Pediatric Ocular Emergencies

7/27/2019 Pediatric Ocular Emergencies

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Pediatric OcularEmergencies

Pamela E. Williams, MD

Pediatric Eye Care Center

Baton Rouge, LA


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Objectives

Review ocular emergencies

Trauma Non-traumatic

Review important questions in history

Review important findings on examination

Treatment


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Pediatric Ocular Trauma

Children are especially vulnerable to ocular trauma An estimated 2.4 million eye injuries occur in

United States each year with 40,000 cases of visionloss One estimate in 2000: more than 7500 hospitalizations

for the treatment of pediatric eye injuries that resultedin more than $88 million in inpatient charges

Second leading cause of monocular vision loss Second leading cause of ocular surgery in children


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Pediatric Ocular Trauma

Can occur at any age Age 11-15: high incidence of severe eye injury

Boys outnumber girls 4:1 In some studies, Up to 60% of pediatric eye injuries

occur during sports and recreational events Toys, balls, guns, darts, paintball, bbs

Other studies show that the home has become the

more common place for pediatric eye injuries Special consideration: children under age 5 Trauma or treatment can lead to visual deprivation

from amblyopia


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History

Difficult to examine kids

History! History! History! Mechanism of injury

Blunt trauma

Penetrating trauma

Associated head injury

Chemical exposure

Animal bites

Foreign body???

Abuse???


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History

Coexisting systemic disease

Allergy Tetanus status


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Examination

First goal: Rule out open globe

Signs: Chemosis; Peaked pupil; Vitreoushemorrhage

Vision!!!

One eye at a time Red reflex


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Lacerations

Eye Lid Lacerations


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Lacerations

History: Mechanism of injury Foreign body possible?

Animal bite or scratch?

Examination: Location of laceration Thin skin

Lid margin = realign tarsus to avoid notching Medial to puncta = canalicular involvement

Eye involvement

Referral to ophthalmologist


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Often requires repair in the operating room.

When not repaired correctly, can cause chronic eyelid and ocular

surface complications.


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Lacerations


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Subconjunctival Hemorrhage

Bruise of the eye Painless

No vision change Mechanism of injury

Trauma Sudden increase of pressure in the chest (coughing,

sneezing, vomiting)

If mild, and no other sign of ocular injury Is benign, and will disappear within a week No treatment necessary


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Subconjunctival Hemorrhage

If moderate or severe, and other signs of trauma

(eyelid bruising, worrisome history) Concern for more extensive eye injury

Refer to ophthalmology or ER

If vision ok & rest of eye looks

normal - probably no other

ocular injury

If vision loss, irregular pupil &

swollen conjunctiva possible

globe rupture


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Corneal Abrasion

Scratch on the cornea and/or conjunctiva

Fingers, fingernails, blowing debris, paper, contact lenswear, chemical exposure

History (OUCH)

Pain/ foreign body sensation

Copius tearing Blepharospasm or inability to open eye


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Corneal Abrasion

Rough edge ofabraded cornea

Exam

Watery discharge Conjunctival injection

Topical anesthetic will relieve pain


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The cornea is comprised

of 1 layer ofepithelium and 50 layers ofstroma


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Corneal Abrasionis a defect in the

epithelial layer only

Typically the rest of the

cornea is not damaged

VERY painful because

of so many nerveendings in the cornea


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Corneal Abrasion

Area of corneal defect stains with fluorescein and

lights up with cobalt blue light.


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Corneal Abrasion Linear Abrasion Look for foreign body

under eyelid.


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Corneal Abrasion Supplies Anesthetic drops and

fluorescent dye paper

Penlight with bluefilter in cap


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Corneal Abrasion

Management

One drop of topical anesthetic NEVER give a bottle of topical anesthetic drops

Antibiotic ointment and pain medication

Bacitracin or erythromycin

Can use drops in young children

Should resolve in 24-48 hours

If not resolved refer to ophthalmologist


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Corneal/Conjunctival ForeignBody

Commonly include dust, dirt or metallic

slivers Metallic foreign bodies can leave a rust ring

in the cornea

History Hammering or working with tools

Pain/foreign body sensation

Tearing


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Exam May or may not visualize foreign body

May see linear corneal abrasions from foreign bodyunder eyelid

Can penetrate the eye

Management

Can remove with aid of topical anesthetic and cottontip applicator May need slit lamp and needle or burr Referral to ophthalmologist


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Open Globe

Perforating injury of the cornea and/or

sclera which violates the integrity of theglobe

History: mechanism of injury

Blunt trauma Penetrating trauma

Intra-Ocular Foreign body possible


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Open Globe

16 YO, 22 caliber shotgun casing,

penetrated thru lid and into eye


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Open Globe

Management

Call ophthalmologist Place fox shield, protective shield or Styrofoam

cup over eye

IV antibiotics broad spectrum coverage Consider CT scan if foreign body suspected

Do NOT let the patient eat or drink!!!


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Chemical Burn

True ophthalmic emergency!!! From alkaline or acidic substance in contact with

eye May be in the form or:

Liquid Solid

Powder Mist Vapor


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Chemical Burn

Begin Irrigating with normal saline!!

