**20.2 Common eye injuries and management**

An external examination should be performed to look for eyelid lacerations which are seen as distortion of eyelids. A good functional and cosmetic result may only be obtained by appropriate suturing technique. Lacerations of the medial part of the lower lid may include lacrimal canaliculi. Tear drainage may be impaired leading to watering of the eye if not repaired properly.

Blunt ocular trauma may lead to traumatic hyphema, ruptured globe, retinal dialysis, retinal tears, macular hole and commosio retina. Hyphema is the collection of blood in the anterior chamber due to rupture of an iris or ciliary body vessel. Hyphema may be noticed as a red collection in the lower part of the anterior chamber or may fill the anterior chamber totally. Treatment includes bed rest, elevation of the head for approximately 45 degrees, cycloplegic and steroid eye drops. Blunt trauma may also rupture the eyeball. Conjunctival edema, soft eye and deep anterior chamber are signs of a posteriorly ruptured eye. Retinal tears and dialysis are severe consequences of blunt trauma which may lead to retinal detachment and therefore a detailed fundus examination is mandatory. Subretinal and intraocular hemorrhages may be highly associated with the shaken baby syndrome. Diffuse involvement of fundus with intravitreal and large subhyaloid hemorrhage are associated with more severe neurological injuries (MacEwen et al., 1999).

Corneal injuries may be in a spectrum from minor abrasions to serious penetrating wounds extending to the sclera. Abrasions are common and present with foreign body sensation, lacrimation and photophobia. It is important to look for a foreign body, which may be embedded at the upper tarsal conjunctiva, by everting the upper lid. Abrasions are treated by topical antibiotics and patching the eye. Irregular pupil due to iris prolapsus from the wound is a general finding of the penetrating injuries. If such an open globe injury is suspected, extreme care should be taken not to exert pressure to the globe and an eye shield should be placed over the eye. Systemic antibiotics, pain relievers and tetanus prophylaxis should be taken into consideration.

Chemical injuries may give damage to the eyelids, cornea and conjunctiva. Burns that penetrate deeper than the cornea are more serious and may lead to cataracts and glaucoma. Chemical injuries in children mostly occur at home from cleaning products or other regular household products. These injuries are dangerous and the treatment must be started

Evaluation starts with a detailed history of the trauma, from the child if possible and also from the parents. Examination of the traumatized eye may be difficult in children. It is important to be patient and gentle. A mild sedative may sometimes be helpful. Visual function should be estimated in the beginning of the examination. Literate or illiterate Snellen charts may be used if possible. Otherwise reading any material or finger counting may help to determine the approximate level of visual acuity. Afterwards lids, conjunctivas and orbit are examined externally to reveal any lid lacerations or orbital rim fractures. The globe is examined carefully and gently. Irregular pupils, edema of the conjunctiva and blood

An external examination should be performed to look for eyelid lacerations which are seen as distortion of eyelids. A good functional and cosmetic result may only be obtained by appropriate suturing technique. Lacerations of the medial part of the lower lid may include lacrimal canaliculi. Tear drainage may be impaired leading to watering of the eye if not

Blunt ocular trauma may lead to traumatic hyphema, ruptured globe, retinal dialysis, retinal tears, macular hole and commosio retina. Hyphema is the collection of blood in the anterior chamber due to rupture of an iris or ciliary body vessel. Hyphema may be noticed as a red collection in the lower part of the anterior chamber or may fill the anterior chamber totally. Treatment includes bed rest, elevation of the head for approximately 45 degrees, cycloplegic and steroid eye drops. Blunt trauma may also rupture the eyeball. Conjunctival edema, soft eye and deep anterior chamber are signs of a posteriorly ruptured eye. Retinal tears and dialysis are severe consequences of blunt trauma which may lead to retinal detachment and therefore a detailed fundus examination is mandatory. Subretinal and intraocular hemorrhages may be highly associated with the shaken baby syndrome. Diffuse involvement of fundus with intravitreal and large subhyaloid hemorrhage are associated

