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Grand Rounds Blepharoptosis After Fall

Explore a case of acquired blepharoptosis in a 4-year-old following a fall with a pencil, including assessment, differential diagnosis, imaging, and postoperative care. Understand the importance of history, imaging, and management strategies in pediatric ocular traumas.

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Grand Rounds Blepharoptosis After Fall

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  1. Grand RoundsBlepharoptosis After Fall Patrick Burchell, MD October 12, 2018

  2. Patient Presentation CC Right Upper Eyelid Ptosis HPI 4 yo female referred for evaluation of RUL ptosis s/p fall 11 months prior. Patient fell while running with unsharpened pencil in hand. Presented to local ED with a small upper eyelid laceration.

  3. HPI • Pencil was intact and did not lodge within the tissue • Underwent EUA with repair of laceration in OR by an outside provider • Constant drooping of RUL, intermittent irritation, erythema, and mucoid drainage OD in months following

  4. History (Hx) Past Ocular Hx: Denies Past Medical Hx: Denies Fam Hx: Non-contributory Meds: None Allergies: NKDA Social Hx: Lives with her parents ROS: + photophobia, redness, mucoid discharge

  5. External Exam

  6. Anterior Segment Exam

  7. Posterior Segment Exam

  8. Assessment • 4 yo female with new onset RUL ptosis along with a pyogenic granuloma s/p fall with pencil in hand 11 months prior • Differential Diagnosis: • Traumatic ptosis • Retained foreign body

  9. Plan • Order CT orbits to rule out possible retained foreign body.

  10. CT Orbits Coronal CT without contrast: Soft tissue window Axial CT without contrast: Soft tissue window

  11. Plan • OR for exam under anesthesia with removal of foreign body.

  12. Post Operative Course • All previous ocular symptoms subsided • RUL ptosis persisted, but will be addressed surgically in near future Post-operative Day # 5

  13. Pediatric Ocular/Orbital Trauma • Estimated 2.4 million eye injuries in the U.S each year • 35% occur in children < 17 yo • Boys 2:1 • Most common causes in children: • Projectiles (20%) • Body parts (12%) • Blunt objects (10%) • Sharp objects (9%) • Motor vehicle accidents (4%)

  14. Trauma Evaluation • History is key • VA, pupils, IOP, EOM • External Exam • Globe Evaluation • Imaging!

  15. Trauma Evaluation • CT orbits is extremely important when septum has been violated

  16. 25 year retrospective review of 3 oculoplastic surgeons • 268 pediatric patients with acquired blepharoptosis • 34.7% - Mechanical (infantile hemangioma) • 15.3% - Traumatic

  17. 512,079 eye injuries • Types of injuries • Abrasions or contusions (44.6%) • Foreign body (8.9%) • Laceration (4.9%)

  18. Conclusions • Kids are often difficult to examine, so history is very important • Look for orbital fat as a sign of violation of the septum • Orbital imaging is your friend in trauma situations • Remember wood can hide on CT

  19. Thank You • Dr. Gerber • Dr. Compton • Dr. Timoney

  20. References • Rasiah S, Hardy TG, Elder JE, et al. Etiology of pediatric acquired blepharoptosis. Journal of AAPOS 2017;21:485-487. • Abbott J, Shah, P. The epidemiology and etiology of pediatric ocular trauma. Survey of Ophthalmology 2013;58:476-485. • Cross JM, Griffin R, Owsley C, McGwin G. Pediatric eye injuries related to consumer products in the United States. Journal of AAPOS 2008;12(6):626-628. • Salvin JH. Systematic approach to pediatric ocular trauma. Current Opinion in Ophthalmology 2007;18:366-372. • Sii F, Barry RJ, Abbott J, et al. The UK Paediatric Ocular Trauma Study 2 (POTS2): demographics and mechanisms of injuries. Clinical Ophthalmology 2018;12:105-111. • Al-Otaibi F, Baeesa S. Occult orbitocranial penetrating pencil injury in a child. Case Reports in Surgery 2012;1-4.

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