Eye Drops for Pediatric Scleral Injury
For a child with scleral injury, immediately initiate broad-spectrum topical antibiotic drops such as moxifloxacin four times daily to prevent bacterial keratitis and endophthalmitis, along with preservative-free lubricating drops (hyaluronate or carmellose) every 2 hours to maintain corneal epithelial integrity. 1
Antibiotic Coverage
Primary Antibiotic Selection
- Moxifloxacin 0.5% four times daily is the preferred topical antibiotic for pediatric scleral trauma, particularly when corneal epithelial compromise is present or suspected 1
- Fluoroquinolones are safe for topical use in children, as systemic toxicity is not a concern with topical administration 2
- Alternative fluoroquinolones include levofloxacin, gatifloxacin, or ciprofloxacin if moxifloxacin is unavailable 2
Rationale for Broad-Spectrum Coverage
- Penetrating scleral injuries carry significant risk of endophthalmitis from both gram-positive and gram-negative organisms 3
- Topical antibiotics alone may not achieve adequate intraocular penetration through intact tissue, but they provide critical surface prophylaxis 3
- Note: Systemic antibiotics (intravenous or oral) should be strongly considered for any full-thickness scleral injury, as topical therapy alone is insufficient for intraocular infection prevention 2
Supportive Eye Drops
Lubricating Agents
- Apply preservative-free hyaluronate or carmellose drops every 2 hours during the acute phase to protect the corneal surface and promote epithelial healing 1
- Preservative-free formulations are essential to avoid additional ocular surface toxicity in already compromised tissue 4
Anti-inflammatory Therapy
- Consider nonpreserved dexamethasone 0.1% twice daily after 48-72 hours if significant inflammation develops, but only after infection has been ruled out or adequately controlled 1
- Topical corticosteroids should never be used initially in bacterial conjunctivitis or suspected infection, as they can potentiate bacterial growth and worsen outcomes 5
- Steroids require close monitoring for elevated intraocular pressure and should be tapered slowly once inflammation is controlled 5
Cycloplegic Agents
- Add a cycloplegic drop (cyclopentolate 1% or atropine 0.5-1%) if significant anterior chamber inflammation or pain is present to prevent synechiae formation and reduce ciliary spasm 2
- For children under 3 years, use cyclopentolate 0.2% or atropine with caution (maximum one drop per eye per day) due to risk of systemic absorption 6
- Atropine is contraindicated in children under 3 months of age 6
Critical Management Considerations
Immediate Ophthalmology Consultation
- All pediatric scleral injuries require urgent ophthalmology evaluation within 24 hours to assess for full-thickness perforation, intraocular foreign body, or vitreous involvement 1
- Daily ophthalmology review is necessary during the acute phase to monitor for infection, inflammation, and healing 2, 1
Infection Prevention
- Prophylactic topical antibiotics must be started within 24 hours of injury to prevent progression to bacterial keratitis or endophthalmitis 2
- If full-thickness perforation is confirmed, intravitreal antibiotics (vancomycin plus ceftazidime or moxifloxacin) are required, as systemic antibiotics do not achieve adequate intraocular levels for gram-positive coverage 3
Common Pitfalls to Avoid
- Never use antibiotic-steroid combination drops initially in traumatic injuries, as steroids can mask infection and delay appropriate treatment 5
- Avoid preserved artificial tears if frequent dosing (more than 4 times daily) is needed, as preservatives cause additional epithelial toxicity 4
- Do not patch the eye or use bandage contact lenses in children with potential contaminated injuries, as this increases infection risk 2