Corneal injuries may be in a spectrum from minor abrasions to serious penetrating wounds extending to the sclera. Abrasions are common and present with foreign body sensation, lacrimation and photophobia. It is important to look for a foreign body, which may be embedded at the upper tarsal conjunctiva, by everting the upper lid. Abrasions are treated by topical antibiotics and patching the eye. Irregular pupil due to iris prolapsus from the wound is a general finding of the penetrating injuries. If such an open globe injury is suspected, extreme care should be taken not to exert pressure to the globe and an eye shield should be placed over the eye. Systemic antibiotics, pain relievers and tetanus prophylaxis

Chemical injuries may give damage to the eyelids, cornea and conjunctiva. Burns that penetrate deeper than the cornea are more serious and may lead to cataracts and glaucoma. Chemical injuries in children mostly occur at home from cleaning products or other regular household products. These injuries are dangerous and the treatment must be started

in the anterior chamber and in the vitreous cavity are signs of severe ocular injury.

**20.2 Common eye injuries and management** 

with more severe neurological injuries (MacEwen et al., 1999).

should be taken into consideration.

**20.1 Evaluation** 

repaired properly.

immediately by irrigation with copious amounts of water as soon as possible. The type of injury, severity and the initial visual acuity are important prognostic factors for the final visual outcome. The visual prognosis is better if immediate diagnosis and treatment is provided and therefore it is important for the general physicians to recognize the severity of the trauma, provide suitable medical management and refer to the ophthalmologist as soon as possible (Moreira et al., 1988; Serrano et al., 2003).

#### **20.3 Prevention of eye injuries**

Most eye injuries can be avoided by simple measures, but still many children face serious visual impairment due to trauma. Most of the eye injuries occur at homes, in streets and roads, in schools and in other child care facilities. Adult supervision is an important factor for the prevention especially for the younger age groups. More than half of the injuries are without adult supervision at the time of event. Trauma is one of the most important preventable causes of blindness in children. Important points in prevention include parental supervision, education of children and protective eye-wears when necessary. Protective eye wears such as polycarbonate goggles should especially be recommended to functionally one eyed children (Mulvihill et al., 1997).

Recognition of eye injuries, taking immediate measures and referral to an ophthalmologist are key components in the management of eye injuries for general practitioners.

#### **21. References**


Pediatric Ophthalmology / Eye and Disorders 29

MacEwen, CJ.; Baines, PS. & Desai, P. (1917). Eye injuries in children; the current picture. *Br J Ophthalmol*, vol.83, no.8, (August 1999), pp. 933-936, ISSN 0007-1161 Maida, JM.; Mathers, K. & Alley, CL. (1990) Pediatric ophthalmology in the developing

Martyn, LJ. ( 2006). Metabolic disease, In : *handbook of pediatrice ye end systemic disease.* 

Matta, NS.; Singman, EL. & Silbert DI. (1951). Evidenced-based medicine: treatment for amblyopia. *Am Orthopt J, vol*.60, (November 2010), pp. 17-22, ISSN 0065-955X Mets, MB. & Kumar, AV. (2006). Eye Manifestations of Intrauterine Infections, In: *Essentials* 

Mickler, C.; Boden, J. & Trivedi, RH.; et al. Pediatric cataract, *Pediatr Ann, vol.*40,

Mollon, JD.; Astell, S. & Reffin, JP. (1991). A minimalist test of colour vision, In: *Colour Vision* 

Moreira, CA., Jr.; Debert-Ribeiro, M. & Belfort, R., Jr. (1960). Epidemiological study of eye

Morishita, H. & Hensch, TK. (1991). Critical period revisited: impact on vision. *Curr Opin* 

Mulvihill, A.; Bowell, R. & Lanigan, B.; et al. (1995). Uniocular childhood blindness: a

