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Pediatric Ocular Trauma and Emergencies

• Dafina M. Good, MD
• Emory University School of Medicine
• Childrens Healthcare of Atlanta
• Pediatric Emergency Medicine Fellow

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Objectives

• 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

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Epidemiology of Eye Injuries

• 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

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Epidemiology of Eye Injuries contd

• 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..

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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
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Normal Eye Anatomy
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Normal Eye Anatomy with Bony Structures
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Lacrimal System
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The History

• Stop.. Emergency if Chemical burns, proceed to
  provide copious irrigation before history and
  physical exam is done
• 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

• 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

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The Eye Exam contd

• Fluorescein Exam
• Using topical anesthetics Tetracaine (onset of
  action lt1min) or Proparacaine (onset
  lt20 secs)
• Applying sterile fluorescein eye strips with
  saline or anesthetic
• Used with Woods 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)
• CT Scans are the radiologic study of choice in
  ophthalmologic emergencies
• Plain films are useful in some instances

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Components of the Eye Exam
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Dilated Eye Exam
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Case 1

• 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..

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Corneal Abrasions
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Corneal Abrasions

• 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!

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Case 2

• 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

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Conjunctival/Corneal FB
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Conjunctival/Corneal FB

• Usually present with similar sxs as abrasions
• Important to evert the eyelids using a cutip!
• 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 pts cheek If cornea involved best
  to get Ophthalmology to remove the FB with a
  needle
• Topical antibiotics

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Case 3

• 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

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Corneal/Scleral Lacerations
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Corneal/Scleral Lacerations

• 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

• A 5yr old was running and fell and hit his face
  on a metal object and cut his eyelid
• What do you want to knowand Why?
• Where on the Lid?

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Lid Lacerations
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Lets Review again the Lacimal System
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Eyelid Lacerations

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

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Case 5

• 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..

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Globe Rupture with Orbital Fracture
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Globe Rupture
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Globe Rupture

• Mechanism of injury usually occurs with 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, EOMs examined for entrapment

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Peaked Pupil
Pupil peaks in the.. direction of the injury
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Seidels Test
Fluorescein Eye Exam of Ruptured Globe
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Lets Review Again. the Eye Anatomy
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Ruptured Globe

• ED Management
• 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)
• 5-10 of penetrating injuries at risk for
  endopthalmitis, which leads to vision loss
• Ophthamology Consult Immediately!!!

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Case 6
You asked her to Look up. What are you
suspicious of?
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Orbital Floor Fracture
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Orbital Floor Fractures

• Mechanism of injury usually blunt force
• The weakest area of the orbital bones is the
  orbital floor/ maxillary roof aka Blow out
  Fracture
• Signs/Sxs
• 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

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Orbital Fractures

• ED Management
• Orbital CT is not routinely indicated unless
  limitation of motion
• Plain films may be helpful A/F levels, Orbital
  emphysema
• 3views Waters, Caldwell and Lateral Views

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Orbital Fractures

• Management
• Tetanus prophylaxis
• Surgery is not always indicated
• Arranging Ophthamology follow up for possible
  surgical repair
• Surgery is most commonly performed after 7-14days
• 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
• Tell patients to avoid blowing their nose

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Case 7

• 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?

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HyphemaGrade 1
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HyphemaGrade 2
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Hyphemas

• 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/Sxs. Pain, Decreased vision, injected
  conjunctiva, irregular pupil
• The following clinical grading system for
  traumatic hyphemas is preferred
• 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

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Hyphemas

• Complications
• Secondary Hemorrhage (Rebleeding)
• 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
• 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.

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Hyphemas

• 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 (gt30mm Hg)
• Topical Cycloplegics(Atropine/Tropicamide)
• Reduce ciliary muscle spasms and Dilate the iris
• Topical Miotics
• Lowers IOP and increases the surface area of the
  iris and enhance hyphema resorption
• Topical vs Systemic AMICAR (Aminocaproic acid)
• Antifibrinolytic
• Prevention of normally occurring clot lysis
  allows blood vessels time to repair
• Topical vs Systemic Steroids
• Decreases the associated iritis and development
  of synechiae
• Sickle Cell prep in African Americans of unknown
  status

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Subconjunctival Hemorrhage
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Subconjunctival Hemorrhage
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Whats Wrong with this picture?
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Retrobulbar Hemorrhage
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Retrobulbar hemorrhage

• Mechanism of injury usually after blunt or
  penetrating injury
• Signs/Sxs.. 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
• Immediate Ophthamology Consult!
• IV Mannitol- to decrease IOP
• IV steroids
• Lateral canthotomy (by experienced person)

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The True Eye Emergency
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The True Eye Emergency
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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
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IRRIGATION!!
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Chemical Burns

• No history, No physical exam.. Copious
  Irrigation is key..1 to 2L of saline or lactated
  ringers
• 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 dont
  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
• Lye, cement cleaner, drain cleaner, fertilizer,
  sparklers, and firecrackers produce alkaline
  burns because they contain sodium hydroxide

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Chemical Burns

• ED Management
• After 30 minutes of copious irrigationand
  Neutralized Eye pH of 7.0
• HP
• 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?

• 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

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Summary

• 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???

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The End
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References

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• Crain, Ellen, Jeffrey Gershel. Clinical Manual of
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• Hamid, Rukaiya, Newfield, Philippa. Pediatric Eye
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• Naradzay, Jerry, Barish, R. Approach to
  Ophthalmologic Emergencies. The Medical Clinics
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• Dua, Harminder, King, A, Joseph A. A new
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  Journal of Ophthalmology 200185 1379-1383.
• Sheppard, John et al. Hyphema. eMedicine.
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  65.htm
• Robson, Joe et al. Globe Rupture. eMedicine.
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