Warning signs

My child was poked in the eye: what to do in the first minutes

A finger, a toy sword, a sibling's elbow. Most blunt knocks to a child's eye settle down on their own. A short list of things, visible to a parent, decide whether this one needs to be seen today.

by Dr Chan Li Yen · MBBS, MOphth (UM), Fellowship in Paediatric Ophthalmology & Strabismus

Practises at Hospital Kuala Lumpur 11 min read · 1,957 words

Key takeaways

Most blunt knocks to a child's eye, with no cut and no red-flag sign, settle at home with comfort and watching.
Any blood visible in the front of the eye, over the coloured part or the pupil, is an emergency-department matter, however small it looks.
A pupil that is not round, not equal to the other, or slow to react, an eye that will not open, or any change in vision, all mean being seen today.
For a blunt knock with no cut, a light cold compress is reasonable; avoid aspirin- or ibuprofen-type painkillers if there is any chance of bleeding inside the eye.
The rule reverses completely for a sharp or penetrating injury: never rinse, never press, and get to an emergency department, as covered on this site's chemical-splash first aid page.

A finger jabbed out mid-tantrum, a toy sword swung too high, a sibling's elbow at bath time. Most blunt knocks to a child's eye settle on their own. The point of this article is the short list that tells you, in the first minutes, whether this particular one is the ordinary kind or the kind that needs to be seen today.

This is about a blunt knock: a finger, a fist, a ball, a fall against furniture, nothing sharp and nothing that pierced the eye. If your child was splashed with a chemical, the whole approach is different, and I have set that out fully in chemical splash in a child's eye: the first sixty seconds. If something sharp went into the eye, skip to the last section of this article, because that reverses almost everything below.

What do I actually check in the first minute?

Four things, and you can do all four while your child is still crying in your arms. Can the eye open, even if reluctantly? Is the pupil, the dark centre, round and roughly the same size as the pupil in the other eye? Is there any blood visible over the coloured part of the eye or the pupil itself? And does vision seem normal, which in a toddler often means watching whether they reach for a small toy or your finger accurately with each eye. None of this needs special equipment or a calm child. A crying, squirming toddler can still show you an open eye, a round pupil and a hand that reaches for a raisin held in front of it.

What makes this a same-day appointment, not a wait-and-see?

Any one of five things. Blood visible in the front of the eye, over the coloured part or the pupil, however small it looks, because that is called a hyphema and it is treated as an eye emergency whatever the amount, due to the risk of raised pressure inside the eye and, uncommonly, lasting damage to vision. A pupil that is not round, is a different size from the other eye, or reacts slowly to light. An eyelid that will not open, or will not open fully, once swelling is accounted for. Vision that seems reduced, blurred, or different in that eye compared with before. And pain that is severe, is not settling with comfort, or comes with vomiting. Any one of these on its own is enough to go today, not to wait for the swelling to go down first.

Blood in the front of the eye, however small it looks, is never a wait-and-see sign.

Is a cold compress safe, and what should I actually do at home?

For a blunt knock with no cut and none of the signs above, a light cold compress is reasonable, and this is consistent with what I already say about blunt injury in the chemical-splash article: hold something cool and clean near the eye rather than pressing it onto the eyeball itself, for short stretches rather than continuously. Keep your child calm and sitting or lying with their head a little raised rather than flat, which helps if there is any bleeding you cannot yet see. Discourage rubbing, which is hard to stop in a small child but genuinely makes things worse if anything is bruised or bleeding underneath. Do not patch the eye tightly or press a bandage against it; current guidance has moved away from firm pressure patching because it does not speed healing and can hide a problem you would otherwise notice.

What should I specifically not do?

Do not rinse the eye with water. That instinct comes from chemical first aid, and it is the wrong move here: guidance is explicit that an eye should not be washed out when the injury involved real force, only when it involved a chemical or something like sand or grit in the eye. Do not give aspirin- or ibuprofen-type painkillers if there is any chance of bleeding inside the eye, because both can make bleeding worse; paracetamol at the correct dose for your child's weight is the safer first choice until an eye doctor has had a look. Do not try to prise the eye open further than it wants to go, and do not press to check "how bad it is" yourself. And do not assume a quiet, settled child means nothing is wrong; a toddler who has stopped crying can still be hiding blurred vision they have no words for yet.

The eye looked fine at first. Why would I need to check again later?

Because some of these signs take time to show. Swelling can mask or mimic a problem in the first minutes and then either resolve or worsen over the following hours. A pupil that reacted normally at first can become sluggish as swelling develops. A hyphema can be too small to see clearly until the initial redness from crying settles. This is why the four checks in the first section are worth repeating every hour or two for the rest of that day while your child is awake, not just once at the start. If everything still looks normal by evening and your child is behaving normally, ordinary comfort and an early night are reasonable. New pain, worsening redness, or light sensitivity that shows up the next morning is still worth a same-day call, not something to leave for a routine appointment.

