y Pediatric Ocular Trauma and Emergencies Dafina M. Good, MD Emory University School of Medicine Children’s Healthcare of Atlanta Pediatric Emergency Medicine Fellow Objectives To Review the Epidemiology of Ocular injuries To Review Normal Eye Anatomy To Discuss a systematic approach to Eye exams To Review Common Ocular injuries and emergencies To Review Preventive approaches for ocular trauma Epidemiology of Eye Injuries One of the most preventable causes of visual impairment in the WORLD……. From sports to war bombings An estimated 2.4 million eye injuries occur in United States each year with 40,000 cases of vision loss The 2000 Kids’ Inpatient Database of the Healthcare Cost and Utilization Project showed more than 7500 hospitalizations for the treatment of pediatric eye injuries that resulted in more than $88 million in inpatient charges Up to 40% of all ocular injuries occur in persons less than 17 years old Eye injuries are the leading cause of visual disability and noncongenital unilateral blindness in children In some studies, Up to 60% of pediatric eye injuries occur during sports and recreational events Other studies show that the home has become the more common place for pediatric eye injuries Epidemiology of Eye Injuries cont’d Males account for almost 70% of all ocular injuries Boys between 11 and 15 years are the most vulnerable… 4 to1 ratio compared to girls Why is that………….. Any SPORTS that include balls, rackets, and sticks can be hazardous…… Rough sports and projectiles, including toys, guns, darts, stones, air guns, paintballs, and BB guns Normal Eye Anatomy Normal Eye Anatomy with Bony Structures Lacrimal System The History Stop….. Emergency… if Chemical burns, proceed to provide copious irrigation before history and physical exam is done The history……. Details and Mechanism of injury…………… Where, When, How, and With what? Symptoms- pain, vision loss, double vision etc History of eyeglasses or contacts Medical History The Eye Exam Stop….. Emergency… if Chemical burns, proceed to provide copious irrigation before eye exam is done Visual Acuity “The vital sign of the eyes” External anatomy exam….. Looking for trauma, foreign bodies, lids and conjunctiva, bony step offs, proptosis, enopthalmos…. Any deviations from normal anatomy Pupillary response, Extraocular movements, and Visual fields Fundoscopic exam…. red reflex and evaluation of the retina, blood vessels and optic nerve The Eye Exam cont’d Fluorescein Exam… Using topical anesthetics Tetracaine (onset of action <1min) or Proparacaine (onset <20 secs) Applying sterile fluorescein eye strips with saline or anesthetic Used with Wood’s light or Cobalt blue light Slit Lamp Exam……..Primarily examines the Anterior Chamber looking at the cornea, intraocular pressure and evaluating for foreign bodies Dilated eye exam allows the slit lamp exam to be used to view the Posterior globe as well (the retina, optic nerve, blood vessels, and the macula) CT Scans are the radiologic study of choice in ophthalmologic emergencies Plain films are useful in some instances Components of the Eye Exam Dilated Eye Exam Case #1 A 10yr old girl was playing with her cousins and got poked in the eye and now c/o pain, redness and tearing After a complete history and eye exam you find this on your fluorescein test…….. Corneal Abrasions Corneal Abrasions Probably the more common eye injury visit to the ED Usually present with pain, tearing, photophobia, FB sensation Topical anesthetics when applied for fluorescein exam provide temporary relief Treatment usually consist of Topical Antibiotic drops Pain Medication No patching in children! Case #2 A 12yr old boy was in the garage with his dad while he was drilling and started to c/o pain, tearing, like something was stuck in his eye After your thorough history and eye exam…… with eversion of the lids you find Conjunctival/Corneal FB Conjunctival/Corneal FB Usually present with similar sx’s as abrasions Important to evert the eyelids using a cutip! Treatment involves Removing the FB….. Apply a topical anesthetic FIRST! Using gentle irrigation or Cotton tip applicator attempt to remove the object If not successful, in cooperative patients a sterile needle can be used while resting your hands on the pts cheek… If cornea involved best to get Ophthalmology to remove the FB with a needle Topical antibiotics Case #3 A 16yr old boy gets into a fight at school and has lacerations on his forearms from a knife and he is holding his eye in pain When you examine his eye…… You find Corneal/Scleral Lacerations Corneal/Scleral Lacerations Usually sustained during penetrating or blunt trauma Corneoscleral Lacerations are repaired surgically by Ophthamology Concerns that ocular tissue may prolapse through the wound depending on extent of wound and intraocular pressure ED Management Most