Transcript Pediatric Ocular Trauma and Emergencies

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Pediatric Ocular Trauma and
Emergencies
Dafina M. Good, MD
Emory University School of Medicine
Children’s Healthcare of Atlanta
Pediatric Emergency Medicine Fellow
Objectives
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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
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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
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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
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Stop….. Emergency… if Chemical burns,
proceed to provide copious irrigation before history
and physical exam is done
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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
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The Eye Exam
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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
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Fluorescein Exam…
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Using topical anesthetics Tetracaine (onset of action <1min) or
Proparacaine (onset <20 secs)
Applying sterile fluorescein eye strips with saline or anesthetic
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Used with Wood’s light or Cobalt blue light
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Slit Lamp Exam……..Primarily examines the Anterior Chamber
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Dilated eye exam allows the slit lamp exam to be used to view the
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CT Scans are the radiologic study of choice in ophthalmologic
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Plain films are useful in some instances
looking at the cornea, intraocular pressure and evaluating for foreign bodies
Posterior globe as well (the retina, optic nerve, blood vessels, and the macula)
emergencies
Components of the Eye Exam
Dilated Eye Exam
Case #1
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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
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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
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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
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Usually present with similar sx’s as abrasions
Important to evert the eyelids using a cutip!
Treatment involves
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Removing the FB…..
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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
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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
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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
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Case #4
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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
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ED management
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Eye exam
Tetanus prophylaxis
Wound closure if superficial laceration
Consult Ophthamology if……
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It involves the medial 1/3 lid (Canaliculi injury)
Lid margins (tarsal plate)
Levator palpebra muscle (ptosis may develop)
Case #5
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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
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Mechanism of injury usually occurs with blunt,
penetrating or perforating objects
Often globe rupture is obvious on exam but sometimes
can be more subtle
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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
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ED Management
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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)
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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
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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…
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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
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ED Management
Orbital CT… is not routinely indicated unless limitation of motion
 Plain films may be helpful… A/F levels, Orbital emphysema
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3views Water’s, Caldwell and Lateral Views
Orbital Fractures
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Management
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Tetanus prophylaxis
Surgery is not always indicated
Arranging Ophthamology follow up for possible surgical
repair
Surgery is most commonly performed after 7-14days
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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
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Tell patients to avoid blowing their nose
Case #7
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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
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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:
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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
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Complications
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Secondary Hemorrhage (Rebleeding)
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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
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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
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Management
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Elevate the head of the bed 30-45º
Eye shield
Pain control (Avoid antiplatelet effects of certain NSAIDS)
Hospitalization vs. Outpatient Bedrest
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Topical Cycloplegics(Atropine/Tropicamide)
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Reduce ciliary muscle spasms and Dilate the iris
Topical Miotics
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Risk of Rebleeding?
Grade of Hyphema (Grade 2 or higher)
IOP at time of presentation (>30mm Hg)
Lowers IOP and increases the surface area of the iris and enhance hyphema resorption
Topical vs Systemic AMICAR (Aminocaproic acid)
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Antifibrinolytic
Prevention of normally occurring clot lysis allows blood vessels time to repair
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Topical vs Systemic Steroids
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Decreases the associated iritis and development of synechiae
Sickle Cell prep in African Americans of unknown status
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Subconjunctival Hemorrhage
Subconjunctival Hemorrhage
What’s Wrong with this picture?
Retrobulbar Hemorrhage
Retrobulbar hemorrhage
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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
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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
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No history, No physical exam…………….. Copious
Irrigation is key…..1 to 2L of saline or lactated ringers
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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
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Battery fluid and chemistry labs solutions
Alkali burns are more harmful than acid burns
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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
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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?
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What can we do to “Save Eyes”?
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Prevention, Prevention, Prevention
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“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
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Educate our children, families, and schools about the
importance of safety eyewear
Summary
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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
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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.