Murphree, AL& Christensen LE. (2006). Retinoblastoma and Other Malignant Intraocular Mutti, DO. (1992). Hereditary and environmental contributions to emmetropization and myopia. Optom Vis Sci., vol.87, no4, (April 2010), pp.255-9, ISSN 1040-5488 Nicholson, B.; Ahmad, B. & Sears, JE. (1961). Congenital optic nerve malformations. Int Ophthalmol Clin, vol.51, no.1, (Winter 2011), pp. 49-76, ISSN 0020-8167 Riordan-Eva P. (2004). Optics & Refraction, In: *General Ophthalmology*, Riordan-Eva P. &

*Neurobiol,* vol.18, no.1, (February 2008), pp. 101-7, ISSN 0959-*4388* 

no.2,(February 2011), pp. 83-87, ISSN 0090-4481

Publishers, Dordrecht, ISBN 0–7506–4174-6, Netherlands

8738

Germany

USA

137831-6, USA

85,ISSN 0020-8167

0-387-27927-X, China

784, ISSN 0003-9950

pp. 111-114, ISSN 0191-3913

world. *Curr opin Ophthalmol,* vol.19, no.5, (September 2008), pp. 403-8, ISSN 1040-

Wright, KW.; Spiegel, PH. & Thompson, LS. (eds.), pp. 350-429. Springer, ISBN 10:

*in Ophthalmology: Pediatric Ophthalmology, Neuro-Ophthalmology, Genetics*, Lorenz, B. & Moore, AT. (Eds.), pp. 205-218. Springer-Verlag, ISSN 1612-3212, Berlin,

*Deficiencies,* Drum B., Moreland JD. & Serra A. (eds), pp. 59-67, Kluwer Academic

injuries in Brazilian children. *Arch Ophthalmol*, vol.106, no.6, (June 1988), pp. 781-

prospective study. *J Pediatr Ophthalmol Strabismus*, vol.34, no.2, (March April 1997),

Whitcher JP. (eds), pp. 380-96, McGraw-Hill Companies, Inc, ISBN 0–07–137831-6,

detachment: a comparison between open and closed globe injuries. *Am J* 

Riordan-Eva, P. & Whitcher, JP. (eds), pp. 353-62, McGraw-Hill Companies, Inc, ISBN 0–07–

Rose, G. (2000). Pediatric lacrimal and orbital disease. In: Pediatric Ophthalmology. Moore, A. & Lightman, S. (eds), pp. 162-176, BMJ Books, ISBN 0-7279-1203-8, London Sarrazin, L.; Averbukh, E. & Halpert, M.; et al. (1884). Traumatic pediatric retinal

*Ophthalmol*, vol.137, no.6, (June 2004), pp. 1042–1049, ISSN 0002-9394 Sauberan, DP. (1961). Pediatric uveitis. *Int Ophthalmol Clin,* vol.50, no.4, (Fall 2010), pp.73-


Drack, AV. & Kimura AE. (2006). Retinitis Pigmentosa and Associated Disorders, In:

Erol N. Treatment of Retinopathy of Prematurity. (2009). *Türkiye Klinikleri Journal of Ophthalmology – Special Topics*, vol.4, no.2, (July 2011), pp. 27-32, ISSN 1380-1160 Fredrick, DR. & Asbury, T. (2004). Strabismus, In: *General Ophthalmology*, Riordan-Eva P. &

Gilbert C. (1977). Retinopathy of prematurity: a global perspective of the epidemics,

Goldstein, SM. & Katowitz, JA. (2008). Infections of the eye and adnexa in children, In:

Harley, RD. Paralytic strabismus in children. Etiologic incidence and management of the

Hughes, D. (2000). Eyelid disorders, In: *Pediatric Ophthalmology*, Moore, A. & Lightman, S.

