During the pandemic, different kinds of ocular trauma have become prominent.
The COVID-19 pandemic has radically changed almost every aspect of our lives, including the rate and nature of pediatric ocular trauma. Though data from early in the pandemic implies a decrease in these cases, perhaps due to less time spent in motor vehicles and the cancellation of sports and recreational activities, physicians and parents must remain aware of shifting trends and possible new risks to children’s eye health, since the visual pathways in these patients are still developing, and any trauma can have severe long-term effects. In this article, we’ll provide a look at how the COVID-19 pandemic has changed the frequency of emergency department visits, created new hazards and altered the main causes of eye trauma in the pediatric population, as well as share tips on how to respond to particular types of ocular trauma often encountered during the pandemic.
The Pandemic Effect
Pediatric ocular trauma accounts for an estimated one-third of all eye-related emergency department visits in the United States each year, occurring at a rate of one injury every three minutes in a 2018 study.1 When the COVID-19 pandemic was declared a national emergency on March 13, 2020, however, emergency medical care sought for reasons other than COVID-19 sharply declined.2 A retrospective cohort study found that pediatric ocular trauma ED visits dropped by 51 percent from early to late March of 2020.3 Public fear of contracting the virus in hospitals peaked during this time and, as lockdown restrictions were put into place, children began spending increasing amounts of time at home engaging in more sedentary activities with less risk of eye injury.
In April 2020, the number of pediatric eye-related ED visits dropped even further, to 30 percent of the pre-COVID volume, bringing pediatric eye-related ED visits to the lowest figure seen in the study. It was during this time that the Kawasaki-like pediatric multi-systemic inflammatory condition was found to affect children, which may have further increased parents’ worries over their children’s safety.3 Mandates keeping children from participating in sports/recreational activities and less time spent in motor vehicles, both of which typically comprise a large proportion of acute pediatric eye injuries, most likely also played a significant role in reducing the incidence of such trauma.3
However, the decrease in ocular trauma may seem counterintuitive considering that pediatric ocular trauma tends to occur in the home.3,4 The decrease may be due to increased parental supervision, as parents and caregivers spent more time at home with their children during the pandemic due to the need to work remotely and/or fewer job-related responsibilities outside of the home. With social distancing efforts in place, children may also have been less likely to gather with friends and instead engaged in more sedentary, less-risky activities. It’s also important to consider that ED visits for ocular trauma may have declined due to a lack of health insurance, as patients were 67 percent less likely to have health insurance after the start of the pandemic.5 This lack of insurance may have resulted in fear of not being able to afford the cost of an ED visit and might have deterred parents and caregivers from seeking treatment.
While the decrease in eye trauma seen during the pandemic is a promising statistic, physicians and parents must remain aware of factors and exposures that may be more prevalent. One such exposure is the use of alcohol-based hand sanitizers, which are being used frequently during the pandemic.
While the use of hand sanitizers is undoubtedly necessary to hinder the spread of the virus, such widespread use may also have negatively impacted children’s eye health. A study conducted in France for the French Poison Control Centre Research Group showed a sevenfold increase in the number of alcohol-based hand sanitizer eye exposures in children and identified several cases of serious corneal lesions. One aspect that might be contributing to this issue is the fact that many sanitizer dispensers are placed in proximity to the level of younger children’s faces. In addition, the composition of sanitizers is highly variable, and other additives may further promote ocular surface irritation and toxicity. Even alcohol-based hand sanitizers following World Health Organization recommendations contain 80% ethanol or 75% isopropanol, both of which can cause immediate cell death of corneal epithelial cells.6 Practitioners and parents should be aware of the potential damage alcohol-based hand sanitizer can cause to children’s eyes, to help prevent such occurrences.
