Pediatrics ocular trauma and emergencies CME 2017

1. Adib Mursyidi
A&E Department

2.  Review basic anatomy
 Review basic component of eyes exam
 Recognize ocular emergencies
 Discuss initial management

3.  Preventable causes of visual impairment
 Eye injuries  leading cause of visual
disability and blindness in children
 60% of pediatric eye injuries occur during
sports and recreational events
 Males account for almost 70% of all ocular
injuries

7.  In CHEMICAL BURNS, proceed to provide
copious irrigation before history and physical
exam is done
 History taking:
 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

8.  Visual acuity (vital sign of eyes)
 External anatomy exam
 Looking for trauma, foreign bodies, lids and
conjunctiva, bony step offs, proptosis, enopthalmos
 Any deviations from normal anatomy
 Pupillary response, extra-ocular movements,
andVisual fields
 Fundoscopic exam
 Red reflex and evaluation of the retina, blood vessels
and optic nerve

9.  Fluorescein Exam
 Using topical anestheticsTetracaine (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)
 Plain films/CT Scans in ophthalmologic emergencies

12.  A 10 years 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

14.  Probably the more common eye injury visit
 Usually present with pain, tearing,
photophobia, FB sensation
 Topical anesthetics when applied for
fluorescein exam provide temporary relief
 Treatment usually consist ofTopical
Antibiotic drops and analgesia

15.  A 12 years 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

17.  Usually present with similar symptoms as
abrasion
 Important to evert the eyelids!
 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 patients cheek
▪ It’s best to get Ophthalmology to remove the FB
 Topical antibiotics

18.  A 11 years 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
 On eyes examination you find…

20.  Sustained during penetrating or blunt trauma
 Corneo-scleral lacerations  surgically repaired
by Ophthalmology
 ED Management
 Most important  to document visual acuity
 Shield the eye and Ophthalmology consult
 ProvideTetanus prophylaxis
 IV Antibiotics as per Opthalmology
 Orbital CT scan may be useful if suspected FB
pierced through the cornea

21.  A 5 years old was running and fell and hit his
face on a metal object and cut his eyelid
 What do you want to know andWhy?
 Where on the Lid?

24.  ED management
 Eye exam
 Tetanus prophylaxis
 Wound closure if superficial laceration
 Consult Ophthamology
 It involves the medial 1/3 lid (Canaliculi injury)
 Lid margins (tarsal plate)
 Levator palpebra muscle (ptosis may develop)

25.  A 16 years old boy playing baseball was at 3rd
base and got hit in the eye with the baseball..
 CT is done and the findings are as below

28.  Mechanism of injury  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

29. Pupil peaks in the…..
direction of the
injury

30. Fluorescein Eye Exam
of Ruptured Globe

31.  ED Management
 Goal To Avoid any increases in intraocular pressure
 Shield the eye (Never patch!)
 Pain relief
 Antiemetics
 KNBM
 Tetanus Prophylaxis
 Broad Spectrum IV Antibiotics
▪ 5-10% of penetrating injuries at risk for endopthalmitis, which
leads to vision loss
 Ophthamology Consult Immediately!!!

32. You asked him to Look up….What are you
suspicious of?

34.  Mechanism of injury usually blunt force
 The weakest area of the orbital bones is the
orbital floor/ maxillary roof or “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

35.  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 LateralViews

36.  Management
 Tetanus prophylaxis
 Arranging Ophthalmology follow up  surgical repair
 Surgery is most commonly performed after 7-14days
▪ INDICATIONS: Entrapped muscle, facial hypoesthesia,
symptomatic diplopia with minimal improvement over time,
large floor fracture leading to enophthalmos
▪ OBSERVATION: Minimal diplopia, good ocular movement, no
significant enophthalmos
 ProphylacticAntibiotics: as sinus involvement may
lead to deeper infections

37.  A 3 years old girl comes in with eye pain after
getting hit in the eye with a toy truck.
 What are the clues to this case diagnosis?

40.  Blood in the Anterior Chamber
 Mechanism: 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 and symptoms:
 Pain, decreased vision, injected conjunctiva, irregular
pupil

41.  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

42.  Complications
 Secondary Hemorrhage (Re-bleeding)
▪ Most likely due to lysis and retraction of the clot and fibrin
aggregates
▪ High risk of re-bleeding within the first 5 days
▪ Higher Grade of Hyphema increases risk of rebleeding
▪ 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
(depends on grade)

43.  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)

48.  Mechanism  blunt or penetrating injury
 Signs and symptoms:
 Acute proptosis, subconjunctival hemorrhage,
decreased vision, pain, limitation of ocular movement
 May lead to loss of vision because of central
retinal vessel occlusion (hemorrhage
compression in the posterior eye)
 ED Management
 ImmediateOphthamologyConsult!
 IV Mannitol  to decrease IOP
 Lateral canthotomy (by experienced person)

51. 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

52.  Copious Irrigation is stat  1 to 2L of saline or lactated ringers 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
 Cement cleaner, drain cleaner, fertilizer, sparklers, and firecrackers
produce alkaline burns because they contain sodium hydroxide

53.  ED Management
 After 30 minutes of copious irrigation
 Neutralized Eye pH of 7.0
 History and physical examination
 Visual acuity assessment
 Fluorescein To check for epithelial defects
 Ophthamology consult stat!!

54.  Conjuctivitis within the 1st month of life
 Causes
 Chlamydia trachomatis
 Staphylococcus aureus
 Streptococcus pneumoniae
 Neisseria gonorrhea
 Herpes simplex virus

55.  Sign/sx
 Purulent or
mucopurulent discharge
 Conjuctival injection
 Eyelid edema
 Chemosis
 Treatment
 Guided by gram stain
 Topical and systemic
antibiotic

56.  Symptoms
 Red eye, discharge,
ocular irritation
 Bacterial : mucopurulent
discharge
 Viral : watery or mucoid
discharge
 Treatment
 Bacterial: topical
antibiotic
 Viral: supportive,
artificial tears
 Contagious !

57.  Preseptal
 Involve soft tissue of
eyelids and periorbital
tissues anterior to the
orbital septu
 Orbital cellulitis
 More serious infection
involving extension of
the infection posterior to
the orbital septum and
into the orbit

58.  Erythema, swelling,
tenderness of the
eyelids and
surrounding periorbital
area

59.  Proptosis,
ophthalmoplegia,
decreased vision,
significant pain on eye
movement, abnormal
pupillary reflexes

60.  Mild preseptal cellulitis  oral antibiotics
 Severe preseptal/orbital cellulitis
 Opthalmology referral
 At risk for cavernous sinus thrombosis,
meningitis, brain abscess
 Start broad spectrum antibotics, add topical as
well

61.  Separation of the neurosensory retina from
the retinal pigment epithelium
 Etiology
 Lattice degeneration (30%)
 Posterior vitreous detachment
 Myopia
 Trauma
 Previous ocular surgery

62.  Presentations
 Acute onset of floaters, shadow/curtain across
visual field
 Evaluation
 Complete history and examination
 Visual acuity, pupil, visual field, tonometry
 USG ?
 Consultation STAT!

63.  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

64.  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
 Pain control PLEASE!
 Over 90% of eye injuries can be prevented with
education and safety wear
 When in doubt Consult Ophthamology!!!

65.  OcularTrauma: An approach to evaluation
and management in ED (EBMedicine Nov
2006)
 Pediatric Eye Emergencies, Rukaiya K.A
Hamid (June 2001)
 Common Ophthalmic Emergencies,
Emedicine