What if it was not a blunt knock but something sharp or fast-moving?

Then almost everything above reverses, and I want to say this plainly rather than let one article give you a single rule for every eye injury. If something sharp has gone into the eye, or something has struck it at real speed, such as a dart, a stick, a pencil, or a flying stone, do not rinse it, do not press on it, and do not pull anything out of it, however small the object looks. Cover the eye loosely with something rigid, a clean paper or plastic cup taped gently over the socket works well as an improvised shield, and get to an emergency department without delay. No aspirin or ibuprofen on the way, for the same bleeding-risk reason as above. This reversed rule, and the chemical-splash first aid that sits alongside it, is covered in full in chemical splash in a child's eye: the first sixty seconds, which is worth reading once on a calm evening so the right instinct is already in your hands if you ever need it in a hurry.

Is there anything that actually prevents these knocks?

Some, though no home is knock-proof with a moving toddler in it. Toy swords, badminton racquets, and anything swung by a sibling are common causes of blunt knocks in young children, and keeping some distance during rough play, along with care around swung toys, lowers the risk. I go through the fuller picture of hazards worth moving out of reach, and which sports genuinely warrant protective eyewear, in eye safety at home. None of that removes the need for the checklist above on the day it actually happens, but it does mean fewer days when you need it.

Go to the emergency department today if…

Any blood is visible in the front of the eye, over the coloured part or the pupil.
Vision in that eye seems reduced, blurred or different from before.
The pupil is not round, is a different size from the other eye, or is slow to react to light.
The eyelid will not open, or will not open fully.
Pain is severe, is not settling, or your child vomits after the knock.

Common questions

My child was poked or knocked in the eye. What do I check first?

Look at four things: whether they can open the eye fully, whether the pupil looks round and the same size as the other one, whether there is any blood visible over the coloured part of the eye, and whether their vision seems normal, for example whether they can find and reach for a small toy with each eye in turn. Any of those being wrong means being seen today rather than waiting.

Is a cold compress safe for a blunt knock to the eye?

Yes, for a blunt knock with no cut. A light cold compress, a clean cloth rather than ice directly on the skin, held gently near the eye rather than pressed onto it, is a reasonable comfort measure. It does not replace being seen if any of the same-day signs are present.

Should I rinse my child's eye with water after a knock?

No, not for a blunt injury with no cut. Rinsing is the right first step for a chemical splash, covered in this site's article on chemical splashes, but NHS guidance is explicit that an eye should not be washed out when the injury involved significant force or any cut to the eye is visible. For a plain knock, comfort and careful watching come first, not water.

What does blood in the eye after a knock actually mean?

It is called a hyphema, blood collecting in the front chamber of the eye, in front of the iris, and it is considered an ophthalmic emergency whatever the amount, because of the risk of raised pressure inside the eye and, in some cases, permanent damage to vision. Any blood visible there after a blunt injury needs same-day assessment by an eye doctor, not a wait-and-see approach at home.

Can I give my child paracetamol or ibuprofen for the pain?

Paracetamol is the safer first choice. If there is any possibility of bleeding inside the eye, aspirin- and ibuprofen-type painkillers are best avoided, because they can increase bleeding risk. If you are already on your way to be seen, mention any pain relief you have given.

The eye looked fine straight after, but now something seems off. Is that normal?

It happens, and it is exactly why watching continues after the first few minutes, not just during them. Swelling, a change in the pupil, or reduced vision can become obvious only in the hours after a knock, once initial shock and crying settle. Recheck the same four things every so often for the rest of the day, and act on any of them appearing late exactly as you would if you had seen them straight away.

What if it was not a blunt knock, but something sharp or something that went into the eye at speed?

Then the whole approach changes, and this matters enough to repeat here. Do not rinse it, do not press on it, and do not try to remove anything from it, however small it looks. Cover the eye loosely with something rigid and get to an emergency department, exactly as set out in this site's chemical-splash first aid article, which covers this reversed rule in full.

How long should I keep watching after a knock that seemed to settle straight away?

For the rest of that day at least, checking the same four signs every hour or two while your child is awake. If everything stays normal by the evening, ordinary comfort and rest are reasonable. Any new pain, redness that is getting worse, or light sensitivity appearing the next day is still worth a same-day call to an eye doctor or clinic, not something to leave until it is convenient.

References

NHS Healthier Together · Eye Injury (child under 5) · www.healthiertogether.nhs.uk
American Academy of Ophthalmology · Trauma: Anterior Segment Injuries · www.aao.org
American Association for Pediatric Ophthalmology and Strabismus (AAPOS) · Hyphema (glossary) · www.aapos.org
American Academy of Ophthalmology · YO Need to Know: 5 Pearls for Managing Hyphema · www.aao.org

By Dr Chan Li Yen. General information only. It does not replace a consultation. If you are worried about your child's eyes or vision, please see an eye doctor.