Pediatric Ocular Trauma By the Numbers
Here’s a review of the statistics and common causes of ocular trauma in kids through the years:
Children younger than 4 years of age tend to be most affected by ocular trauma overall. This age group is also more likely to incur injuries with a high risk of vision loss. High-risk injuries in young children are commonly attributed to lapses in caregivers’ attention combined with exposure to household cleaners, sharp-edged items around the home or toys with projectile parts.1 Pediatric eye trauma most commonly occurs in boys at a rate approximately three times higher than in girls.1,2 Traumatic ocular injuries more frequently occur in children living in large metropolitan regions with populations of over 1 million and in areas with median household incomes falling in the lowest quartile. In addition, most children suffering ocular injuries have public insurance.1
In 2000, a study of pediatric eye trauma in the United States found that the majority of injuries occurred as a result of motor vehicle accidents.3 Over time, the predominant etiology has shifted, as a later study in 2014 determined sports injuries to be the leading cause of eye trauma in children.1 The change is largely attributed to a decrease in vehicle-related injuries due to legislation passed beginning in 1993 that increased automotive safety by mandating upgrades in head protection, airbags and appropriate restraints for children under 8 years of age.1 Additionally, there was a 26.1-percent decrease in the overall number of ED visits for pediatric eye injuries from 2006 to 2014, suggesting that such mandates were instrumental in decreasing the incidence of pediatric ocular trauma.1 This large decrease may also be partly explained by a decrease in pediatric gun-related eye injuries. An earlier study conducted from 1990 to 2012 showed injuries due to non-powder guns had increased by 168.8 percent and accounted for almost half of all pediatric ocular trauma hospitalizations.2 However, more recent data suggests this trend is changing as a 68.5-percent decline in such injuries was seen from 2006 to 2014.1
While overall numbers of ocular trauma injuries in the pediatric population may be decreasing, several types of ocular injury are on the rise. In particular, sports-related injuries have been found to be increasing in prevalence, with basketball, football, baseball and softball as the most common causes.1,2 Participation in sports and recreational activities is immensely beneficial to children physically, socially and psychologically but puts them at risk of injury. With the use of appropriate eyewear and protection, however, it’s estimated that around 90 percent of sports-related eye trauma in children is preventable.2
Eye injuries from household/domestic activities and pet-related injuries are also on the rise. From 2006 to 2014, injuries resulting from pet-related incidents increased by 16.9 percent, while other home-related causes of eye injury increased by 29.6 percent. Other sources of injury in the home include common household items such as cleaning fluids and automotive chemicals. Substances with colorful packaging are especially enticing to children, and while child-resistant mechanisms, printed warnings and age recommendations are proven prevention strategies, parents must still take care to safely store such items in a way that reduces accessibility, and properly dispose of harmful items.1 This is particularly relevant with the onset of the COVID-19 pandemic, as children are spending significantly more time at home, which increases the chance of exposure to such substances.
1. Matsa E, Shi J, Wheeler KK, McCarthy T, McGregor ML, Leonard JC. Trends in US emergency department visits for pediatric acute ocular injury. JAMA Ophthalmology 2018;136:8:895.
2. Miller KN, Collins CL, Chounthirath T, Smith GA. Pediatric sports- and recreation-related eye injuries treated in US emergency departments. Pediatrics 2018;141:2.
3. Brophy M. Pediatric eye injury-related hospitalizations in the United States. Pediatrics 2006;117:6.
If a child presents with a chemical burn from hand sanitizer, flush the eye immediately, test the pH, check the intraocular pressure and assess the patient at slit lamp to determine extent of damage to the ocular surface. When assessing the damage, the Roper-Hall classification of ocular chemical injuries can be used, which proceeds as follows:7
- Grade I—there’s damage to the corneal epithelium, no limbal ischemia, and the prognosis is good;
- Grade II—corneal haze is present and iris details are visible; there’s less than one-third limbal ischemia and the prognosis remains good;
- Grade III—there’s complete loss of the epithelium, stromal haze and the iris details are obscured; there’s one-third to one-half limbal ischemia, and the prognosis is guarded;
- Grade IV—the cornea is opaque, and iris and pupil details are obscured; there’s greater than one-half limbal ischemia and the prognosis is poor.
Once you’ve classified the injury, you—or in severe cases, a corneal specialist—can begin treatment based on the severity. Based on recommendations from the American Academy of Ophthalmology,8 treatment consists of the following:
For grade I injuries:
- topical antibiotic ointment (erythromycin ointment or similar) four times a day;
- prednisolone acetate 1% four times a day;
- preservative-free artificial tears as needed; and
- for pain, consider a short-acting cycloplegic like cyclopentolate three times a day.
For grade II injuries:
- topical antibiotic drop four times daily;
- prednisolone acetate 1% hourly while awake for the first seven to 10 days. Consider tapering the steroid if the epithelium has not healed by around day 10 to 14. If an epithelial defect persists after day 10, consider progestational steroids (1% medroxyprogesterone four times daily);
- long-acting cycloplegic like atropine;
- oral Vitamin C, 2 g four times a day;
- doxycycline, 100 mg twice a day (avoid in children, however);
- sodium ascorbate drops (10%) hourly while awake;
- preservative-free artificial tears as needed; and
- debridement of necrotic epithelium and application of tissue adhesive as needed.
