Paediatric Ocular Trauma: What the Experts and Ophthalmologists Needs to Know

Paediatric ocular trauma is a common yet often underestimated area of ophthalmic

medicolegal practice. Children present with a wide range of injuries, from innocuous appearing superficial trauma to sight threatening internal damage. The legal system relies heavily on ophthalmic experts to interpret the mechanism of injury, the potential for long-term harm, and whether the clinical management met accepted standards of care.

This blog is written for medical professionals, expert witnesses, and all stakeholders involved in paediatric assessment. Understanding how trauma presents in children and how courts evaluate these cases is essential for accurate reporting and safe clinical practice.

1. Why Paediatric Trauma Is Medico-legally Important

Unlike adults, children may not articulate symptoms clearly. Their accounts are influenced by age, fear, and limited understanding. In some cases, trauma may be attributed to an accidental mechanism even when the clinical picture suggests otherwise.

Medicolegal significance arises because:

• missed trauma can lead to permanent visual loss

• the pattern of injury may not match the reported mechanism

• safeguarding concerns may be raised in specific scenarios

• documentation is often scrutinised

• minor appearing injuries may mask significant damage

The court relies on experts to bring clarity and developmental context to these cases.

2. Mechanism of Injury: The Expert’s Role in Interpretation

A central task for the expert witness is analysing whether the described mechanism is consistent with the clinical findings. Key considerations include:

• direction of force

• magnitude of force

• presence of multiple or inconsistent injuries

• whether certain findings can arise accidentally

• timing of trauma relative to symptoms

• alignment with known patterns of ocular injury

Medical professionals and expert witnesses should be familiar with the typical forces required to produce:

• subconjunctival haemorrhage

• corneal abrasions

• hyphema

• retinal dialysis

• vitreous haemorrhage

• orbital fractures

• retinal haemorrhages

Expert interpretation is critical, particularly when safeguarding questions arise or when mechanisms appear implausible.

3. Recognising Safeguarding Red Flags

Although most paediatric trauma is accidental, certain patterns require careful evaluation. Red flags include:

• injury inconsistent with child’s developmental ability

• multiple injuries at different stages of healing

• retinal haemorrhages without adequate explanation

• injuries not aligning with reported mechanism

• delay in seeking treatment

• recurrent attendances for ocular trauma

Medical professionals and expert witnesses should be alert to these indicators and understand their medicolegal relevance.

4. Standards of Care in Assessing Paediatric Trauma

The expected standard of care includes:

• thorough history taking from parent and child

• careful examination of the external eye and adnexae

• assessment of visual acuity appropriate for age

• fluorescein staining for corneal injuries

• intraocular pressure measurement when appropriate

• dilated fundus examination in significant trauma

• arranging imaging where required

• escalation to paediatric ophthalmology when findings are uncertain

Failure to undertake these steps may constitute a breach of duty, especially when injuries progress or complications develop.

5. Common Breach Scenarios in Litigation

Typical breaches encountered in paediatric ocular trauma claims include:

• failure to perform fluorescein examination

• missed corneal abrasion or foreign body

• delayed diagnosis of penetrating injury

• failure to dilate when retinal involvement was possible

• inappropriate reassurance in cases of apparent trivial trauma

• missed signs of non accidental injury

• inadequate follow up leading to complications such as amblyopia or infection

Each breach must be assessed within the child’s developmental context and the urgency of the situation.

6. Causation: Could Harm Have Been Prevented?

The court requires the expert to determine whether earlier recognition or intervention would have changed the outcome. Key questions include:

• would timely treatment have preserved vision

• was the injury progressive

• did the child require more urgent imaging

• should referral to ophthalmology have occurred sooner

• was amblyopia avoidable

• would the long-term outcome differ with appropriate care

Causation analysis must be balanced, evidence based, and consistent with paediatric ophthalmic principles.

7. Prognosis and Long-term Impact

Ocular trauma in children may result in:

• permanent corneal scarring

• retinal damage

• reduced acuity

• amblyopia

• strabismus

• impaired depth perception

• cosmetic impact

• psychosocial consequences

• long-term risk of ocular complications such as glaucoma

Expert witnesses must articulate how the injury affects the child’s future development, education, and functional capability.

8. Documentation: A Frequent Ground for Challenge

Poor documentation is common in trauma cases and often forms the basis of breach findings.

Frequent issues include:

• missing acuity measurement

• inadequate description of injury

• no documentation of dilated examination

• unclear plan or follow up timing

• lack of safety netting advice

Experts must interpret these gaps carefully, ensuring that their conclusions remain grounded in evidence, clinical expectation, and legal standards.

Conclusion

Paediatric ocular trauma is a challenging area of clinical and medicolegal practice. Experts must understand not only the clinical presentation and the standards of care, but also the nuance involved in interpreting mechanisms of injury and identifying safeguarding concerns.

For medical professionals, correct examination, documentation, and escalation are essential. For expert witnesses, clarity of reasoning and developmental understanding allow the court to evaluate causation and breach with confidence. Ultimately, accurate assessment protects both the child and the integrity of the legal process.