Soreness and photophobia after a conker strike

The question:

A 14-year-old boy has been hit in the eye at school with a conker, thrown across his classroom. His mother phones the practice the next morning as his eye is still sore, mildly photophobic and a little red. She sends the practice a photo showing that his pupil looks smaller in the eye that has been hit. What might be going on, and how would you manage this?

OT’s panel says...

Ceri Smith-Jaynes: Mum hasn’t mentioned blurred vision yet, but it is important to ask if his vision is affected. I’ll be checking acuity as standard; if it is reduced there may be an abrasion or a fundus problem, eg haemorrhage or macular oedema. I’ll also ask about flashes and floaters.

Let’s go front-to back…

Lid oedema may happen as a result of a direct hit or because of a corneal abrasion.

Corneal abrasion will be easily seen with fluorescein. A superficial defect will heal in a day or two, but may need a thick lubricant or antibiotic cover with chloramphenicol ointment.

His pupil has probably gone into spasm because the shock wave of the conker hitting the eye causes inflammation internally. If it were dilated there might be an iris tear, but I doubt that a thrown conker could do that much damage. I’m expecting to see some cells and perhaps some mild flare in the anterior chamber. Hopefully, there won’t be hyphema.

Intraocular pressure may be raised due to damage to the trabecular meshwork or lowered due to ciliary body damage, so I’ll need to check that.

I may give a steroid for an anterior chamber reaction, but not if there is an open corneal abrasion. Prednisolone is not licensed for children, therefore dexamethasone would be my choice.

Cyclopentolate, twice a day, will help with the pain and the pupil spasm, preventing synechiae. Dilating the pupil will allow me to check the fundus for commotio retinae or retinal tear; I might as well put in a drop for the examination.

For the pain, I would suggest an analgesic such as paracetamol or ibuprofen (not in asthmatics). A 14-year-old can be dosed as per an adult.

I haven’t handled this type of presentation myself in practice very often, and I recognise it is important to work within your own level of experience. Personally, I would ring the local ophthalmology team – usually we agree a plan, I start treatment, and they do the follow up in a few days. Once the trauma response has cleared, the steroid can be tapered over a couple of weeks. Generally, the taper can be more rapid in traumatic iritis than if it were anterior uveitis.

Style for attribution is to use attribution when piece has more than one voice His pupil has probably gone into spasm because the shock wave of the conker hitting the eye causes inflammation internally

Kevin Wallace: I don’t have a lot to add to Ceri’s plan – because that’s exactly what I’d do. I’d definitely want to have a good look at the anterior eye to rule out a retained foreign body, including using fluorescein and everting the lids.

If the vision is good that would definitely make me feel better, and I usually do a macular optical coherence tomography to check for any signs of damage there – although they are usually very subtle.

A smaller pupil is less common than a larger pupil in my experience, so it would be ideal to have previous records, but that doesn’t particularly worry me at this stage and I’d expect it to resolve in the next few days.

In most cases a cycloplegic drop, lubricants, systemic pain relief, and a few days to recover is all this will need.

Usually in cases of trauma we would discuss protection – but this feels more like a freak accident, and I wouldn’t be recommending safety glasses in the classroom.

Ankur Trivedi: We do need to be mindful that the history provided would need to be taken at face value – the rare possibility of this being a non-accidental injury either from another child or an adult should not be overlooked.

This, for me, highlights the importance of notification to the patient’s GP. This may be one of a number of incidents that may raise suspicions with the GP.

As ever, good notes with comprehensive imaging, if available, are invaluable here. Good safety netting with red flag advice with notification and discussion with secondary care in case of escalation again would reflect good practice, as outlined by Ceri.