Idrees, F.; Vaideanu, D. & Fraser, SG.; et al. (1970).A review of anterior segment dysgeneses; Surv Ophthalmol, vol.51, no.3, (May 2006), pp. 213-31, ISSN 0039-6257 Jancevski, M. & Foster, CS. (1990). Cataracts and uveitis. *Curr Opin Ophthalmol,* vol.21, no.1,

Kanski, JJ. & Bowling, B. (2011). Congenital cataract, *In Clinical Ophthalmology: A Systematic* 

Kanski, JJ. & Bowling, B. (2011). Cornea, *In Clinical Ophthalmology: A Systematic approach, pp.* 

Kanski, JJ. & Bowling, B. (2011). Hereditary fundus dystrophies. *In Clinical Ophthalmology: A Systematic approach.* pp. 648-85, Elsevier, ISBN-13:9780702040931, China Kanski, JJ. & Bowling, B. (2011). Neuro-ophthalmology. *In Clinical Ophthalmology: A Systematic approach.* pp.789-812, Elsevier, ISBN-13:9780702040931, China Kanski, JJ. & Bowling, B. (2011). Orbit, *In Clinical Ophthalmology: A Systematic approach, pp.* 

Kanski, JJ. & Bowling, B. (2011). Uveitis, *In Clinical Ophthalmology: A Systematic approach, pp.* 

Khani SC. & Fasiuddin A. (2011). Generalized Inherited Retinal Dystrophies, In: *Pediatric* 

Kherani, F. & Robb, RM. (2008). Congenital and developmental abnormalities of the eye,

Levin, AV. (1954). Congenital eye anomalies. *Pediatr Clin North Am*, vol.50, no.1, (February

*Retina,* Reynolds, JD. & Olitsky SE. (Eds.), pp. 295-303, Springer-Verlag, ISBN 978-3-

orbit, and ocular adnexa, In: *Principles and Practice of Ophthalmology,* Albert, DM. & Miller, JW. (eds), pp. 4177-83, Elsevier, ISBN 978-1-4160-0016-7, Philadelphia Krishnamurthy, R. & Vanderveen, DK. (1961). Infantile cataracts. *Int Ophthalmol Clin,* vol.48,

Fredrick, DR. (2004). Special subjects of Pediatric Interest, In: *General Ophthalmology*,

no.2, (January 2008), pp. 77-82, ISSN 0378-3782

Elsevier, ISBN 978-1-4160-0016-7, Philadelphia

(January 2010), pp.10-14, ISSN 1040-8738

168-238, Elsevier, ISBN-13:9780702040931, China

79-117, Elsevier, ISBN-13:9780702040931, China

402-474, Elsevier, ISBN-13:9780702040931, China

no.2, (Spring 2008), pp. 175-192, ISSN 0020-8167

2003), pp. 56-76, ISSN 0031-3955

(eds), pp. 154-61, BMJ Books, ISBN 0-7279-1203-8, London

*approach, pp.298-304*, Elsevier, ISBN-13:9780702040931, China

pp. 24-43, ISSN 0161-6420

642- 12040-4, Berlin.

USA

*Handbook of Pediatric Retinal Disease*, Wright, KW; Spiegel PH. & Thompson LS. (Eds.), pp 135-177, Springer Science+Business Media, ISBN 10: 0-387-27932-6, USA.

Whitcher JP. (eds), pp. 230-49, McGraw-Hill Companies, Inc, ISBN 0–07–137831-6,

population of babies at risk and implications for control. *Early Hum Dev*, vol.84,

*Principles and Practice of Ophthalmology,* Albert, DM. & Miller, JW. (eds), pp. 4171-76,

third, fourth and sixth nerve palsies. Ophthalmology, vol.87, no.1, (January 1980),


**Part 2** 

**Pediatric Surgery**


**Part 2** 

**Pediatric Surgery**

30 Complementary Pediatrics

Serrano, JC; Chalela, P. & Arias, JD. (1960). Epidemiology of childhood ocular trauma in a

Shields, CL& Shields JA. (2006). Pediatric Ocular Oncology, In: *Essentials in Ophthalmology:* 

Traboulski, EI. & Martyn, LJ. ( 2006). Connective tissue, skin, and bone disorders, In :

Tumors, In: *Handbook of Pediatric Retinal Disease*, Wright, KW; Spiegel, PH. & Thompson LS

Valenzuela, A; Chan, HSL. & Heon, E; et al. (2011). A language for retinoblastoma:

Yokoyama T.; Kato, T. &, Minamoto, A.; et al. Characteristics and surgical outcomes of