History Alkaline worse than acid

Contact with household solutions/cleaners

Pain Tearing


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Chemical Burn

Severity of the injury depends on

the pH Alkaline agents (high pH) much more damaging

than acidic

Denatures proteins and lyses cell membranes

Volume

Duration of contact


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Chemical Burn

Treatment

If history of chemical injury, defer exam andbegin STAT lavage with normal saline

COPIOUSLY irrigate

Continue until neutral pH

pH can be tested with litmus paper Prognosis is dependent on number of clock

hours of avascular cornea and scleral whitening


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Acidic Injury

Corneal abrasion Corneal haze heals

with little or no scar


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Alkaline Injury

Damage to epithelium White sclera = POOR

prognosis


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Alkaline Injury


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Hyphema

Blood in the anterior chamber

Caused by blunt force trauma External compression causes tearing of the iris

root

Incidence 2/10,000 children per year Smaller = better visual prognosis


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Hyphema

Management Evaluation for associated ocular problems Referral to ophthalmologist

Eye SHIELD (not patch) Elevate head of bed Bed rest for 5 days

NO NSAIDS Tylenol OK for comfort May require hospitalization for large hyphema +/- Cycloplegic and topical steroids Watch for increased IOP


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Hyphema

Special considerations

Rebleeding possible First 2-5 days Associated with fibrinolysis

May be worse than initial bleed

Sickle cell disease More likely to develop increased IOP

Tolerate increased IOP poorly

Cannot use carbonic anyhdrase inhibitors

STAT sickle cell prep or SPEP


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Hyphema

Special considerations

Spontaneous hyphema no history of trauma Juvenile Xanthogranuloma (JXG)

Children under 2

Red/brown papules


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Traumatic Iritis

History Blunt Trauma

Pain, photophobia usually 1 to 2 days after injury Exam Slit Lamp Exam shows cell and flare in anterior chamber Perilimbal conjunctival injection, photophobia

Treatment

Refer to Ophthalmology Cycloplegia Steroids Sunglasses


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Shaken Baby Syndrome

Child abuse can manifest in injury to any

structure of the eye But frequently no external signs of abuse

SBS Characterized by SDH, bone fractures

and retinal hemorrhages (83%) DFE: hemorrhages in multiple retinal layers


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Retinal hemorrhages frequently in children

less than 18 months Often associated with intracranial

hemorrhages (SDH, SAH)

Caused by combination of factors includingacceleration/deceleration forces


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Controversy over whether accidental

trauma and CPR can cause retinalhemorrhages

Previous studies and anecdotal evidence ofpatients after CPR and known accidental

trauma support evidence of low incidence of

retinal hemorrhage

Photo documentation important


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Orbital Fracture

Management

CT scan better than MRI Referral to orbital surgeon


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Orbit


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Air Bag Trauma

Air bag deployment is a recognized cause ofocular injury

From minor (corneal abrasion, lidecchymosis) to severe (hyphema andretinal detachment)

Blunt impact from airbag to eye Chemical burns from alkaline sodium azide

gas that inflates airbag


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Air Bag Trauma


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Air Bag Trauma

Management

Flush eyes with saline to irrigate alkalinebyproducts

Administer first aid to burns

Eye exam

Refer to ophthalmologist as needed


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All That Bruises Is Not Trauma

Specific entities cause periocular

ecchymosis in the absence of trauma


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4 year old

Acute onset of pain Ecchymosis and proptosis

Diagnosis=

Lymphangioma


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Infant admitted with bilateral periorbitalecchymosis

Extensive workup including suspected abuse

Diagnosis=

Neuroblastoma


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Leukocoria

Literally means white pupil

Many disorders can cause leukocoria andall represent a serious threat to vision.

Any patient with Leukocoria should be

referred to Ophthalmology immediately.


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Retinoblastoma


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Retinoblastoma

Malignant tumor of the eye originating from the retina Unilateral or bilateral

Nearly 100% mortality when untreated, but >95%survival with prompt treatment

Suspect with any of the following: Abnormal red reflex/leukocoria Strabismus Chronic red eye ( conjunctivitis clears in 10 to 14 days)

Urgent referral of Ophthalmology


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Congenital Cataract


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Congenital Cataract

Opacity in the lens of the eye May be unilateral or bilateral

Inherited (Usually Autosomal Dominant) Metabolic Infectious Traumatic

Requires removal in eyes at risk for amblyopia Urgent referral to Ophthalmology in newborns

Risk of irreversible amblyopia if not removed by 4 to 6 weeks ofage


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Congenital Glaucoma


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Congenital Glaucoma

Elevated intraocular pressure

Signs: Cloudy cornea


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Congenital Glaucoma

Bupthalmos or big eye (big eyes or cornealenlargement = rule out glaucoma)

Tearing, photophobia and blepharospasm

Urgent referral to Ophthalmology

Surgery nearly always indicated incongenital glaucoma


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Corneal Ulcer

Vision and eye threating condition History

Contact lens wear, esp. SLEEPING in contact lenses Red, painful eye

White opacity with overlying epithelial defect Treatment

Stop contact use immediately Urgent Ophthalmology consult Antibiotics (3rd or 4th generation quinolone: ciprofloxin or

moxifloxin drops)


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Cellulitis

Infection or inflammation of the eyelid skinand/or orbit

The orbital septum is a fibrous membrane thatseparates the eyelid skin from the deeper

structures of the orbit

Preseptal cellulitis effects the skin and does notextend beyond the septum into the orbit

Orbital cellulitis is infection within the orbit itself,often from sinus disease


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Cellulitis

Preseptal cellulitis can often be managed with oralantibiotics and close follow up

Orbital cellulitis is much more serious(Ophthalmology involved)

Signs: Proptosis (versus lid swelling)

Red, injected eye Limitation of ocular motility Decreased vision (can be signs of optic nerve

compromise)


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Cellulitis

Treatment

IV Antibiotics

CT scan to rule outsinus disease/abscess

Management withOphthalmology to

monitor signs of

compromise,

infectious disease and

ENT if sinus

disease/abscess


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Thank You

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Pediatric Ocular Emergencies

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