Evaluation and Management of Pediatric Eye Trauma with Periorbital Rash
This 12-year-old requires immediate assessment for vision-threatening injuries, including visual acuity testing, fluorescein staining to detect corneal involvement, and urgent ophthalmology referral if any red flags are present, while initiating symptomatic treatment with oral analgesics and cool compresses. 1
Immediate Assessment Required
Perform these critical evaluations immediately to identify vision-threatening injuries:
- Visual acuity testing - Any vision loss indicates severe injury requiring immediate ophthalmology consultation 1
- Pupillary examination - Asymmetry or poor reactivity suggests serious trauma 1
- Globe integrity assessment - Look for active bleeding from the eye, hyphema, or subconjunctival hemorrhage 1
- Extraocular movement testing - Restriction, especially on upward gaze, may indicate orbital floor fracture with muscle entrapment 1
- Fluorescein staining - This is mandatory to detect corneal involvement that may not be clinically apparent 2, 3
- Eyelid function - Check for lagophthalmos or inability to close the eye 1
- Palpation over frontal bone - Tenderness suggests possible fracture requiring CT imaging 1
Red Flags Requiring Urgent Ophthalmology Referral
Refer immediately (within 24 hours) if any of the following are present:
- Visual loss or changes in visual behavior 2
- Moderate or severe pain causing significant distress 2, 3
- Corneal involvement detected on fluorescein examination 2, 3
- Proptosis or impaired extraocular muscle function 2, 3
- Restricted extraocular movements suggesting orbital fracture 1
- Active bleeding from the eye or hyphema 1
Initial Management
Initiate these treatments while arranging ophthalmology evaluation:
- Oral acetaminophen or ibuprofen for pain control and swelling reduction 1
- Cool compresses for symptomatic relief 3
- Avoid applying pressure to the eye if open globe injury is suspected; protect with a rigid eye shield without pressure 1
- Do not patch the eye if corneal abrasion is possible, as this increases bacterial keratitis risk 1
Imaging Considerations
CT orbit without contrast is indicated when:
- Tenderness over the frontal bone suggests orbital fracture 1
- Clinical suspicion of orbital wall fracture exists 1
- Diplopia with restricted extraocular movements is present 1
- CT has 94.9% sensitivity for intraorbital foreign bodies and is the study of choice for orbital trauma 4, 1
However, do not delay ophthalmology consultation for imaging if open globe injury is clinically obvious. 1
Differential Diagnosis for Periorbital Rash
The rash component requires consideration of:
- Traumatic periorbital soft tissue injury - Most likely given mechanism of blunt trauma with sweatshirt 4, 1
- Contact dermatitis - From fabric or detergent exposure 3
- Viral conjunctivitis with periorbital involvement - Though less likely with isolated trauma history 3
- HSV/VZV infection - Look for vesicular lesions; requires immediate ophthalmology referral if present 3
Critical Pitfalls to Avoid
Common errors that can lead to vision loss:
- Assuming simple soft tissue swelling without thorough examination - 24% of orbital floor fractures present with severe eye injury 1
- Missing corneal involvement by failing to perform fluorescein staining 2
- Delaying ophthalmology consultation for imaging when clinical findings are obvious 1
- Reassurance based on normal initial visual acuity - high-velocity mechanisms can cause delayed complications even with preserved initial vision 5
Follow-Up Monitoring
Close monitoring is essential even if initial evaluation is reassuring:
- Periorbital swelling from trauma can evolve over 24-48 hours 1
- Delayed complications such as orbital compartment syndrome or infection can develop 1
- Instruct parents to return immediately for: worsening pain, vision changes, or development of fever 1
- Standard follow-up in 3-4 days if no red flags present to assess improvement 3