|
|
Open globe injury in a 3-year-old child presenting 3 days later!!!
Avinash Mishra1, VK Baranwal2, Saurabh Luthra3, Vijay K Srivastava4
1 Military Hospital, Ahemdabad Cant; Hanuman Camp, Shahibag, Ahemdabad, Gujarat, India
2 Command Hospital (NC), Udhampur, India
3 Drishti Eye Centre, Dehradun, India
4 Military Hospital, Jodhpur, India
| Date of Web Publication | 10-Dec-2013 |
Correspondence Address:
Avinash Mishra
Military Hospital, Ahmedabad Cant; Hanuman Camp, Shahibag, Ahemdabad, Gujarat
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0975-2870.122798
Open globe injuries are a very common cause of unilateral visual loss, with children accounting for up to 20% of all these injuries. The principles of management of ocular injuries are the same for children and adults. However, the management in the case of a child is made much more difficult due to variable cooperation with assessment and continuing therapy as well as the subsequent possibility of amblyopia further complicating the treatment. Here we report the successful management of a 3-year-old child who was brought to this center with a full thickness penetrating injury to her cornea, with a pencil, and the presence of hypopyon, 3 days after the occurrence of the injury. Keywords: Hypopyon, Open globe injury, penetrating injury cornea
How to cite this article:
Mishra A, Baranwal V K, Luthra S, Srivastava VK. Open globe injury in a 3-year-old child presenting 3 days later!!!. Med J DY Patil Univ 2014;7:88-90 |
| Introduction | |  |
Open globe injuries are a frequent cause of unilateral visual loss. The highest proportion of injuries occurs at home and sharp objects were the most frequent causative agents. [1] The longstanding adage "the pen is mightier than the sword" still holds true, both in general life and specifically in relation to risk of ocular injury from pens, pencils, or swords. Unlike other sharp objects, pens and pencils are readily available to children both at home and school and penetrating trauma from writing instruments are a common source of injury and often requires surgical intervention. [2]
| Case Report | | |
A 3-year-old girl was brought to this center with a history of injury right eye with a pencil, sustained 3 days back. Her father was working elsewhere and his wife was staying in a village 6 hours from this city. On presentation a throughout ocular examination was difficult because of the child being very uncooperative; however the following could be seen with a torch light, a severe circum corneal congestion and a large freshly healed macular grade corneal opacity at the point of entry. However what was alarming was the large hypopyon evident in the anterior chamber. Ideally we should have recorded her vision, done a detailed dilated fundoscopy as well as carried out a B scan ultrasound. However the child did not allow it and so she was taken up for an urgent examination and surgical repair under general anesthesia (GA). Examination under GA confirmed the above findings and revealed a small, self-sealed, entry wound near the pupillary margin. This was surrounded by a 4 mm × 3 mm large macular grade corneal opacity. The remaining part of the cornea too was hazy due to edema. The anterior chamber (AC) was shallow with the hypopyon occupying the lower 1/4 th part of the AC [Figure 1]. Fundoscopy was attempted; however the fundus details could not be appreciated due to the media being hazy. Initially a sideport entry was made; the hypopyon was aspirated out and sent for the following laboratory tests, culture and antibiotic sensitivity test, potassium hydroxide (KOH) mount, and gram staining. The AC was then reformed with air [Figure 2]. No suturing of the corneal wound was done as it had already self-sealed and there was no leakage even after gentle pressure on the eyeball. Also any suturing at this site would have led to a permanent corneal scarring in the child's visual axis thus further compromising her vision. Finally an intravitreal injection of vancomycin (1 mg in 0.1 ml) and ceftazidime (2.25 mg in 0.1 ml) was given. The vitreous aspirate too was sent for the above-mentioned investigations. Postoperatively the child was started on broad spectrum systemic antibiotics (injection cefotaxime 250 mg IV 6 hourly (QID) and systemic steroids (syp prednisolone 20 mg daily) in a tapering schedule. The first postoperative day revealed the AC to be well formed with air and no hypopyon. By the fourth post op day the air bubble was still present in the AC and there was no evidence of any hypopyon [Figure 3]. The child was then started on topical steroids (prednisolone 1% eye drop 4 hourly) and fortified topical antibiotics (Vancomycin 25 mg/ml q 1 hourly and Ceftazidime 50 mg/ml q 1 hour), along with mydriatics (atropine 1% eye drop QID) and antiglaucoma medication (timolol 0.5% eye drop 12 hourly). These drops were tapered off over the next 2 weeks [Figure 4]. A detailed fundoscopy under sedation, done at this stage, too revealed a normal fundus. The samples of the hypopyon as well as the vitreous aspirate sent for investigations too were all negative with no growth evident even after 2 weeks. The child was discharged after 3 weeks with an absolutely quite eye and just a small nebular grade corneal opacity as an indication to her very narrow escape [Figure 5]. However she is being regularly followed up on an outpatient basis [Figure 6]. | Figure 1: Entry wound seen overlying the pupillary area as well as the hypopyon occupying the lower portion of the anterior chamber
