July 2009

Toy Gun Injury Not Child’s Play

History and Presentation

A 38-year-old man presented with extreme pain in his right eye with the following explanation.

As he arrived home from work, his wife jokingly shot a soft foam projectile at him using a toy gun her children had been playing with. Ironically, his wife said she’d spent the day warning the children not to aim their guns at each other’s faces, trying to avoid eye injuries.

The patient’s uncorrected vision was 20/200, and 20/40 pinhole in the right eye. I instilled 1 drop of proparacaine hydrochloride 0.5% and examined the eye. A large, ragged abrasion was apparent. After staining with fluorescein sodium strips and using a Wratten filter, I observed limited stromal perfusion.

Discussion

There is no consensus on the best way to manage corneal abrasions. A literature review by Turner and Rabiu at the Royal Victorian Eye and Ear Hospital in Victoria, Australia, showed that pressure patching does not improve healing rates and does not improve pain.¹ Donnenfield and associates showed that a bandage contact lens significantly reduces pain in the management of a corneal abrasion, and the combination of an NSAID and a bandage lens is even more effective in pain management.²

I prefer to use a bandage contact lens worn overnight, over-the-counter analgesics and topical antibiotics.

Treatment

After gently irrigating the eye with sterile saline, I applied an 8.6/14.0 Biofinity soft contact lens (CooperVision) as close to the patient’s distance prescription as possible (he is a low myope with spherical equivalent –0.50D). Although the Biofinity lens is not yet approved for use as a bandage lens, I chose it because it has ideal bandage properties: a low modulus and a Dk/t of 160. I avoid high-modulus silicone hydrogel lenses as bandage lenses for superior corneal abrasions because they have been shown to be associated with superior epithelial arcuate lesions in susceptible patients.³

I always follow abrasions over the first 24 hours; this abrasion was 90% healed the following day. At the day 1 follow-up visit, I remove the bandage lens and if the discomfort is minimal with the lens removed and the abrasion is either closed or close to being resolved, I do not reapply a bandage lens. The topical antibiotic and daily follow-up continue until fluorescein staining shows that the abrasion is fully closed. I saw this patient the next morning and discontinued the antibiotic because the abrasion had fully resolved.

Obviously, I would advise all parents to have their children wear low cost safety glasses when playing with toy guns, especially air guns. It is clear from this case that even a soft foam projectile shot from a toy gun can do significant damage.

References

1. Turner A, Rabiu M. Patching for corneal abrasion. Cochrane Database Sys Rev. 2006;2:CD004764.
2. Donnenfeld ED, Selkin BA, Perry HD, et al. Controlled evaluation of a bandage contact lens and a topical nonsteroidal anti-inflammatory drug in treating traumatic corneal abrasions. Ophthalmology. 1995;102:979-984.
3. Jalbert I, Sweeney DF, Holden BA. Epithelial split associated with wear of a silicone hydrogel contact lens. CLAO Journal. 2001;4:231-233.

By Donald J. Siegel, OD
Sun City West, Ariz.

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