Case Presentation

1. Case Presentation Mary Palomaki November 11, 2009

2. 9 y/o female with difficulty seeing far

3. HPIHistory obtained from grandmother and patient • 9 y/o female with difficulty seeing the blackboard x 3 days. • She noticed the change in vision while playing with her dolls. • + slight pain with eye movements • + increased lacrimation • No alleviating factors, no provoking factors • Denies trauma, proptosis, edema, erythema of eye or eyelids, fever, headache, weight loss, nausea/vomiting, weakness, vertigo, neck stiffness • ROS: + cough, runny nose, sore throat x 4 days, no diarrhea or dysuria, good PO

4. Past Medical History • Birth History: FT, NSVD, no complications • Tonsillectomy at age 7 • History of headaches • MRI (2008): cystic lesion in left hippocampus/tail of caudate nucleus, cleared by neurosurgery • FH: Mother: deceased, cancer

5. Other History • Medications: Tylenol for sore throat • Allergies: NKDA • Immunizations: up to date (verified by CIR) • Social: lives with grandmother, three brothers, 7,9,14 y/o.

6. Physical Exam • VS: T: 98.6 F, HR: 82, RR 16, BP: 80/60, wt: 39.9 kg, Ht 135 cm, BMI 21 (>95%tile) • Gen: Obese, NAD, AAO x 3 • HENT: NC/AT, TM: b/l shinny, grey, no fluid, + rhinorrea, oropharynx: no lesion, neck supple

7. Physical Exam • Orbit: no edema, no discoloration, no crepitus on bony deformities, no proptosis • Eyelids: no edema, no lesion • Acuity: R: 20/20, L: 20/70, + diplopia on L • Pupils: round, symmetrical, direct and consensual pupillary reflexes intact • EOMI • No lacrimation • No nystagmus • Conjunctivae pink, no lesion, no hemorrhage

9. Physical Exam • CVS: S1/S2, no murmur, RRR • Resp: CTA • Abd: BS+, soft, NT/ND, no organomegaly • Ext: FROM, 5/5 strength, no edema, cap refill < 2 sec. • Skin: no rash • Neuro: CN II-XII intact, normal tone, normal gait, heel-shin intact, failed pass pointing with right eye closed • GU: normal female, Tanner 1

10. Differential Diagnosis

11. Ophthalmology Consult • Corneal abrasion on left eye, 4mm long • Erythromycin ointment x 3 days • Follow up with ophthalmology in 1 week

12. Ocular Trauma Ocular Trauma

13. Ocular trauma • 1/3 of blindness in children results from trauma • Boys age 11-15 are most at risk (M:F = 4:1) • Sports, toy darts, sticks, stones, fireworks, paintballs, air-powered BB guns are common causes of trauma

14. Outline • Review of Anatomy • History • Eye exam • Corneal Abrasions • Orbital fractures • Lacerations • Globe rupture • Retinal Detachment • Chemical Burns • Prevention

15. Review of anatomy

16. History • Mechanism of injury, events after injury • Onset/duration of symptoms • Preexisting eye disorders • Systemic disorders • Drug allergies • Contraindications to anesthesia • When patient last ate • Prior tetanus immunization

17. Physical Exam • Observation/inspection with pen light • External examination: • Orbital bones: palpate orbital rim • Position of globes (exophthalmos or enophthalmos) • Mobility of globes: note pain, diplopia, limitation of ocular rotation, and abnormal movements (nystagmus) • Inspection of lids (Do NOT palpate if globe ruptured!) • Skin, conjunctival surfaces of lids should be inspected for foreign body or laceration • Palpate lid for crepitus

18. Physical Exam • Pupil exam: • Size • Shape • Reaction to light • Look for corneal opacities or defects • Look for blood in anterior chamber • Look for lens opacification or dislocation • Iridodonesis is a moving/shaking iris, a sign of dislocation

19. Examination of Visual Acuity in Children • Preverbal children • Allow child to reach for a small toy with one eye covered, then the other eye covered