Click here to view |
 | Figure 2: Hypopyon aspirated out and the anterior chamber formed with air
Click here to view |
 | Figure 3: 4th Day Post Op - Anterior chamber well formed with air bubble still present and no hypopyon
Click here to view |
| Discussion | | |
Ocular injury is the most important causal factor of unilateral blindness worldwide [3] with a large percentage of such injuries occurring in children. Home is the most common place for ocular injuries in children followed next by the playground. [4] The cornea is the most common site involved in over 6o% of the cases. [5] Though ocular injuries from writing instruments such as pens or pencils have been reported earlier, its exact incidence is still uncertain. [6] Like darts, writing instruments too have a pointed end causing the kinetic energy to be concentrated over a very small area. This increases the chance of ocular penetration, particularly on impact with a very delicate structure like the cornea. [6]
The prognosis of penetrating ocular trauma in children is usually guarded and significantly poorer in eyes where the primary repair was delayed beyond 24 hours. [7] Delayed arrival of patients with open globe injury is also more commonly associated with endopthalmitis. [8],[9] It has also been seen that the proportion of enucleation/evisceration of eyes with endophthalmitis was up to 16 %, much higher than that without endophthalmitis. [10]
In our case it was a female child, though previous studies have shown that boys are by far more commonly involved. [5] She was brought 3 days after the injury with various signs of infection such as corneal edema and hypopyon in the anterior chamber. [9],[11] A posttraumatic endophthalmitis was suspected and she was immediately taken up for surgical repair and intravitreal antibiotics injection under GA. [8],[11] The hypopyon was aspirated out and sent for the necessary investigations and the AC was reformed with air. Since the wound had self-sealed, no suturing was attempted. As it is any suturing of the cornea at this site, overlying the pupillary axis would only cause a further corneal opacification and further visually compromise the child. For clinically diagnosed posttraumatic endophthalmitis, intravitreal vancomycin, and ceftazidime are routinely used. [9] In such cases postoperative fortified topical as well as intravenous, broad spectrum antibiotics too are recommended. [11]
| Conclusion | | |
Open globe injuries, associated with a delayed presentation, are probably the worst prognostic factors for a successful visual outcome. [12] Open globe injuries in children are a very common cause of unilateral blindness and more adequate adult supervision measures are necessary in order to reduce the prevalence of these accidents. We also recommend appropriately educating all parents and teachers regarding the potential risks of children using these sharp pointed writing instruments. [2] This will go a long way in preventing such avoidable causes of blindness in future.
| References | | |
| 1. | Beby F, Kodjikian L, Roche O, Donate D, Kouassi N, Burillon C, et al. Perforating ocular injuries in children: A retrospective study of 57 cases. J Fr Ophtalmol 2006;29:20-3. 
[PUBMED] |
| 2. | Fisher SB, Clifton MS, Bhatia AM. Pencils and pens: An under-recognized source of penetrating injuries in children. Am Surg 2011;77:1076-80.
[PUBMED] |
| 3. | Negrel AD, Thylefors B. The global impact of eye injuries. Ophthalmic Epidemiol 1998;5:143-69.
|
| 4. | Dulal S, Ale JB, Sapkota YD. Profile of pediatric ocular trauma in mid western hilly region of Nepal. Nepal J Ophthalmol 2012;4:134-7.
[PUBMED] |
| 5. | Skiker H, Laghmari M, Boutimzine N, Ibrahimy W, Benharbit M, Ouazani B, et al. Open globe injuries in children: retrospective study of 62 cases. Bull Soc Belge Ophtalmol 2007;306:57-61.
[PUBMED] |
| 6. | Kelly SP, Reeves GM. Penetrating eye injuries from writing instruments. Clin Ophthalmol 2012;6:41-4.
[PUBMED] |
| 7. | Narang S, Gupta V, Simalandhi P, Gupta A, Raj S, Dogra MR. Paediatric open globe injuries. Visual outcome and risk factors for endophthalmitis. Indian J Ophthalmol 2004;52:29-34.
[PUBMED]  |
| 8. | Junejo SA, Ahmed M, Alam M. Endophthalmitis in paediatric penetrating ocular injuries in Hyderabad. J Pak Med Assoc 2010;60:532-5.
[PUBMED] |
| 9. | Ahmed Y, Schimel AM, Pathengay A, Colyer MH, Flynn HW Jr. Endophthalmitis following open-globe injuries. Eye (Lond) 2012;26:212-7.
[PUBMED] |
| 10. | Zhang Y, Zhang MN, Jiang CH, Yao Y, Zhang K. Endophthalmitis following open globe injury. Br J Ophthalmol 2010;94:111-4.
[PUBMED] |
| 11. | Chen KC, Yang CS, Hsieh MC, Tsai HY, Lee FL, Hsu WM. Successful management of double penetrating ocular trauma with retinal detachment and traumatic endophthalmitis in a child. J Chin Med Assoc 2008;71:159-62.
[PUBMED] |
| 12. | Kinderan YV, Shrestha E, Maharjan IM, Karmacharya S. Pattern of ocular trauma in the Western Region of Nepal. Nepal J Ophthalmol 2012;4:5-9
|
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
|
Search Pubmed for