important PE component is to document visual acuity Shield the eye and Ophthalmology consult Cycloplegics may be used to relieve ciliary muscle spasms (which can cause tissue prolapse) Provide Tetanus prophylaxis IV Antibiotics Orbital CT scan may be useful if suspected FB pierced through the cornea Case #4 A 5yr old was running and fell and hit his face on a metal object and cut his eyelid What do you want to know……and Why? Where on the Lid? Lid Lacerations Let’s Review again the Lacimal System…… Eyelid Lacerations ED management Eye exam Tetanus prophylaxis Wound closure if superficial laceration Consult Ophthamology if…… It involves the medial 1/3 lid (Canaliculi injury) Lid margins (tarsal plate) Levator palpebra muscle (ptosis may develop) Case #5 A 16yr old boy playing baseball was at 3rd base and got hit in the eye with the baseball after the hitter hit the ball And before entering the room you see the CT from the outside facility….. Globe Rupture with Orbital Fracture Globe Rupture Globe Rupture Mechanism of injury usually occurs with blunt, penetrating or perforating objects Often globe rupture is obvious on exam but sometimes can be more subtle Symptoms… PAIN, greatly decreased vision, diplopia Signs…. Teardrop pupil, prolapsed iris, hyphema PE…… Focused…..Visual acuity (counting fingers) or light perception, EOM’s examined for entrapment Peaked Pupil Pupil peaks in the….. direction of the injury Seidel’s Test Fluorescein Eye Exam of Ruptured Globe Let’s Review Again…. the Eye Anatomy Ruptured Globe ED Management Goal….. To Avoid any increases in intraocular pressure Shield the eye (Never patch!) Pain relief Please!!! Antiemetics NPO Tetanus Prophylaxis Broad Spectrum IV Antibiotics….Ancef/Ceftaz/Vanco (depends on the surgeon) 5-10% of penetrating injuries at risk for endopthalmitis, which leads to vision loss Ophthamology Consult Immediately!!! Case #6 You asked her to Look up…. What are you suspicious of ? Orbital Floor Fracture Orbital Floor Fractures Mechanism of injury usually blunt force The weakest area of the orbital bones is the orbital floor/ maxillary roof aka “Blow out Fracture” Signs/Sx’s… Eyelid swelling and Ecchymosis Enophthalmos “sinking in” of the affected eye Ptosis Diplopia Anesthesia of the cheek (infraorbital nerve) Inability to move the eye upward Orbital Fractures ED Management Orbital CT… is not routinely indicated unless limitation of motion Plain films may be helpful… A/F levels, Orbital emphysema 3views Water’s, Caldwell and Lateral Views Orbital Fractures Management Tetanus prophylaxis Surgery is not always indicated Arranging Ophthamology follow up for possible surgical repair Surgery is most commonly performed after 7-14days Indications for surgery… Entrapped muscle, facial hypoesthesia, symptomatic diplopia w/ minimal improvement over time, large floor fracture leading to enophthalmos Observation…. Minimal diplopia, good ocular movement, no significant enophthalmos Prophylactic Antibiotics may be an option depending on the surgeon as sinus involvement may lead to deeper infections Tell patients to avoid blowing their nose Case #7 A 3yr old African American girl comes in with eye pain after getting hit in the eye with a toy truck……….. What are the clues to this case diagnosis? Hyphema Grade 1 Hyphema Grade 2 Hyphemas Blood in the Anterior Chamber Mechanism of injury usually blunt, projectile or penetrating trauma Occurs 70% of the time in the Pediatric population Majority (80%) of hyphemas have less than 50% of the anterior chamber filled with blood Signs/Sx’s…. Pain, Decreased vision, injected conjunctiva, irregular pupil The following clinical grading system for traumatic hyphemas is preferred: Grade 1 - Layered blood occupying less than one third of the anterior chamber Grade 2 - Blood filling one third to one half of the anterior chamber Grade 3 - Layered blood filling one half to less than total of the anterior chamber Grade 4 - Total clotted blood, often referred to as blackball or 8-ball hyphema Hyphemas Complications Secondary Hemorrhage (Rebleeding) Most likely due to lysis and retraction of the clot and fibrin aggregates High risk of rebleeding within the first 5 days Occurs in almost 25% of all patients with hyphemas (range, 7-38%) Higher Grade of Hyphema increases risk of rebleeding Increased risk with younger ages…. Up to 30% of patients younger than 6 yrs old have secondary hemorrhages Occurs 2-5% in blue eyed individuals and 25-40% in African Americans Decreases recovery of visual acuity of 20/50 to about 60-65% Corneal blood staining, Optic Atrophy, Anterior/Posterior Synechiae Prognosis/Outcomes Judged by regaining near normal visual acuity Visual acuity, is good in approximately 75-80% of patients Approximately 80% of those with Grade 1Hyphema, regain visual acuity of 20/40, 60% of those with a