Transcript Case Presentation

Case Presentation
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Mary Palomaki
November 11, 2009
9 y/o female with
difficulty seeing far
HPI
History obtained from grandmother and patient
• 9 y/o female with difficulty seeing the blackboard x 3
days.
• She noticed the change in vision while playing with her
dolls.
• + slight pain with eye movements
• + increased lacrimation
• No alleviating factors, no provoking factors
• Denies trauma, proptosis, edema, erythema of eye or
eyelids, fever, headache, weight loss,
nausea/vomiting, weakness, vertigo, neck stiffness
• ROS: + cough, runny nose, sore throat x 4 days, no
diarrhea or dysuria, good PO
Past Medical History
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Birth History: FT, NSVD, no complications
Tonsillectomy at age 7
History of headaches
MRI (2008): cystic lesion in left
hippocampus/tail of caudate nucleus, cleared
by neurosurgery
• FH: Mother: deceased, cancer
Other History
• Medications: Tylenol for sore throat
• Allergies: NKDA
• Immunizations: up to date (verified by
CIR)
• Social: lives with grandmother, three
brothers, 7,9,14 y/o.
Physical Exam
• VS: T: 98.6 F, HR: 82, RR 16, BP:
80/60, wt: 39.9 kg, Ht 135 cm, BMI 21
(>95%tile)
• Gen: Obese, NAD, AAO x 3
• HENT: NC/AT, TM: b/l shinny, grey, no
fluid, + rhinorrea, oropharynx: no lesion,
neck supple
Physical Exam
• Orbit: no edema, no discoloration, no crepitus
on bony deformities, no proptosis
• Eyelids: no edema, no lesion
• Acuity: R: 20/20, L: 20/70, + diplopia on L
• Pupils: round, symmetrical, direct and
consensual pupillary reflexes intact
• EOMI
• No lacrimation
• No nystagmus
• Conjunctivae pink, no lesion, no hemorrhage
Physical Exam
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CVS: S1/S2, no murmur, RRR
Resp: CTA
Abd: BS+, soft, NT/ND, no organomegaly
Ext: FROM, 5/5 strength, no edema, cap refill
< 2 sec.
• Skin: no rash
• Neuro: CN II-XII intact, normal tone, normal
gait, heel-shin intact, failed pass pointing with
right eye closed
• GU: normal female, Tanner 1
Differential Diagnosis
Ophthalmology Consult
• Corneal abrasion on left eye, 4mm long
• Erythromycin ointment x 3 days
• Follow up with ophthalmology in 1 week
Ocular Trauma
Ocular Trauma
Ocular trauma
• 1/3 of blindness in children results from
trauma
• Boys age 11-15 are most at risk (M:F =
4:1)
• Sports, toy darts, sticks, stones,
fireworks, paintballs, air-powered BB
guns are common causes of trauma
Outline
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Review of Anatomy
History
Eye exam
Corneal Abrasions
Orbital fractures
Lacerations
Globe rupture
Retinal Detachment
Chemical Burns
Prevention
Review of anatomy
History
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Mechanism of injury, events after injury
Onset/duration of symptoms
Preexisting eye disorders
Systemic disorders
Drug allergies
Contraindications to anesthesia
– When patient last ate
• Prior tetanus immunization
Physical Exam
• Observation/inspection with pen light
• External examination:
– Orbital bones: palpate orbital rim
– Position of globes (exophthalmos or
enophthalmos)
– Mobility of globes: note pain, diplopia, limitation of
ocular rotation, and abnormal movements
(nystagmus)
– Inspection of lids (Do NOT palpate if globe
ruptured!)
• Skin, conjunctival surfaces of lids should be inspected for
foreign body or laceration
• Palpate lid for crepitus
Physical Exam
• Pupil exam:
– Size
– Shape
– Reaction to light
• Look for corneal opacities or defects
• Look for blood in anterior chamber
• Look for lens opacification or dislocation
– Iridodonesis is a moving/shaking iris, a sign of
dislocation
Examination of Visual Acuity
in Children
• Preverbal children
• Allow child to reach for a small toy with
one eye covered, then the other eye
covered
Examination of Visual Acuity
in Children
• Children 4-8 years old:
• Eye chart with Pictures, tumbling E’s,
numbers, or letters
• 2 inch wide paper taped to brow to cover one
eye
• Test with corrective lenses in place if possible
• Vision difference more important than
absolute vision
• Referral to ophthalmologist if both eyes in 5
year old are 20/50 or worse, or 20/60 or
worse in 6 year old
Examination Visual Acuity in
Children
• Children > 8 years old
• Use standard Snellen
Chart at 20 ft.
