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The eyes have it. Ophthalmologic emergencies Cecilia Guthrie, MD Emory University Case- History • CC : Blind in right eye • 9y.o. HM hit in right eye with a rock 24 hours ago by same age boy at school • No loss of consciousness and eye pain on being struck resolved quickly • Some persistent blurriness of vision • Mother noted red marks on white parts of eye, but no other injury Case- History • 2 hours to presentation, pt developed headache, dizziness, and loss of vision in right eye. Denied fever, pain, repeated trauma and vomiting. • PMH - Asthma • Meds - albuterol mdi • Allergies - none • FH - N/C • ROS - o/w negative Case - PE • VS : 88 16 116/60 • HEENT - no signs of trauma • OD – mild ptosis of right upper eyelid. No echymosis of eyelid. – Sclera with multiple subconjunctival hemorrhages – globe intact w/o swelling – conjunctiva injected diffusely – fundus - unable to visualize the retina Case - PE – Unable to visualize the pupil secondary to blood in anterior chamber. – Pt could distinguish light – EOMI • OS – PERRLA – No erythema, normal sclera and conjunctiva – 4mm--> 2mm • Visual Acuity: OD none OS 20/40 Ophthalmology trauma • Ocular trauma is leading cause of visual loss in the pediatric population • Estimated approximately 1 million eye injuries occurring in children annually. • M>F 3:1 • Adolescent males at increased risk • 1/2 of injuries occur secondary to sporting activities (baseball, basketball) Ophthamology trauma • BB guns, paint ball guns,sticks, collision with fixed objects • Visual system matures at 9 years of age • Amblyopia may occur • May be difficulty to obtain mechanism of injury, history and exam You did what?? • • • • • • • • Mechanism of injury Time of injury Place of injury Caregiver at time of injury Initial intervention Possibility of retained foreign body Pertinent PMH and ocular hx Any vision changes Open…Your…Eyes!! • Non contact aspects of exam first • Suspect ruptured globe, don’t touch eye • Assess visual acuity in each eye separately • Pupils • Ocular motility • Lids and orbits Open… Your… Eyes!! • Examine conjunctiva and sclera for lacs or foreign body • Cornea for abrasion or lacerationflourescein • Anterior chamber depth and clarity • Assess red reflex Trauma Foreign Body • Foreign bodies can lodge underneath the upper eyelid or on the anterior surface • Foreign body sensation • Pain on blinking • Watery Discharge • Unilateral • Photophobia Trauma Foreign Body • Extraocular vs intraocular • Treatment – Topical anesthetic (tetracaine) – Eversion of the lid and flush with water – Remove foreign body – Question of retained foreign body after flush-call opthomology – Flourescein after flushing Trauma Subconjunctival hemorrhage • • • • • • Unilateral Underlying sclera not visible Adjacent conjunctiva normal No discharge No pain Vision intact Trauma Subconjunctival hemorrhage • Etiology – Minor trauma – Bleeding disorders – Anticoagulation therapy – Hypertension – Coughing, vomiting • Treatment – Resolves in 2-3 weeks Trauma Corneal abrasion • Cornea – Epithelium – Bowman membrane (protective layer) – corneal stroma (90% of thickness) – Descemet membrane – Endothelium • Superficial to Bowman membrane • If deeper to Bowman membrane - scar Trauma Corneal abrasion • • • • • Moderate to severe pain Photophobia Conjunctival erythema Tearing Diagnosis – Better exam with topical anesthetic – Fluorescein Trauma Corneal abrasion • Treatment – – – – – Topical antibiotic therapy for 4-5 days Patching vs No Patching Cool compresses intermittently Tylenol or ibuprofen Cycloplegic agents for severe pain • 5% homotropine • 1% cyclopentolate (cyclogel) – If not healing in 48 hours, opthamology referral Trauma Eyelid lacerations • Determine if laceration or injury to globe/conjunctiva underneath the eyelid laceration, especially with pointed objects • Determine if a complete perforation of eyelid present • Determine if involvement of tearducts Trauma Eyelid lacerations • Uncomplicated superficial eyelid lacerations may be sutured by ED physician – Shallow sutures used – Sedation may be needed Trauma Eyelid lacerations • Indications for opthamology consult – Full thickness perforation of lid – Ptosis – Involvement of the lid margin – Possible damage to tear drainage system – Tissue avulsion – Global injury Trauma “Black eye” • Can be associated with traumatic iritis, hyphema and cataracts. • Dramatic ecchymosis and swelling may occur from mild trauma because of loose