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Case Presentation. Mary Palomaki November 11, 2009. 9 y/o female with difficulty seeing far. HPI History 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.

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Case Presentation

Mary Palomaki

November 11, 2009



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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


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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


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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.


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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


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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


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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



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Ophthalmology Consult

  • Corneal abrasion on left eye, 4mm long

  • Erythromycin ointment x 3 days

  • Follow up with ophthalmology in 1 week


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Ocular Trauma

Ocular Trauma


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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


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Outline

  • Review of Anatomy

  • History

  • Eye exam

  • Corneal Abrasions

  • Orbital fractures

  • Lacerations

  • Globe rupture

  • Retinal Detachment

  • Chemical Burns

  • Prevention



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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


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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


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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


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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


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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


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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


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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


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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


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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.)


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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


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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



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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


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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


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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.


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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


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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


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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


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Blow-Out fracture: Management

  • Oral antibiotic prophylaxis x 5-7 days

  • Surgical correction 2-3 weeks later by otolaryngologist


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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


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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



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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


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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


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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


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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


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Imaging

  • Axial and coronal CT of the eye without contrast

    • 1 to 2 mm cuts through the orbits


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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


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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


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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


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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


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Retinal detachment

  • PE: loss of vision (curtain moving across visual field), secondary strabismus, nystagmus, leukocoria

  • Management: Prompt referral to ophthalmologist


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Chemical Injury

  • Immediate irrigation indicated:

  • Retract lids:

    • Double lid eversion with small vein retractor

  • Check pH (pH of tears is 7.3-7.7)

  • Topical anesthetic

  • 20-30 min. or irrigation

  • Recheck pH

  • Cycloplegic drops prevent adhesions between the iris and lens


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Chemical Injury

  • Strong Alkalis (pH >11.5) penetrate the eye rapidly and cause intraocular inflammation.

  • Complications include: infection, glaucoma, conjunctival and corneal scarring


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Prevention of Eye injury

  • Protective eyewear should be worn by athletes and patients that are one-eyed

    • Criteria is visual acuity less than 20/40 in the poorer eye--loss of the good eye would render patient unable to drive legally

  • Recommended eyewear is frames or goggles with polycarbonate lenses

    • Need plano lenses if contacts are worn


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References:

  • Arbour, JD, Brunette, I, Boisjoly, HM, et al. Should we patch corneal erosions?. Arch Ophthalmol 1997; 115:313

  • Bienfang, D.C. Overview of diplopia. Online available @ uptodate.com. 12/1/2008.

  • Calhoun, J. Eye examinations in infants and children. Peds in Review 1997; 18:28.

  • Hulbert, MF. Efficacy of eyepad in corneal healing after corneal foreign body removal. Lancet 1991; 337:643.

  • Iqbal, S. Approach to acute vision loss in children. Online available at uptodate.com 6/15/2009

  • Jackson, H. Effect of eye-pads on healing of simple corneal abrasions. Br Med J 1960; 5200:713.

  • Jacobs, D et al. Corneal abrasions and corneal foreign bodies. Online available @ uptodate.com 11/20/2008

  • Hodge, C and Lawless, M. Ocular Emerencies. Aust. Fam. Phys. 2008; 37:506

  • Kaiser, PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology 1995; 102:1936

  • Klein, B. and Sears, M. Consultation with the specialist: eye injury. Peds in Review 1992;13:127.

  • Luke, A. and Micheli, L. Sports Injuries: Emergency Assessment and Field-side care. Peds In Review 1999;20:291.

  • Stout, Ann. Corneal Abrasions. Peds in Review. 2006; 27:433

  • Tingley, D.H. Eye trauma: corneal abrasions. Peds in review 1999;20:320