• Most common ocular
condition in this age
group is myopia
– blurred vision at distance
– can develop over several
months
Fluorescein Staining
• First use topical anesthetic drops (proparacaine)
– Warn patients and parents of transient pain before
anesthesia takes effect
• Moisten a fluorescein strip, and touch to lower
fornix
• Or use fluorescein drops
• Fluorescein stains tear film, washes away on
intact epithelium and stains exposed corneal
stroma
• Yellow dye is visible in white light, but better
under ultraviolet light (Wood Lamp)
– Wood’s lamp is better tolerated if photophobia present
Physical Exam--Slit Lamp Exam
• Binocular microscope that allows the
examiner to have a three-dimensional view of
the eye
• Beam of light (rather than diffuse light) can be
adjusted by height and width
• Provides 10-25 x magnification
• Anterior segment of the eye:
– lids, lashes, conjunctiva, cornea,
– anterior chamber, iris, and lens
• Ocular foreign body removal
Physical Exam: Dilation
• Perform after visual acuity tested and pupil
exam
• Perform only if patient is neurologically intact
• Use Topical 2.5% phenylephrine plus 1-2
drops of 0.5% tropicamide
• Wait 20 minutes
• Complete the ophthalmoscopic exam
• Dilation lasts 2-5 hours
• (Atropine is contraindicated because dilation
can last for days.)
Corneal Abrasions: Corneal Anatomy
• Avascular
• Densely innervated
– Sensory pain fibers from CN V
• 5 layers:
– Epithelium: outermost, 5-6 cell-thick
• Cells quickly regenerate after injury
– Boman’s layer: tough layer, protects
– Stroma: thick layer composed of
collagen fibrils aligned in parallel
– Descemet’s membrane
– Endothelium: if damaged will not
regenerate
Corneal Abrasions
• Most common eye trauma
• Symptoms: photophobia, tearing, intermittent
sharp pain due to ciliary body spasm, foreign
body sensation
• PE: irritability, blurry vision, conjunctival
injection, blepharospasm, irregular red reflex,
dulled corneal light reflex, fluorescein staining
of epithelial defect
• Be sure to evert the lid to examine tarsus
• Lid
Eversion
Corneal Abrasions
• Traumatic corneal abrasions: mechanical
trauma to the eye, or foreign body under the
lid
• Foreign body related corneal abrasion:
objects embedded in cornea
• Contact lens related corneal abrasions:
from over-worn, poorly fitting, dirty lens
• Spontaneous defects: previous trauma
Corneal Abrasions: Treatment
• Remove foreign bodies with moist cotton swab or sterile needle (by
ophthalmologist only)
• Long-acting topical cycloplegic drop
– Homatropine 5%
– For pain relief caused by ciliary body spasm
• Antibiotic ointment
– Better than drops because it lubricates
– Erythromycin
– Aminoglycosides should be avoided since they can be toxic to the
epithelium.
– Drops with steroids are contraindicated; they slow epithelial healing and
decrease immune response.
• Semi-pressure patch
– controlled studies have found that patching does not improve the rate of
healing or comfort
Corneal Abrasions: Follow Up
• Small (<3 mm) abrasions with no
change in vision do not need follow up
– Except patients with contact lens related
abrasions, where daily follow up
recommended
• Large abrasions (>3 mm), or any
abrasion with diminished vision, need
daily follow-up.
Corneal Abrasion--Refer to
Ophthalmologist when:
• corneal infiltrate, white spot, or opacity
– Refer same day
• epithelial defect is larger at 24 hours,
• purulent discharge present
• Patient has experienced a drop in vision
Orbital Fractures
•Lateral Orbit fractures: zygomatic bone fracture
•Cosmetic deformity, pain, difficulty opening mouth
•Lateral canthus tendon inserts in the zygomatic, with
fracture, the lateral canthus is inferiorly displaced
•Orbital Apex fracture:
•Can cause optic nerve compression, central retinal
artery occlusion, retrobulbar hemorrhage
•Blow-Out fracture:
•Orbital floor and medial wall
•Usually caused by blunt trauma with a large object
Blow-Out fracture
• Four signs:
• Enophthalmos
• Loss of sensation over malar eminence
and cheek
• Inability to look up on affected side
• Diplopia on up-gaze
• Positive traction test
– Inability to rotate eye upward with forceps
Blow-Out fracture:
Management
• Oral antibiotic prophylaxis x 5-7 days
• Surgical correction 2-3 weeks later by
otolaryngologist
Complicated Lid Lacerations
• Lid Margin lacerations: must be aligned
properly to avoid lash inversion,
damaging the cornea
• Medial canthus lacerations:
– May go through canaliculi
– Cause persistant tearing
– Canaliculi must be reattached
Traumatic Hyphema
• Blood in anterior chamber secondary to
trauma
• (Spontaneous Hemorrhage can occur secondary to juvenile
xanthogranuloma)
• Vision impaired until blood settles and forms
a red meniscus
• 20% of patients re-bleed
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“Blackball hyphema”
Usually occurs at 3-5 days after initial injury
Occurs from lysis of clot
Recurrence of bleeding is more severe; possibly
causing glaucoma, hemophthalmitis
Black ball Hyphema
Primary Hyphema: Management
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Bed rest, elevation of the head
Eye Shield
Cycloplegia
Topical Steroids
Systemic antifibrinolytics
– Aminocaproic acid: in your healthy patients
• Measurement and control of intraocular
pressure
• Screen all black patients with hemoglobin
electrophoresis
– Secondary glaucoma is more likely with SS or trait
Open Globe Injuries
• Blunt trauma: globe rupture, most
common site is near the insertion of the
rectus muscles in the sclera
• Penetrating trauma: laceration to the
globe, most common in the cornea
Open globe Injuries
• Avoid any examination procedure that might
apply pressure to the eyeball
• For young children, an examination facilitated
by procedural sedation or anesthesia should
be performed by an ophthalmologist
• Avoid medication (anesthetic drops or
fluorescein) into the eye.