If a patient has a grade III injury:
- all the treatments done for Grade II; and
- possible amniotic membrane transplant, best performed in the first week after injury. Recommendations are to place the amniotic membrane so that it covers the palpebral conjunctiva by suturing it to the lids in the operating room, not just covering the cornea and bulbar conjunctiva with it.
For grade IV:
- The same approaches as for grade II/III; and
- early surgery is usually necessary. If there’s significant necrosis, a tenonplasty can help reestablish the limbal vessels. An amniotic membrane transplant is often necessary due to the severity of the damage.
Physical Abuse and Neglect
Other potential sources of pediatric ocular trauma during the pandemic may arise due to the added stresses on caregivers. Due to people losing their sources of income, social isolation and school closures, many families are facing dramatically heightened levels of stress. Physicians and families must be cognizant of the fact that with added stress comes increased risk of child abuse and neglect.
A study conducted from January 2019 to September 2020 found the percentage of ED visits related to child abuse and neglect ending in hospitalization has increased significantly among children and adolescents under 18.9
If a child presents with trauma to the ocular region, be aware of the following key signs that could possibly indicate abuse:
- retinal hemorrhages, which are seen in approximately 75 percent of abuse cases involving head trauma (indirect ophthalmoscopy, ideally with dilation, will help identify these);
- acquired strabismus from increased intracranial pressure from injury;
- traumatic hyphema;
- Marcus Gunn pupil;
- periorbital ecchymosis;
- subconjunctival hemorrhages; and/or
- changes in mental status with no obvious cause.10
With the above signs in mind, medical personnel must maintain suspicion for possible child abuse and appropriately report abuse to the authorities when identified.
In conclusion, the COVID-19 pandemic has brought unprecedented changes to health care. While pre-pandemic data suggests the incidence of pediatric ocular trauma appears to be decreasing overall, COVID-19 has dramatically changed the way we live and therefore the risks we face each day that may impact our health. As ocular trauma is a leading cause of visual loss in the pediatric population, it’s imperative for physicians and parents to remain vigilant, particularly during the pandemic, as conditions continue to change with the introduction of vaccines and attempts to return to a new state of normalcy.
Ms. Casella is a pursuing a medical degree at the Miller School of Medicine.
Dr. Cavuoto practices at the University of Miami’s Bascom Palmer Eye Institute, and is an associate professor of clinical ophthalmology at the University of Miami Miller School of Medicine.
They report no relationships with companies that make products mentioned in this article.
1. Matsa E, Shi J, Wheeler KK, et al. Trends in US emergency department visits for pediatric acute ocular injury. JAMA Ophthalmology 2018;136:8:895.
2. Hartnett KP, Kite-Powell A, DeVies J, et al. Impact of the COVID-19 pandemic on emergency department visits — United States, January 1, 2019–May 30, 2020. MMWR Morbidity and Mortality Weekly Report 2020;69:23:699.
3. Shah K, Camhi SS, Sridhar J, Cavuoto KM. Impact of the coronavirus pandemic on pediatric eye-related emergency department services. Journal of American Association for Pediatric Ophthalmology and Strabismus 2020;S1091-8531:20:30225-1.
4. Brophy M. Pediatric eye injury-related hospitalizations in the United States. Pediatrics 2006;117:6.
5. Wu C, Patel SN, Jenkins TL, et al. Ocular trauma during COVID-19 stay-at-home orders: A comparative cohort study. Current Opinion in Ophthalmology 2020;31:5:423.
6. Martin GC, Le Roux G, Guindolet D, et al. Pediatric eye injuries by hydroalcoholic gel in the context of the coronavirus disease 2019 pandemic. JAMA Ophthalmology. 2021. doi:10.1001/jamaophthalmol.2020.6346 (Epub ahead of print)
7. Roper-Hall M.J., Thermal and chemical burns. Trans Ophthalmological Soc UK 1965;85:631-53.
8. Colby K. Chemical injuries of the cornea. Focal points in American Academy of Ophthalmology 2010;28:1:1-14.
9. Swedo E, Idaikkadar N, Leemis R, et al. Trends in U.S. emergency department visits related to suspected or confirmed child abuse and neglect among children and adolescents aged <18 years before and during the COVID-19 pandemic — United States, January 2019–September 2020. Morbidity and Mortality Weekly Report 2020;69:49:1841-1847.
10. American Academy of Ophthalmology Clinical Statement. The eye examination in the evaluation of child abuse—2018. https://www.aao.org/clinical-statement/eye-examination-in-evaluation-of-child-abuse-2018. Accessed March 5, 2021.