20. Examination of Visual Acuity in Children • Children 4-8 years old: • Eye chart with Pictures, tumbling E’s, numbers, or letters • 2 inch wide paper taped to brow to cover one eye • Test with corrective lenses in place if possible • Vision difference more important than absolute vision • Referral to ophthalmologist if both eyes in 5 year old are 20/50 or worse, or 20/60 or worse in 6 year old

21. Examination Visual Acuity in Children • Children > 8 years old • Use standard Snellen Chart at 20 ft. • Most common ocular condition in this age group is myopia • blurred vision at distance • can develop over several months

22. Fluorescein Staining • First use topical anesthetic drops (proparacaine) • Warn patients and parents of transient pain before anesthesia takes effect • Moisten a fluorescein strip, and touch to lower fornix • Or use fluorescein drops • Fluorescein stains tear film, washes away on intact epithelium and stains exposed corneal stroma • Yellow dye is visible in white light, but better under ultraviolet light (Wood Lamp) • Wood’s lamp is better tolerated if photophobia present

24. Physical Exam--Slit Lamp Exam • Binocular microscope that allows the examiner to have a three-dimensional view of the eye • Beam of light (rather than diffuse light) can be adjusted by height and width • Provides 10-25 x magnification • Anterior segment of the eye: • lids, lashes, conjunctiva, cornea, • anterior chamber, iris, and lens • Ocular foreign body removal

25. Physical Exam: Dilation • Perform after visual acuity tested and pupil exam • Perform only if patient is neurologically intact • Use Topical 2.5% phenylephrine plus 1-2 drops of 0.5% tropicamide • Wait 20 minutes • Complete the ophthalmoscopic exam • Dilation lasts 2-5 hours • (Atropine is contraindicated because dilation can last for days.)

26. Corneal Abrasions: Corneal Anatomy • Avascular • Densely innervated • Sensory pain fibers from CN V • 5 layers: • Epithelium: outermost, 5-6 cell-thick • Cells quickly regenerate after injury • Boman’s layer: tough layer, protects • Stroma: thick layer composed of collagen fibrils aligned in parallel • Descemet’s membrane • Endothelium: if damaged will not regenerate

27. Corneal Abrasions • Most common eye trauma • Symptoms: photophobia, tearing, intermittent sharp pain due to ciliary body spasm, foreign body sensation • PE: irritability, blurry vision, conjunctival injection, blepharospasm, irregular red reflex, dulled corneal light reflex, fluorescein staining of epithelial defect • Be sure to evert the lid to examine tarsus

28. Lid Eversion

29. Corneal Abrasions • Traumatic corneal abrasions: mechanical trauma to the eye, or foreign body under the lid • Foreign body related corneal abrasion: objects embedded in cornea • Contact lens related corneal abrasions: from over-worn, poorly fitting, dirty lens • Spontaneous defects: previous trauma

30. Corneal Abrasions: Treatment • Remove foreign bodies with moist cotton swab or sterile needle (by ophthalmologist only) • Long-acting topical cycloplegic drop • Homatropine 5% • For pain relief caused by ciliary body spasm • Antibiotic ointment • Better than drops because it lubricates • Erythromycin • Aminoglycosides should be avoided since they can be toxic to the epithelium. • Drops with steroids are contraindicated; they slow epithelial healing and decrease immune response. • Semi-pressure patch • controlled studies have found that patching does not improve the rate of healing or comfort

31. Corneal Abrasions: Follow Up • Small (<3 mm) abrasions with no change in vision do not need follow up • Except patients with contact lens related abrasions, where daily follow up recommended • Large abrasions (>3 mm), or any abrasion with diminished vision, need daily follow-up.

