Pediatric Ocular Emergencies

Pamela E. Williams, MD Pediatric Eye Care Center Baton Rouge, LA

Objectives
Review ocular emergencies
Trauma Non-traumatic

Review important questions in history Review important findings on examination Treatment

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 vision loss

One estimate in 2000: more than 7500 hospitalizations for the treatment of pediatric eye injuries that resulted in more than $88 million in inpatient charges

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

Pediatric Ocular Trauma

Can occur at any age
Age 11-15: high incidence of severe eye injury Boys outnumber girls 4:1 Toys, balls, guns, darts, paintball, bbs

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 Special consideration: children under age 5
Trauma or treatment can lead to visual deprivation from amblyopia

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???

History
Coexisting systemic disease Allergy Tetanus status

Examination
First goal: Rule out open globe
Signs: Chemosis; Peaked pupil; Vitreous hemorrhage

Vision!!!
One eye at a time

Red reflex

Lacerations
Eye Lid Lacerations

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

Often requires repair in the operating room.

When not repaired correctly, can cause chronic eyelid and ocular surface complications.

Lacerations

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

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

Corneal Abrasion
Scratch on the cornea and/or conjunctiva
Fingers, fingernails, blowing debris, paper, contact lens wear, chemical exposure

History (OUCH)
Pain/ foreign body sensation Copius tearing Blepharospasm or inability to open eye

Corneal Abrasion
Exam
Watery discharge Conjunctival injection Topical anesthetic will relieve pain
Rough edge of abraded cornea

The cornea is comprised of 1 layer of epithelium and 50 layers of stroma

Corneal Abrasion
is a defect in the epithelial layer only Typically the rest of the cornea is not damaged VERY painful because of so many nerve endings in the cornea

Corneal Abrasion
Area of corneal defect stains with fluorescein and lights up with cobalt blue light.

Corneal Abrasion
Linear Abrasion
Look for foreign body under eyelid.

 Anesthetic drops and fluorescent dye paper

Corneal Abrasion Supplies

Penlight with blue filter in cap

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

 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

Corneal/Conjunctival Foreign Body

Corneal/Conjunctival Foreign Body

 Exam

Corneal/Conjunctival Foreign Body

May or may not visualize foreign body May see linear corneal abrasions from foreign body under eyelid Can penetrate the eye

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

Open Globe
Perforating injury of the cornea and/or sclera which violates the integrity of the globe History: mechanism of injury
Blunt trauma Penetrating trauma Intra-Ocular Foreign body possible

Open Globe
16 YO, 22 caliber shotgun casing, penetrated thru lid and into eye

Open Globe
Exam:
Chemosis Peaked pupil Prolapse of iris or uveal tissue Hyphema Vitreous hemorrhage

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!!!

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

Chemical Burn
Begin Irrigating with normal saline!! History
Alkaline worse than acid Contact with household solutions/cleaners Pain Tearing

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

Chemical Burn
Treatment
If history of chemical injury, defer exam and begin 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

Acidic Injury
Corneal abrasion

Corneal haze heals with little or no scar

Alkaline Injury
Damage to epithelium

White sclera = POOR prognosis

Alkaline Injury

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

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

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

Hyphema
Special considerations
Spontaneous hyphema no history of trauma Juvenile Xanthogranuloma (JXG)
Children under 2 Red/brown papules

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

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

Shaken Baby Syndrome

Retinal hemorrhages frequently in children less than 18 months Often associated with intracranial hemorrhages (SDH, SAH) Caused by combination of factors including acceleration/deceleration forces

Shaken Baby Syndrome

Controversy over whether accidental trauma and CPR can cause retinal hemorrhages
Previous studies and anecdotal evidence of patients after CPR and known accidental trauma support evidence of low incidence of retinal hemorrhage

Photo documentation important

Orbital Fracture
History
Blunt force trauma ball, fist Nausea and vomiting Double vision

Exam
May have periocular edema and ecchymosis Enophthalmos Inability to look up

Orbital Fracture

Management
CT scan better than MRI Referral to orbital surgeon

Orbit

Air Bag Trauma

Air bag deployment is a recognized cause of ocular injury From minor (corneal abrasion, lid ecchymosis) to severe (hyphema and retinal detachment) Blunt impact from airbag to eye Chemical burns from alkaline sodium azide gas that inflates airbag

Air Bag Trauma

Air Bag Trauma

Management
Flush eyes with saline to irrigate alkaline byproducts Administer first aid to burns Eye exam Refer to ophthalmologist as needed

All That Bruises Is Not Trauma

Specific entities cause periocular ecchymosis in the absence of trauma

All That Bruises Is Not Trauma

4 year old Acute onset of pain Ecchymosis and proptosis Diagnosis= Lymphangioma

All That Bruises Is Not Trauma

Infant admitted with bilateral periorbital ecchymosis Extensive workup including suspected abuse Diagnosis= Neuroblastoma

Leukocoria
Literally means white pupil Many disorders can cause leukocoria and all represent a serious threat to vision. Any patient with Leukocoria should be referred to Ophthalmology immediately.

Retinoblastoma

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

Congenital Cataract

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 of age

Congenital Glaucoma

Congenital Glaucoma
Elevated intraocular pressure Signs:
Cloudy cornea

Congenital Glaucoma
Bupthalmos or big eye (big eyes or corneal enlargement = rule out glaucoma) Tearing, photophobia and blepharospasm

Urgent referral to Ophthalmology Surgery nearly always indicated in congenital glaucoma

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)

Cellulitis
Infection or inflammation of the eyelid skin and/or orbit The orbital septum is a fibrous membrane that separates the eyelid skin from the deeper structures of the orbit Preseptal cellulitis effects the skin and does not extend beyond the septum into the orbit Orbital cellulitis is infection within the orbit itself, often from sinus disease

Cellulitis
Preseptal cellulitis can often be managed with oral antibiotics 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)

Cellulitis
Treatment
IV Antibiotics CT scan to rule out sinus disease/abscess Management with Ophthalmology to monitor signs of compromise, infectious disease and ENT if sinus disease/abscess

Thank You