ocular emergency in pedi clinics
TRANSCRIPT
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Ocular Trauma Ocular Trauma
Robin L. Grendahl, MD
Pediatric OphthalmologyAnd Strabismus
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Ocular TraumaOcular Trauma
Corneal abrasionContact lens related traumaForeign bodiesHyphemaRuptured globeLid lacerationsOrbital traumaShaken baby syndrome
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Vision HistoryVision History
Are both eyes affected?Blurry vision?Was vision normal prior to trauma?Symptoms? (Pain, FB sensation, photophobia)Mechanism of injury, date, place? (litigation)
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Complete Eye ExamComplete Eye Exam
Vision in both eyesExternal examPupilsMotilityAnterior segmentOphthalmoscopy
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Tools Used for Examination Tools Used for Examination
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Corneal AbrasionCorneal Abrasion
Epithelial layer abradedIntense painVision blurredEye redTearing
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Corneal AnatomyCorneal Anatomy
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WelderWelder’’s Flash Burn or Solar s Flash Burn or Solar Keratopathy Keratopathy
Form of corneal abrasion = treatment similarVery painfulDiffuse, punctate “corneal abrasions” from thermal injury
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Corneal Abrasion: TreatmentCorneal Abrasion: Treatment
Promote rapid healingRelieve painPrevent infections
1% cyclopentolateTopical antibioticPressure patch x 24-48 hours in someDo not patch children or contact lens wearers+/- Oral analgesics
Goals
Rx
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Pressure PatchPressure Patch
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Corneal Abrasions:Corneal Abrasions:Follow upFollow up
Follow up in 24 hoursRefer to ophthalmologist if:– Not healed in 24 hours– Abrasion is related to contact lens wear– White corneal infiltrate develops
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Rx Rx Topical Topical
AnestheticsAnesthetics
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Soft Contact Lens ProblemsSoft Contact Lens Problems
“Overwear” syndromeInfiltratesBacterial ulcerations
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Prolonged contact lens wearProlonged contact lens wear
Severe pain and tearing in early AM,Severe pain and tearing in early AM,corneal edemacorneal edema
Natural resolution if no corneal abrasionNatural resolution if no corneal abrasion
May progress to infiltrate or ulcerMay progress to infiltrate or ulcer
Devastating vision loss if not treatedDevastating vision loss if not treated
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Contact lens problemsEpithelial defect with infiltrate
Florescein helps with visualizing epithelial defect
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Removal of a contact lens
Removal necessary for healing
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Corneal UlcerCorneal Ulcer
Ocular emergencyBacterial infection of corneaMay lead to ocular perforation and need for corneal transplantMore common in contact lens wearersCorneal abrasion can lead to ulcer
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Corneal UlcerCorneal Ulcer
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Corneal Ulcer TreatmentCorneal Ulcer Treatment
Fortified topical antibiotics around the clockHospital admission in some cases
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Ocular Foreign BodyOcular Foreign Body
Conjunctival, cornealMetal, glass, organic material
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Conjuctival foreign body in upper lid
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Metal foreign body lodged in upper lid conjunctiva
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Multiple corneal foreign bodies
Rusted pieces of metal lodged in superficial layer of cornea
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Treatment of Corneal Treatment of Corneal Foreign BodyForeign Body
RemoveTopical antibioticsFollow up for infection and secondary rust ring
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HyphemaHyphema
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Blunt Force to GlobeBlunt Force to Globe
Iris blood vessels bleed
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Layered blood in anterior chamber
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Hyphema ManagementHyphema ManagementAssume globe is rupturedShield eye and refer to ophthalmologistOphthalmologic management:– Restricted activity– Protective metal sheild– Topical cycloplegic and corticosteroids– Possibly systemic corticosteroids or
aminocaproic acid
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“8 Ball” hyphema
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Hyphema ComplicationsHyphema Complications
Rebleeding into anterior chamberGlaucomaAssociated ocular injuries in 25% of patients
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Traumatic IritisTraumatic Iritis
Blunt force to globeConjunctival injection around limbusWBCs in the anterior chamberSevere photophobiaMid dilated pupilTreat with topical steroid and dilation