• Foreign bodies should be removed by
ophthalmologist
Open Globe Injuries: PE
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Markedly decreased visual acuity
Volume loss
Afferent pupillary defect
Increased anterior chamber depth
Leakage of vitreous
Outward prolapse of the uvea (iris, ciliary body, or choroid)
Tenting of the cornea or sclera
Low intraocular pressure
– (checked by an ophthalmologist only)
• Seidel sign
– fluorescein streaming away from the laceration site
Imaging
• Axial and coronal CT of the eye without
contrast
– 1 to 2 mm cuts through the orbits
Open Globe injuries:
Management
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Place eye shield over the affected eye
Do not touch, move eye
Bed rest
Antiemetic therapy (eg, IV ondansetron 0.15
mg/kg, maximum dose: 16 mg)
• Pain medication: morphine, fentanyl
– Don’t use NSAIDs --> platelet inhibiting properties
• Sedation: lorazepam
• NPO
Open Globe Injury: Prognosis
• Depends on:
– Primary closure by ophthalmologist within 24
hours
– Blunt trauma has worst outcome
– Initial visual acuity
– Wound location: posterior lacerations have
poorest outcome
– Afferent pupillary defect
Open Globe Injuries: Complications
• Endophthalmitis: internal eye infection
• Endophthalmitis is associated with poor
prognosis
• Prophylactic antibiotic treatment:
– Vancomycin (15 mg/kg, maximum dose: 1 gram)
– ceftazidime (50 mg/kg: maximum dose 1 gram)
• Organisms:
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Bacillus species
coagulase-negative Staphylococcus
Streptococcal species
S. aureus
gram negative organisms
Retinal detachment
• Rhegmatogenous detachment: a break
in the retina allows fluid to enter the
subretinal space
– (child abuse/shaking)
• Traction retinal detachments: adhesions
between the vitreous and the retina pull
on the retina
Retinal detachment
• PE: loss of vision (curtain moving
across visual field), secondary
strabismus, nystagmus, leukocoria
• Management: Prompt referral to
ophthalmologist
Chemical Injury
• Immediate irrigation indicated:
• Retract lids:
– Double lid eversion with small vein retractor
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Check pH (pH of tears is 7.3-7.7)
Topical anesthetic
20-30 min. or irrigation
Recheck pH
Cycloplegic drops prevent adhesions
between the iris and lens
Chemical Injury
• Strong Alkalis (pH >11.5) penetrate the
eye rapidly and cause intraocular
inflammation.
• Complications include: infection,
glaucoma, conjunctival and corneal
scarring
Prevention of Eye injury
• Protective eyewear should be worn by
athletes and patients that are one-eyed
– Criteria is visual acuity less than 20/40 in
the poorer eye--loss of the good eye would
render patient unable to drive legally
• Recommended eyewear is frames or
goggles with polycarbonate lenses
– Need plano lenses if contacts are worn
References:
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Arbour, JD, Brunette, I, Boisjoly, HM, et al. Should we patch corneal erosions?. Arch
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Bienfang, D.C. Overview of diplopia. Online available @ uptodate.com. 12/1/2008.
Calhoun, J. Eye examinations in infants and children. Peds in Review 1997; 18:28.
Hulbert, MF. Efficacy of eyepad in corneal healing after corneal foreign body removal.
Lancet 1991; 337:643.
Iqbal, S. Approach to acute vision loss in children. Online available at uptodate.com
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Jackson, H. Effect of eye-pads on healing of simple corneal abrasions. Br Med J 1960;
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