32. Corneal Abrasion--Refer to Ophthalmologist when: • corneal infiltrate, white spot, or opacity • Refer same day • epithelial defect is larger at 24 hours, • purulent discharge present • Patient has experienced a drop in vision

33. Orbital Fractures • Lateral Orbit fractures: zygomatic bone fracture • Cosmetic deformity, pain, difficulty opening mouth • Lateral canthus tendon inserts in the zygomatic, with fracture, the lateral canthus is inferiorly displaced • Orbital Apex fracture: • Can cause optic nerve compression, central retinal artery occlusion, retrobulbar hemorrhage • Blow-Out fracture: • Orbital floor and medial wall • Usually caused by blunt trauma with a large object

36. Blow-Out fracture • Four signs: • Enophthalmos • Loss of sensation over malar eminence and cheek • Inability to look up on affected side • Diplopia on up-gaze • Positive traction test • Inability to rotate eye upward with forceps

37. Blow-Out fracture: Management • Oral antibiotic prophylaxis x 5-7 days • Surgical correction 2-3 weeks later by otolaryngologist

38. Complicated Lid Lacerations • Lid Margin lacerations: must be aligned properly to avoid lash inversion, damaging the cornea • Medial canthus lacerations: • May go through canaliculi • Cause persistant tearing • Canaliculi must be reattached

40. Traumatic Hyphema • Blood in anterior chamber secondary to trauma • (Spontaneous Hemorrhage can occur secondary to juvenile xanthogranuloma) • Vision impaired until blood settles and forms a red meniscus • 20% of patients re-bleed • “Blackball hyphema” • Usually occurs at 3-5 days after initial injury • Occurs from lysis of clot • Recurrence of bleeding is more severe; possibly causing glaucoma, hemophthalmitis

41. Black ball Hyphema

42. Primary Hyphema: Management • Bed rest, elevation of the head • Eye Shield • Cycloplegia • Topical Steroids • Systemic antifibrinolytics • Aminocaproic acid: in your healthy patients • Measurement and control of intraocular pressure • Screen all black patients with hemoglobin electrophoresis • Secondary glaucoma is more likely with SS or trait

43. Open Globe Injuries • Blunt trauma: globe rupture, most common site is near the insertion of the rectus muscles in the sclera • Penetrating trauma: laceration to the globe, most common in the cornea

44. Open globe Injuries • Avoid any examination procedure that might apply pressure to the eyeball • For young children, an examination facilitated by procedural sedation or anesthesia should be performed by an ophthalmologist • Avoid medication (anesthetic drops or fluorescein) into the eye. • Foreign bodies should be removed by ophthalmologist

45. Open Globe Injuries: PE • Markedly decreased visual acuity • Volume loss • Afferent pupillary defect • Increased anterior chamber depth • Leakage of vitreous • Outward prolapse of the uvea (iris, ciliary body, or choroid) • Tenting of the cornea or sclera • Low intraocular pressure • (checked by an ophthalmologist only) • Seidel sign • fluorescein streaming away from the laceration site

46. Imaging • Axial and coronal CT of the eye without contrast • 1 to 2 mm cuts through the orbits

47. Open Globe injuries: Management • Place eye shield over the affected eye • Do not touch, move eye • Bed rest • Antiemetic therapy (eg, IV ondansetron 0.15 mg/kg, maximum dose: 16 mg) • Pain medication: morphine, fentanyl • Don’t use NSAIDs --> platelet inhibiting properties • Sedation: lorazepam • NPO

48. Open Globe Injury: Prognosis • Depends on: • Primary closure by ophthalmologist within 24 hours • Blunt trauma has worst outcome • Initial visual acuity • Wound location: posterior lacerations have poorest outcome • Afferent pupillary defect

49. Open Globe Injuries: Complications • Endophthalmitis: internal eye infection • Endophthalmitis is associated with poor prognosis • Prophylactic antibiotic treatment: • Vancomycin (15 mg/kg, maximum dose: 1 gram) • ceftazidime (50 mg/kg: maximum dose 1 gram) • Organisms: • Bacillus species • coagulase-negative Staphylococcus • Streptococcal species • S. aureus • gram negative organisms

50. Retinal detachment • Rhegmatogenous detachment: a break in the retina allows fluid to enter the subretinal space • (child abuse/shaking) • Traction retinal detachments: adhesions between the vitreous and the retina pull on the retina