LS. (eds.), pp. 227-290. Springer, ISBN 10: 0-387-27927-X, China

(Eds.), pp. 111-113. Springer-Verlag, ISSN 1612-3212, Berlin, Germany. Sullivan, JH. (2004). Orbit, In: *General Ophthalmology*, Riordan-Eva P. & Whitcher JP. (eds), pp. 250-60, McGraw-Hill Companies, Inc, ISBN 0–07–137831-6, USA Topbas S, Toprak A, Erol N.; et al. Results of Conventional Retinal Detachment Surgery in

1439-1445, ISSN 0003-9950

pp. 193, ISSN 0030-3755

1444-0938

892, ISSN 1476–5454

northestern Colombian region. *Arch Ophthalmol*, vol.121, no.10, (October 2003), pp.

*Pediatric Ophthalmology, Neuro-Ophthalmology, Genetics*, Lorenz B. & Moore AT

Paediatric Age Group. Special Topic Issue: Ophthalmologica, vol. 214, no. 3, (2000),

*handbook of pediatrice ye end systemic disease.* Wright, KW.; Spiegel, PH. & Thompson,

(Eds.), pp 246-283. Springer Science+Business Media, ISBN 10: 0-387-27932-6, USA .

Guidelines and Standard operating procedures, In: *Pediatric Retina,* Reynolds, JD & Olitsky, SE. (Eds.), pp. 205-234. Springer-Verlag, ISBN 978-3-642-12040-4, Berlin Webber, AL. &, Wood, J. (1969). Amblyopia: prevalence, natural history, functional effects

and treatment. *Clin Exp Optom,* vol.88, no.6, (November 2005), pp. 365-75, ISSN

paediatric retinal detachment. *Eye (London)*, vol.18, no.9, (September 2004), pp. 889–

**2** 

*Greece* 

**Acquired Cryptorchidism:** 

**The Results of a Systematic Review** 

Cryptorchidism or undescended testis (UDT) is the most common genital abnormality seen at term in boys (Meij-de Vries A et al 2010, Topari & Kalieva 1999 ). Traditionally UDT was thought to be a congenital disease, with a prevalence of about 0.8-1% by 1 year of age (Berkowitz G Set al 1993). The term acquired UDT was introduced the last few decades, after well documented clinical observations in individuals and groups of patients that many boys continue to be diagnosed and treated later in childhood (Myers NA & Officer CB 1975, Atwell JD 1985, Clarnette TD et al 1977, Schiffer KA et al 1987, Robertson JF & Azmy AF 1988, Wright JE 1989, Fenton EJM et al 1990,Mayr J et al 1995) despite the recommendations for early surgical treatment by orchidopexy (Ritzén M et al 2007). Today, acquired UDT is a recognized separate entity, and after a new clinical classification in 2003, UDT is categorized

Although the pathogenesis of congenital UDT is considered multifactorial including hormonal, genetic, and environmental influences (Ghacko JK & Barthold JS 2009, Barthold JS 2008 ), the exact etiology of acquired UDT remains unclear (Meijer RW 2004). Furthermore, while surgical treatment is recommended for congenital UDT patients as young as 6 months (Ritzén M, 2007), to reduce the increased risks of progressive infertility, testicular malignancy, torsion, associated inguinal hernia, and because of cosmetic and psychological aspects (Ashley RA et al 2010, Lamah M et al 2001) there is much controversy in the

In this article, we present the current data of the literature of this distinct entity in a concise

A systematic review of the literature was performed focusing on the diverse aspects of the epidemiology, pathogenesis, diagnosis and management of acquired UDT. Data were

into two forms: congenital UDT and acquired UDT (Hack WW et al 2003a).

management of acquired UDT (Hack WW et al 2010).

but comprehensive review.

**2. Patients and methods** 

Corresponding Author

 \*

**1. Introduction** 

*1"ATTIKO" University Hospital, Medical School of Athens,* 

**What Should We Know?** 

N. Zavras1,\*, A. Charalampopoulos1, K. Velaoras2 and E. Iakomidis2

*2Penteli General Children's Hospital, Athens* 
