Transcript The Red Eye - Emory University Department of Pediatrics

The eyes have it.
Ophthalmologic emergencies
Cecilia Guthrie, MD
Emory University
Case- History
• CC : Blind in right eye
• 9y.o. HM hit in right eye with a rock 24
hours ago by same age boy at school
• No loss of consciousness and eye pain
on being struck resolved quickly
• Some persistent blurriness of vision
• Mother noted red marks on white parts
of eye, but no other injury
Case- History
• 2 hours to presentation, pt developed
headache, dizziness, and loss of vision
in right eye. Denied fever, pain,
repeated trauma and vomiting.
• PMH - Asthma
• Meds - albuterol mdi
• Allergies - none
• FH - N/C
• ROS - o/w negative
Case - PE
• VS : 88 16 116/60
• HEENT - no signs of trauma
• OD
– mild ptosis of right upper eyelid. No
echymosis of eyelid.
– Sclera with multiple subconjunctival
hemorrhages
– globe intact w/o swelling
– conjunctiva injected diffusely
– fundus - unable to visualize the retina
Case - PE
– Unable to visualize the pupil secondary to
blood in anterior chamber.
– Pt could distinguish light
– EOMI
• OS
– PERRLA
– No erythema, normal sclera and conjunctiva
– 4mm--> 2mm
• Visual Acuity: OD none OS 20/40
Ophthalmology trauma
• Ocular trauma is leading cause of visual
loss in the pediatric population
• Estimated approximately 1 million eye
injuries occurring in children annually.
• M>F 3:1
• Adolescent males at increased risk
• 1/2 of injuries occur secondary to
sporting activities (baseball, basketball)
Ophthamology trauma
• BB guns, paint ball guns,sticks, collision
with fixed objects
• Visual system matures at 9 years of age
• Amblyopia may occur
• May be difficulty to obtain mechanism of
injury, history and exam
You did what??
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Mechanism of injury
Time of injury
Place of injury
Caregiver at time of injury
Initial intervention
Possibility of retained foreign body
Pertinent PMH and ocular hx
Any vision changes
Open…Your…Eyes!!
• Non contact aspects of exam first
• Suspect ruptured globe, don’t touch eye
• Assess visual acuity in each eye
separately
• Pupils
• Ocular motility
• Lids and orbits
Open… Your… Eyes!!
• Examine conjunctiva and sclera for lacs
or foreign body
• Cornea for abrasion or lacerationflourescein
• Anterior chamber depth and clarity
• Assess red reflex
Trauma
Foreign Body
• Foreign bodies can lodge underneath
the upper eyelid or on the anterior
surface
• Foreign body sensation
• Pain on blinking
• Watery Discharge
• Unilateral
• Photophobia
Trauma
Foreign Body
• Extraocular vs intraocular
• Treatment
– Topical anesthetic (tetracaine)
– Eversion of the lid and flush with water
– Remove foreign body
– Question of retained foreign body after
flush-call opthomology
– Flourescein after flushing
Trauma
Subconjunctival hemorrhage
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Unilateral
Underlying sclera not visible
Adjacent conjunctiva normal
No discharge
No pain
Vision intact
Trauma
Subconjunctival hemorrhage
• Etiology
– Minor trauma
– Bleeding disorders
– Anticoagulation therapy
– Hypertension
– Coughing, vomiting
• Treatment
– Resolves in 2-3 weeks
Trauma
Corneal abrasion
• Cornea
– Epithelium
– Bowman membrane (protective layer)
– corneal stroma (90% of thickness)
– Descemet membrane
– Endothelium
• Superficial to Bowman membrane
• If deeper to Bowman membrane - scar
Trauma
Corneal abrasion
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Moderate to severe pain
Photophobia
Conjunctival erythema
Tearing
Diagnosis
– Better exam with topical anesthetic
– Fluorescein
Trauma
Corneal abrasion
• Treatment
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Topical antibiotic therapy for 4-5 days
Patching vs No Patching
Cool compresses intermittently
Tylenol or ibuprofen
Cycloplegic agents for severe pain
• 5% homotropine
• 1% cyclopentolate (cyclogel)
– If not healing in 48 hours, opthamology referral
Trauma
Eyelid lacerations
• Determine if laceration or injury to
globe/conjunctiva underneath the eyelid
laceration, especially with pointed
objects
• Determine if a complete perforation of
eyelid present
• Determine if involvement of tearducts
Trauma
Eyelid lacerations
• Uncomplicated superficial eyelid
lacerations may be sutured by ED
physician
– Shallow sutures used
– Sedation may be needed
Trauma
Eyelid lacerations
• Indications for opthamology consult
– Full thickness perforation of lid
– Ptosis
– Involvement of the lid margin
– Possible damage to tear drainage system
– Tissue avulsion
– Global injury
Trauma
“Black eye”
• Can be associated with traumatic iritis,
hyphema and cataracts.
• Dramatic ecchymosis and swelling may occur
from mild trauma because of loose
connections of eyelid skin and underlying
tissues.
