Management of Periorbital Swelling After Eye Trauma in a 3-Year-Old
Immediately assess for vision-threatening injuries and obtain urgent ophthalmology consultation if there is any concern for serious ocular injury, as 24% of orbital fractures in children present with severe eye injury and 5.5% of facial fractures result in complete vision loss. 1
Immediate Assessment Required
Perform a focused examination looking specifically for:
- Visual acuity testing (even informal fixation and following in a 3-year-old) 2, 1
- Pupillary examination for reactivity and symmetry 2, 3
- Red reflex testing to detect intraocular pathology 2
- Eye movement assessment in all directions of gaze 2
- Presence of proptosis or enophthalmos 2, 1
- Signs of globe injury: subconjunctival hemorrhage, hyphema, or abnormal eye appearance 2
Red Flags Requiring Urgent Ophthalmology Referral
Refer immediately to ophthalmology if any of the following are present:
- Decreased or abnormal visual acuity 1, 4
- Restricted eye movements or diplopia 2, 5
- Abnormal pupils (asymmetric, poorly reactive) 2, 3
- Proptosis or significant globe displacement 2, 1
- Subconjunctival hemorrhage, hyphema, or corneal abnormality 2
- High-velocity mechanism of injury (even if examination appears normal initially) 4
- Vital sign abnormalities: bradycardia, nausea, vomiting, or altered consciousness suggesting oculocardiac reflex from muscle entrapment 2, 5
Critical caveat: Normal visual acuity at presentation does not rule out serious injury—high-velocity mechanisms require ophthalmology evaluation regardless of initial examination findings. 4
Imaging Decision
Obtain non-contrast CT orbits with thin cuts and multiplanar reconstructions if:
- Any of the red flags above are present 2, 1
- Suspected orbital fracture based on mechanism or examination 2, 3
- Concern for intraorbital foreign body (CT has 94.9% sensitivity) 2, 1
- Suspected muscle entrapment 5, 3
Do NOT obtain imaging if:
- Isolated periorbital soft tissue swelling only 2
- Normal visual acuity, normal eye movements, normal pupils 2
- Low-velocity mechanism (simple fall from standing) 4
- No globe abnormalities on examination 2
Important note: MRI is absolutely contraindicated if metallic foreign body is suspected. 3
Management Based on Findings
If Examination is Reassuring (No Red Flags):
- Observe with close follow-up in 24-48 hours 2
- Apply cold compresses to reduce swelling 6
- Educate parents on warning signs requiring immediate return: vision changes, increasing pain, restricted eye movement, or worsening swelling 6
If Serious Injury Identified:
- Life-threatening and vision-threatening conditions take absolute priority over any other manifestations 1
- Immediate surgical repair indicated for: muscle entrapment with oculocardiac reflex, "white-eyed blowout fracture" (trap-door fracture in children), or globe subluxation 2, 5
- Repair within 1-2 weeks for: symptomatic diplopia with positive forced ductions, significant tissue entrapment on CT, or large floor fractures 2, 5
Key Pediatric Considerations
Children under 8 years have unique injury patterns:
- Orbital roof fractures are most common in this age group (versus floor fractures in older children) 2
- Trap-door fractures occur due to elastic, cancellous bone with resilient periosteum, causing muscle entrapment that can rapidly lead to ischemic injury 2, 5
- Serious ocular injuries are less common in children compared to adults (20% versus higher rates in adults) 2
Common Pitfalls to Avoid
- Do not assume normal vision rules out serious injury—high-velocity mechanisms require evaluation even with preserved visual acuity 4
- Do not attribute diplopia solely to swelling—it may indicate muscle entrapment requiring urgent intervention 5
- Do not delay ophthalmology consultation if any red flags are present—early identification prevents complications 1, 6
- Do not obtain routine imaging for simple periorbital swelling without concerning features—this exposes children to unnecessary radiation 2