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2. Pediatric Ocular Trauma and Emergencies
Dafina M. Good, MD
Emory University School of Medicine
Children’s Healthcare of Atlanta
Pediatric Emergency Medicine Fellow

3. 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

4. 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

5. Epidemiology of Eye Injuries cont’d
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…………..

6. 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

7. Normal Eye Anatomy

8. Normal Eye Anatomy with Bony Structures

9. Lacrimal System

10. 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

11. 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

12. The Eye Exam cont’d Fluorescein Exam…
Using topical anesthetics Tetracaine (onset of action <1min) or Proparacaine (onset <20 secs)
Applying sterile fluorescein eye strips with saline or anesthetic
Used with Wood’s 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

13. Components of the Eye Exam

14. Dilated Eye Exam

15. 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……..

16. Corneal Abrasions

17. 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!

18. 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

19. Conjunctival/Corneal FB

20. Conjunctival/Corneal FB
Usually present with similar sx’s 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

21. 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

22. Corneal/Scleral Lacerations

23. 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

24. 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 know……and Why?
Where on the Lid?

25. Lid Lacerations

26. Let’s Review again the Lacimal System……

27. Eyelid Lacerations ED management Consult Ophthamology if…… 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)

28. 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…..

29. Globe Rupture with Orbital Fracture

30. Globe Rupture

31. 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, EOM’s examined for entrapment

32. Peaked Pupil
Pupil peaks in the…..
direction of the injury

33. Seidel’s Test
Fluorescein Eye Exam of Ruptured Globe

34. Let’s Review Again…. the Eye Anatomy

35. 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!!!

36. You asked her to Look up…. What are you suspicious of?
Case #6
You asked her to Look up…. What are you suspicious of?

37. Orbital Floor Fracture

38. 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/Sx’s…
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

39. 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 Water’s, Caldwell and Lateral Views

40. 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

41. 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?

42. Hyphema Grade 1

43. Hyphema Grade 2

44. 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/Sx’s…. 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

45. Hyphemas Complications Prognosis/Outcomes
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.

46. 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 (>30mm 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

47. Subconjunctival Hemorrhage

48. Subconjunctival Hemorrhage

49. What’s Wrong with this picture?

50. Retrobulbar Hemorrhage

51. Retrobulbar hemorrhage
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
Immediate Ophthamology Consult!
IV Mannitol- to decrease IOP
IV steroids
Lateral canthotomy (by experienced person)

52. The “True” Eye Emergency

53. The “True” Eye Emergency

54. Roper-Hall Classification Table
Grade
Prognosis
Limbial Ischemia
Corneal Involvement I
Good
None
Epithelial Damage II
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

55. IRRIGATION!!

56. 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 don’t 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

57. Chemical Burns 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?

58. 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

59. 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???

60. The End

61. References
Brophy M, Sinclair S, Grim Hostetler S, Xiang H. Pediatric Eye Injury-Related Hospitalizations in the United States. Pediatrics 2006;
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;
Naradzay, Jerry, Barish, R. Approach to Ophthalmologic Emergencies. The Medical Clinics of North America 2006;
Dua, Harminder, King, A, Joseph A. A new classification of ocular surface burns. British Journal of Ophthalmology 2001;85:
Sheppard, John et al. “Hyphema.” eMedicine. November
Robson, Joe et al. “Globe Rupture.” eMedicine. July
Suwarno, Omar. Assessing and managing ophthalmic emergencies. Journal of the American Academy of Physician Assistants 2003;16:18-33.