Grade 3 hyphema, regain visual acuity of 20/40 or better, while only approximately 35% of those with an initially total hyphema or a Grade 4 hyphema have good visual results. Hyphemas Management Elevate the head of the bed 30-45º Eye shield Pain control (Avoid antiplatelet effects of certain NSAIDS) Hospitalization vs. Outpatient Bedrest Risk of Rebleeding? Grade of Hyphema (Grade 2 or higher) IOP at time of presentation (>30mm Hg) Topical Cycloplegics(Atropine/Tropicamide) Reduce ciliary muscle spasms and Dilate the iris Topical Miotics Lowers IOP and increases the surface area of the iris and enhance hyphema resorption Topical vs Systemic AMICAR (Aminocaproic acid) Antifibrinolytic Prevention of normally occurring clot lysis allows blood vessels time to repair Topical vs Systemic Steroids Decreases the associated iritis and development of synechiae Sickle Cell prep in African Americans of unknown status Subconjunctival Hemorrhage Subconjunctival Hemorrhage What’s Wrong with this picture? Retrobulbar Hemorrhage Retrobulbar hemorrhage Mechanism of injury usually after blunt or penetrating injury Signs/Sx’s….. Acute proptosis, subconjunctival hemorrhage, decreased vision, pain, limitation of ocular movement May lead to loss of vision because of central retinal vessel occlusion…. From hemorrhage compression in the posterior eye ED Management Immediate Ophthamology Consult! IV Mannitol- to decrease IOP IV steroids Lateral canthotomy (by experienced person) The “True” Eye Emergency The “True” Eye Emergency Roper-Hall Classification Table Grade Prognosis Limbial Ischemia Corneal Involvement I Good None Epithelial Damage II Good Less than 1/3 Haze but the iris details are visible III Guarded 1/3 to 1/2 Total epithelial loss with haze that obscures the iris details IV Poor Greater than 1/2 Cornea Opaque with the iris and pupil obscured IRRIGATION!! Chemical Burns No history, No physical exam…………….. Copious Irrigation is key…..1 to 2L of saline or lactated ringers Immediately begin irrigation for 30mins……… until the pH of the eye is near neutral at 7.0 using Litmus paper Time is of the essence with chemical burns to the eye Acid burns cause coagulation necrosis and denature surface proteins but usually don’t penetrate the eye Battery fluid and chemistry labs solutions Alkali burns are more harmful than acid burns Alkali burns cause rapid penetration through the cornea and anterior chamber combining with cell membrane lipids Alkali burns cause corneal liquefaction necrosis Lye, cement cleaner, drain cleaner, fertilizer, sparklers, and firecrackers produce alkaline burns because they contain sodium hydroxide Chemical Burns ED Management After 30 minutes of copious irrigation……and Neutralized Eye pH of 7.0 H&P Visual acuity assessment Fluorescein…. To check for epithelial defects Ophthamology consult… if severe burn, subnormal vision or epithelial defects May require corneal or limbal transplantation? What can we do to “Save Eyes”? Prevention, Prevention, Prevention “Almost 90% of eye injuries could have been prevented or decreased in severity with better education, appropriate use of safety eyewear and removal of common and dangerous risk factors” Education, Education, Education Educate our children, families, and schools about the importance of safety eyewear Summary The Eyes are very important!!! The Eyes are small but very complex!!! Ocular injury is the leading cause of preventable vision loss or blindness worldwide Using a systematic approach to the eye exam is best Ocular trauma can be mild to severe and lead to blindness Ouch…. Pain control PLEASE! When in doubt give a tetanus shot Over 90% of eye injuries can be prevented with education and safety wear When in doubt Consult Ophthamology!!! If it were your child would you want Ophthamology called??? The End References Brophy M, Sinclair S, Grim Hostetler S, Xiang H. Pediatric Eye Injury-Related Hospitalizations in the United States. Pediatrics 2006;1171263-1271. Crain, Ellen, Jeffrey Gershel. Clinical Manual of Emergency Pediatrics 4th edition; New York, 2003. Hamid, Rukaiya, Newfield, Philippa. Pediatric Eye Emergencies. Anesthesiology Clinics of North America 2001;19 1-7. Naradzay, Jerry, Barish, R. Approach to Ophthalmologic Emergencies. The Medical Clinics of North America 2006;90305-328. Dua, Harminder, King, A, Joseph A. A new classification of ocular surface burns. British Journal of Ophthalmology 2001;85: 1379-1383. Sheppard, John et al. “Hyphema.” eMedicine. November 2006. http://www.emedicine.com/oph/topic765.htm Robson, Joe et al. “Globe Rupture.” eMedicine. July 2005. http://www.emedicine.com/emerg/topic218.htm Suwarno, Omar. Assessing and managing ophthalmic emergencies. Journal of the American Academy of Physician Assistants 2003;16:18-33.
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