Pediatric Ocular Trauma and Emergencies by mikesanye

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Pediatric Ocular Trauma and
          Dafina M. Good, MD
       Emory University School of Medicine
         Children’s Healthcare of Atlanta
       Pediatric Emergency Medicine Fellow

   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
   To Review Preventive approaches for ocular
     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
   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
            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
   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
       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
   What are the clues to this case diagnosis?
  Grade 1
  Grade 2
   Blood in the Anterior Chamber
   Mechanism of injury usually blunt, projectile or penetrating
   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
       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
   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
   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.
   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
 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
                         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
   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
   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.
   Robson, Joe et al. “Globe Rupture.” eMedicine. July 2005.
   Suwarno, Omar. Assessing and managing ophthalmic emergencies. Journal of the
    American Academy of Physician Assistants 2003;16:18-33.

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