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Ruptured or Lacerated GlobeRuptured or Lacerated Globe
Must be identified earlyVision may remain good despite laceration
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Suspect Ruptured Globe if:Suspect Ruptured Globe if:
History of hammering metal on metal, FBExtensive bullous subconjunctival hemorrhagePresence of uveal prolapseIrregular or pear shaped pupilPresence of hyphema or vitreous hemorrhageLow IOP
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Suspect globe laceration if history of hammering metal
Metallic foreign body
View of retina
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Location of foreign body seen with sagittal and coronal CT scan Order “fine cuts
through the orbit”
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Bullous subconjunctival hemorrhage
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Prolapse of ciliary body or iris (uvea)
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Irregular pupil
Bullous SCH
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Sutures in lacerated cornea
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If Globe Rupture or LacerationIf Globe Rupture or Lacerationis Suspected:is Suspected:
Stop examShield the eye (do not patch)Give tetanus prophylaxisRefer immediately to ophthalmologist
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Technique for shielding a ruptured globe
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Lid LacerationsLid Lacerations
Can result from sharp or blunt traumaRule out associated ocular injury
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Full thickness lid laceration
Must be closed in layers by ophthalmologist
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Canalicular laceration-suspect if medial 1/3 of lid involved
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Anatomy of the Anatomy of the NasolacrimalNasolacrimalSystemSystem
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CanalicularCanalicular lacerationlaceration
Common in dog bites, common in children
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Blunt Orbital TraumaBlunt Orbital Trauma
Periorbital swellingSubconjunctival hemorrhageEcchymosisOrbital bone fracturesHemorrhage into orbital tissue = Retrobulbar hemorrhage
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Mild blunt orbital trauma
“Shiner”
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Retrobulbar hemorrhage after trauma
Massive proptosis, eye firm to palpation, no vision
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Treatment of Treatment of Retrobulbar Retrobulbar HemorrhageHemorrhage
Emergency lateral canthotomySystemic IV steroids
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Orbital bone fracture- left
Blow-out fracture
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Orbital BlowOrbital Blow--Out FractureOut Fracture
Diplopia-muscle entrapment in bony fragment, bleeding into a muscleEpistsaxisBony step-offDecreased sensation over cheek and upper lip = damage to infraorbital nerveEnophthalmos
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Bony Components of the OrbitBony Components of the OrbitFrontal bone
maxillazygoma
ethmoidlacrimal
Infraorbital foramen
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Sensory Nerves of the OrbitSensory Nerves of the Orbit
CN V
V 2Infraorbital nerve
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Left eye limitation in upgaze
BlowBlow--Out FractureOut Fracture
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Orbital BlowOrbital Blow--Out FracturesOut Fractures
Surgical repair if muscle entrapment, diplopia or enophthalmosMust rule out occult ocular trauma
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Shaken Baby SyndromeShaken Baby Syndrome
Traumatic Brain InjuryRetinal HemorrhagesSkeletal Injury
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Normal retina
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Shaken Baby SyndromeShaken Baby Syndrome
Less that age 3 years, usually under 12 monthsSevere repeated shaking injury with or without impact injuryInfant head is large and unsupported, moves violently with aggressive shaking
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Differential Diagnosis of Differential Diagnosis of Retinal HemorrhagesRetinal Hemorrhages
Shaken baby syndromeBirth traumaCoagulopathy LeukemiaMeningitisSevere hypertensionSepsis, SBESickle cell retinopathyGalactosemia
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Work up of Retinal Work up of Retinal HemorrhagesHemorrhages
Detailed HPIPT, PTT ,CBC with PLT and differentialPhysical examinationOphthalmology exam
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PearlsPearlsAlways check the uninvolved eyeCorneal abrasion- Never patch children or contact lens wearersBeware of the teenage contact lens wearer with a red eye/consider ulcerLoosely cover a severely traumatized eyeRemember hidden nasolacrimal duct lacerationsDon’t ignore diplopia complaint after orbital trauma
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Questions?