• Resolving midline forehead injuries/
hematomas can cause bilateral ecchymosis
Trauma
Orbital fractures
• Most common-inferior and medial walls
• 50% of pediatric orbital fractures are
associated with other ocular injuries
• Enopthalmia or proptosis
• Decreased extraocular muscle movement
– hallmark of orbital fracture
– entrapped muscle/tissue
– orbital hemorrhage
Trauma
Orbital fractures
• Inferior wall fx - infraorbital nerve injury
• Superior (roof) wall fx - pulsating
proptosis
• Diploplia - eom entrapment
• May be subtle with normal rim
• CT of orbits with head CT (especially
with possible superior wall fx)
Trauma
Orbital fractures
• Ophthalmology consult
• May also need “face” consult• If no entrapment, hemorrhage or global
injury and fracture is nondepressed or
displaced, may not require surgery
• Broad spectrum antibiotics
• Don’t blow nose
Trauma
Hyphema
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Children and young adults
M>F (4:1)
After blunt trauma to the face/eye
Traumastretching of iris and ciliary
bodytear
• Blood in the anterior chamber
• Layering
Trauma
Hyphema
• 3-5 days post injury, spontaneous rebleeding
• Rebleed complications
– Corneal staining
– Secondary glaucoma
– Optic atrophy
• Sickle cell disease patients
– Increased risk of rebleeding
– ~30% have increased intraocular pressure (10-20
normal)
– Central artery occlusion and optic nerve damage
with marginal increases in intraocular pressure
Trauma
Hyphema
Distribution
Severity
0
Degree of
Hyphema
microscopic
58%
1
< 1/3
20%
2
1/3- 1/2
14%
3
½-3/4
8%
4
¾-complete
(8 ball)
Trauma
Hyphema
• Treatment
– Eye shield
– Strict bedrest with head elevated 45º
– Ophthalmology consult
– Long acting cycloplegic
– Aminocaproic acid (antifibrinolytic)
• Initial: 200mg/kg/dose po (max 6 gm)
• Maintenance 50 - 100 mg/kg/dose q 6 hr.
– Admission for  30% hyphema
Trauma
Iritis
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Eye pain
Photophobia
Visual loss
Ciliary flush
Constricted pupil on affected side
24 - 72 hours after blunt injury to the
eye ball
Trauma
Iritis
• Treatment
– Ophthalmology consult
– Short acting cyclopegia
– Topical antibiotic
Trauma
Ruptured globe
• S/P blunt trauma or projectile of sharp
object
– Guns (22%), sticks/tree branches (11%)
• M>F 6:1
• Laceration or puncture of the sclera or
cornea
• Iris or choroid plugs wound
– tear drop pupil
– brown,blue or black on scleral surface
Trauma
Ruptured Globe
• If small may have a normal global
appearance
• Limbus most susceptible area
• 360 degree subconjunctival
hemorrhage-be suspicious
Trauma
Ruptured Globe
• Management
– Keep pt calm-may need sedation
– Cover eye with hard shield
– Ophthalmology consult-True emergency
– CT of orbits
– Tetanus
– Antibiotics
Conjunctivitis
Chemical injuries
• Chemical contact
• Most common cause are voluntary eye
solutions
– Neomycin, atropine, pilocarpine,
idoxuridine, gentamycin
• Neonate
• Discontinue irritating agent
Chemical Burns
• Alkali Burns
– Most serious burns
– Hair straighteners, lye, ammonia
– Penetrates corneacoagulative necrosis
• Acid Burns
– Limiting burn
– Protein precipitation in the corneal epithelium and
stroma
• Limits acid penetration of the cornea
• Corneal opacifications
• Conjunctiva blanching
Chemical Burns
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Topical anesthetic
Immediate irrigation-1 L NS
Check pH of eye-conjunctiva
Continue to irrigate until pH is normal
Ophthalmology consult
Red is better than white
Chemical Injuries
• Mace/Tear gas/Pepper spray
– Superficial injury
– Flush eyes well
• Super glue
– Ophthalmic ointment
– Check global movement beneath closed
eyelid
Radiation Injury
• Prolonged exposure to ultraviolet light w/o
proper eye protection
• Ultraviolet keratitis-corneal epithelium swells
and dies
• Foreign body sensation
• Photophobia
• Pain
• Redness
• blepharospasm
Radiation Injury
• Fluorescein-diffuse punctate staining
• Treatment similar to corneal abrasion
References
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Albert, D and Jakobiec F Eds. Atlas of Clinical Ophthalmology. Philadelphia:
W.B. Saunders, 1996
Arffa, R. Craven L ed. Grayson’s Diseases of the Cornea. St. Louis: Mosby,
1997
Levine, L “Pediatric ocular trauma and shaken infant syndrome” Peditr Clinic N
Am. 2003;50 (1)
Hatton MP, et al. “Orbital fractures in children” J Am Society of Opthalmic
Plastic and Reconstructive Surgery. 2001;17(3), 174-9.
Walton, W. et al. “Management of Traumatic Hyphema.” Survey of
Opthalmology. 2002;47(4) 297-334.
Fleisher and Ludwig. Textbook of Pediatric Emergency Medicine, 4th ed.
Philadelphia: Lippinicott Williams and Wilkins, 200.