Ocular emergency in pedi clinics
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- 1.Ocular TraumaOcular Trauma Robin L. Grendahl, MD Pediatric Ophthalmology And Strabismus
2. Ocular TraumaOcular Trauma Corneal abrasion Contact lens related trauma Foreign bodies Hyphema Ruptured globe Lid lacerations Orbital trauma Shaken baby syndrome 3. 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) 4. Complete Eye ExamComplete Eye Exam Vision in both eyes External exam Pupils Motility Anterior segment Ophthalmoscopy 5. Tools Used for ExaminationTools Used for Examination 6. Corneal AbrasionCorneal Abrasion Epithelial layer abraded Intense pain Vision blurred Eye red Tearing 7. Corneal AnatomyCorneal Anatomy 8. WelderWelders Flash Burn or Solars Flash Burn or Solar KeratopathyKeratopathy Form of corneal abrasion = treatment similar Very painful Diffuse, punctate corneal abrasions from thermal injury 9. Corneal Abrasion: TreatmentCorneal Abrasion: Treatment Promote rapid healing Relieve pain Prevent infections 1% cyclopentolate Topical antibiotic Pressure patch x 24-48 hours in some Do not patch children or contact lens wearers +/- Oral analgesics Goals Rx 10. Pressure PatchPressure Patch 11. Corneal Abrasions:Corneal Abrasions: Follow upFollow up Follow up in 24 hours Refer to ophthalmologist if: Not healed in 24 hours Abrasion is related to contact lens wear White corneal infiltrate develops 12. RxRx TopicalTopical AnestheticsAnesthetics 13. Soft Contact Lens ProblemsSoft Contact Lens Problems Overwear syndrome Infiltrates Bacterial ulcerations 14. 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 15. Contact lens problems Epithelial defect with infiltrate Florescein helps with visualizing epithelial defect 16. Removal of a contact lens Removal necessary for healing 17. Corneal UlcerCorneal Ulcer Ocular emergency Bacterial infection of cornea May lead to ocular perforation and need for corneal transplant More common in contact lens wearers Corneal abrasion can lead to ulcer 18. Corneal UlcerCorneal Ulcer 19. Corneal Ulcer TreatmentCorneal Ulcer Treatment Fortified topical antibiotics around the clock Hospital admission in some cases 20. Ocular Foreign BodyOcular Foreign Body Conjunctival, corneal Metal, glass, organic material 21. Conjuctival foreign body in upper lid 22. Metal foreign body lodged in upper lid conjunctiva 23. Multiple corneal foreign bodies Rusted pieces of metal lodged in superficial layer of cornea 24. Treatment of CornealTreatment of Corneal Foreign BodyForeign Body Remove Topical antibiotics Follow up for infection and secondary rust ring 25. HyphemaHyphema 26. Blunt Force to GlobeBlunt Force to Globe Iris blood vessels bleed 27. Layered blood in anterior chamber 28. Hyphema ManagementHyphema Management Assume globe is ruptured Shield eye and refer to ophthalmologist Ophthalmologic management: Restricted activity Protective metal sheild Topical cycloplegic and corticosteroids Possibly systemic corticosteroids or aminocaproic acid 29. 8 Ball hyphema 30. Hyphema ComplicationsHyphema Complications Rebleeding into anterior chamber Glaucoma Associated ocular injuries in 25% of patients 31. Traumatic IritisTraumatic Iritis Blunt force to globe Conjunctival injection around limbus WBCs in the anterior chamber Severe photophobia Mid dilated pupil Treat with topical steroid and dilation 32. Ruptured or Lacerated GlobeRuptured or Lacerated Globe Must be identified early Vision may remain good despite laceration 33. Suspect Ruptured Globe if:Suspect Ruptured Globe if: History of hammering metal on metal, FB Extensive bullous subconjunctival hemorrhage Presence of uveal prolapse Irregular or pear shaped pupil Presence of hyphema or vitreous hemorrhage Low IOP 34. Suspect globe laceration if history of hammering metal Metallic foreign body View of retina 35. Location of foreign body seen with sagittal and coronal CT scan Order fine cuts through the orbit 36. Bullous subconjunctival hemorrhage 37. Prolapse of ciliary body or iris (uvea) 38. Irregular pupil Bullous SCH 39. Sutures in lacerated cornea 40. If Globe Rupture or LacerationIf Globe Rupture or Laceration is Suspected:is Suspected: Stop exam Shield the eye (do not patch) Give tetanus prophylaxis Refer immediately to ophthalmologist 41. Technique for shielding a ruptured globe 42. Lid LacerationsLid Lacerations Can result from sharp or blunt trauma Rule out associated ocular injury 43. Full thickness lid laceration Must be closed in layers by ophthalmologist 44. Canalicular laceration- suspect if medial 1/3 of lid involved 45. Anatomy of theAnatomy of the NasolacrimalNasolacrimal SystemSystem 46. CanalicularCanalicular lacerationlaceration Common in dog bites, common in children 47. Blunt Orbital TraumaBlunt Orbital Trauma Periorbital swelling Subconjunctival hemorrhage Ecchymosis Orbital bone fractures Hemorrhage into orbital tissue = Retrobulbar hemorrhage 48. Mild blunt orbital trauma Shiner 49. Retrobulbar hemorrhage after trauma Massive proptosis, eye firm to palpation, no vision 50. Treatment ofTreatment of RetrobulbarRetrobulbar HemorrhageHemorrhage Emergency lateral canthotomy Systemic IV steroids 51. Orbital bone fracture- left Blow-out fracture 52. Orbital BlowOrbital Blow--Out FractureOut Fracture Diplopia-muscle entrapment in bony fragment, bleeding into a muscle Epistsaxis Bony step-off Decreased sensation over cheek and upper lip = damage to infraorbital nerve Enophthalmos 53. Bony Components of the OrbitBony Components of the Orbit Frontal bone maxillazygoma ethmoid lacrimal Infraorbital foramen 54. Sensory Nerves of the OrbitSensory Nerves of the Orbit CN V V 2 Infraorbital nerve 55. Left eye limitation in upgaze BlowBlow--Out FractureOut Fracture 56. Orbital BlowOrbital Blow--Out FracturesOut Fractures Surgical repair if muscle entrapment, diplopia or enophthalmos Must rule out occult ocular trauma 57. Shaken Baby SyndromeShaken Baby Syndrome Traumatic Brain Injury Retinal Hemorrhages Skeletal Injury 58. Normal retina 59. Shaken Baby SyndromeShaken Baby Syndrome Less that age 3 years, usually under 12 months Severe repeated shaking injury with or without impact injury Infant head is large and unsupported, moves violently with aggressive shaking 60. Differential Diagnosis ofDifferential Diagnosis of Retinal HemorrhagesRetinal Hemorrhages Shaken baby syndrome Birth trauma Coagulopathy Leukemia Meningitis Severe hypertension Sepsis, SBE Sickle cell retinopathy Galactosemia 61. Work up of RetinalWork up of Retinal HemorrhagesHemorrhages Detailed HPI PT, PTT ,CBC with PLT and differential Physical examination Ophthalmology exam 62. PearlsPearls Always check the uninvolved eye Corneal abrasion- Never patch children or contact lens wearers Beware of the teenage contact lens wearer with a red eye/consider ulcer Loosely cover a severely traumatized eye Remember hidden nasolacrimal duct lacerations Dont ignore diplopia complaint after orbital trauma 63. Questions?