connections of eyelid skin and underlying tissues. • Resolving midline forehead injuries/ hematomas can cause bilateral ecchymosis Trauma Orbital fractures • Most common-inferior and medial walls • 50% of pediatric orbital fractures are associated with other ocular injuries • Enopthalmia or proptosis • Decreased extraocular muscle movement – hallmark of orbital fracture – entrapped muscle/tissue – orbital hemorrhage Trauma Orbital fractures • Inferior wall fx - infraorbital nerve injury • Superior (roof) wall fx - pulsating proptosis • Diploplia - eom entrapment • May be subtle with normal rim • CT of orbits with head CT (especially with possible superior wall fx) Trauma Orbital fractures • Ophthalmology consult • May also need “face” consult• If no entrapment, hemorrhage or global injury and fracture is nondepressed or displaced, may not require surgery • Broad spectrum antibiotics • Don’t blow nose Trauma Hyphema • • • • Children and young adults M>F (4:1) After blunt trauma to the face/eye Traumastretching of iris and ciliary bodytear • Blood in the anterior chamber • Layering Trauma Hyphema • 3-5 days post injury, spontaneous rebleeding • Rebleed complications – Corneal staining – Secondary glaucoma – Optic atrophy • Sickle cell disease patients – Increased risk of rebleeding – ~30% have increased intraocular pressure (10-20 normal) – Central artery occlusion and optic nerve damage with marginal increases in intraocular pressure Trauma Hyphema Distribution Severity 0 Degree of Hyphema microscopic 58% 1 < 1/3 20% 2 1/3- 1/2 14% 3 ½-3/4 8% 4 ¾-complete (8 ball) Trauma Hyphema • Treatment – Eye shield – Strict bedrest with head elevated 45º – Ophthalmology consult – Long acting cycloplegic – Aminocaproic acid (antifibrinolytic) • Initial: 200mg/kg/dose po (max 6 gm) • Maintenance 50 - 100 mg/kg/dose q 6 hr. – Admission for 30% hyphema Trauma Iritis • • • • • • Eye pain Photophobia Visual loss Ciliary flush Constricted pupil on affected side 24 - 72 hours after blunt injury to the eye ball Trauma Iritis • Treatment – Ophthalmology consult – Short acting cyclopegia – Topical antibiotic Trauma Ruptured globe • S/P blunt trauma or projectile of sharp object – Guns (22%), sticks/tree branches (11%) • M>F 6:1 • Laceration or puncture of the sclera or cornea • Iris or choroid plugs wound – tear drop pupil – brown,blue or black on scleral surface Trauma Ruptured Globe • If small may have a normal global appearance • Limbus most susceptible area • 360 degree subconjunctival hemorrhage-be suspicious Trauma Ruptured Globe • Management – Keep pt calm-may need sedation – Cover eye with hard shield – Ophthalmology consult-True emergency – CT of orbits – Tetanus – Antibiotics Conjunctivitis Chemical injuries • Chemical contact • Most common cause are voluntary eye solutions – Neomycin, atropine, pilocarpine, idoxuridine, gentamycin • Neonate • Discontinue irritating agent Chemical Burns • Alkali Burns – Most serious burns – Hair straighteners, lye, ammonia – Penetrates corneacoagulative necrosis • Acid Burns – Limiting burn – Protein precipitation in the corneal epithelium and stroma • Limits acid penetration of the cornea • Corneal opacifications • Conjunctiva blanching Chemical Burns • • • • • • Topical anesthetic Immediate irrigation-1 L NS Check pH of eye-conjunctiva Continue to irrigate until pH is normal Ophthalmology consult Red is better than white Chemical Injuries • Mace/Tear gas/Pepper spray – Superficial injury – Flush eyes well • Super glue – Ophthalmic ointment – Check global movement beneath closed eyelid Radiation Injury • Prolonged exposure to ultraviolet light w/o proper eye protection • Ultraviolet keratitis-corneal epithelium swells and dies • Foreign body sensation • Photophobia • Pain • Redness • blepharospasm Radiation Injury • Fluorescein-diffuse punctate staining • Treatment similar to corneal abrasion References • • • • • • Albert, D and Jakobiec F Eds. Atlas of Clinical Ophthalmology. Philadelphia: W.B. Saunders, 1996 Arffa, R. Craven L ed. Grayson’s Diseases of the Cornea. St. Louis: Mosby, 1997 Levine, L “Pediatric ocular trauma and shaken infant syndrome” Peditr Clinic N Am. 2003;50 (1) Hatton MP, et al. “Orbital fractures in children” J Am Society of Opthalmic Plastic and Reconstructive Surgery. 2001;17(3), 174-9. Walton, W. et al. “Management of Traumatic Hyphema.” Survey of Opthalmology. 2002;47(4) 297-334. Fleisher and Ludwig. Textbook of Pediatric Emergency Medicine, 4th ed. Philadelphia: Lippinicott Williams and Wilkins, 200.
