Pediatric emergency medicine trisk 918
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FIGURE 114.2 Upper lid eversion. Note that patient is looking down throughout procedure. In
frame C, the swab is being rolled clockwise to engage skin and indirectly lift lash line. In frame
E, the swab is being pushed downward as the examiner lifts the lashes upward in the opposite
direction. In F, note that patient is wearing a contact lens.
Evaluate the Pupils and the Extraocular Movements
Examine for symmetric shape and size of the pupil, as well as responsiveness to
direct and consensual light exposure. The presence of an afferent pupillary defect
suggests the possibility of serious eye injury. This can be tested with the swinging
flashlight test (see Chapter 29 Eye: Unequal Pupils ). Evaluate for pain or
limitation of eye movement, which may suggest muscle entrapment, nerve palsy,
or retrobulbar hemorrhage.
Evaluate the Anterior Surface of the Eye
Inspect the conjunctiva and sclera for hemorrhage, trauma, or foreign body. With
the patient sitting upright, examine the anterior chamber for grossly visible
layered blood. Slit-lamp examination, preferably by an ophthalmologist, is
required for evaluation of microhyphema.
Once an open-globe injury and a hyphema are ruled out, the administration of
topical anesthetic should be considered. A drop of proparacaine 0.5% or
tetracaine 0.5% may have diagnostic and temporary therapeutic usefulness. The
child who is crying and refusing to open his/her eyes may be compliant just a few
minutes after the instillation of a topical anesthetic. Any patient who is made
more comfortable by the instillation of topical anesthetics likely has an ocular
surface problem (conjunctiva or cornea) as a cause of pain (but it does not rule
out concomitant deeper injuries). Topical fluorescein is used as a diagnostic agent
to stain the affected area in order to evaluate for corneal abrasions. Fluorescein is
available as impregnated paper strips and as a solution combined with a topical
anesthetic. When strips are used, they must be wet with either saline or topical
anesthetic before instillation. Otherwise, the strip itself may cause a corneal
abrasion. Examiners should be careful to instill just a touch of this dye to avoid
false positive readings. Fluorescein, which is orange, fluoresces yellow-green
when exposed to blue light. The examiner can view this fluorescence using the
blue filter on the direct ophthalmoscope or using a Wood or Burton lamp. If the
staining pattern reveals one or more vertical linear abrasions, the examiner should
suspect the presence of a retained foreign body under the upper eyelid. This
foreign body may be viewed and removed by upper eyelid eversion ( Fig. 114.2 ).
Perform Direct Ophthalmoscopy to Evaluate for Papilledema
or Retinal Hemorrhages
If either is noted, emergency consultation with ophthalmology is required.
Pharmacologic dilation of the pupil may be used to assist in evaluating the
posterior portion of the eye ( Table 114.2 ). Even so, this is a difficult procedure
to perform for most providers especially in children with eye injuries. If this
cannot be completed successfully, ensure that an attempt has been made to obtain
a red reflex (see “Check the Red Reflex” above).
Consider Bedside Ultrasound
Emerging evidence suggests that bedside ocular ultrasound can identify serious
injuries to the globe, particularly in patients who are unable to open the affected
eye. Papilledema, retinal detachment, vitreous hemorrhage, and lens dislocation
have been identified successfully. Of the applications, retinal detachment is the
best-established, with high sensitivity and specificity for identification. However,
bedside ultrasound is highly user-dependent, and experience affects performance
of the modality. Therefore, proper training and credentialing are necessary before
using bedside ultrasound clinically in the evaluation of ocular trauma.
TABLE 114.2
Emergency Department Ocular Dilating Regimen a
Phenylephrine
2.5%
Tropicamide 1%
For brown irides replace tropicamide with cyclopentolate
1%
a May
repeat regimen in 30 minutes if needed. Instilling proparacaine or tetracaine prior to these dilating
drops will enhance the dilation effect.
OPEN-GLOBE INJURY
CLINICAL PEARLS AND PITFALLS
In order to avoid extrusion of intraocular contents, open-globe injury
requires rapid recognition and emergent evaluation by an
ophthalmologist.
Clinical findings include teardrop pupil, 360 degrees of bullous
subconjunctival hemorrhage, or enophthalmos ( Fig. 114.3 ).
If any of the above is present, immediately place an eye shield and
minimize disturbing the child.
Current Evidence
The visual prognosis in pediatric open-globe injury may be poor. The following
factors seem to be most predictive of poor visual outcome: blunt injury, injury
resulting from a gun, age <5 years, large wounds (>5 mm), wounds involving the
sclera and associated injuries such as hyphema, vitreous hemorrhage, or retinal
detachment. Prompt recognition and immediate referral to an ophthalmologist,
ideally one with pediatric expertise, is the accepted standard of care.
Goals of Treatment
Open-globe injury is an ominous trauma that warrants emergent ophthalmology
consultation. The goal of treatment in the emergency department (ED) is to avoid
causing extrusion of contents from the eye, while awaiting definitive surgical
repair. Further ocular examination should be stopped immediately when an openglobe injury is suspected and pain control and antiemetics should be initiated.
Clinical Considerations
Clinical Recognition
An open-globe injury is defined by the presence of a full-thickness break in the
cornea or sclera ( Fig. 114.4 ). This condition can occur following trauma by
sharp implements, projectiles, or blunt trauma. Sharp objects can directly
penetrate the globe. In the case of blunt trauma, significant force causes
compression of the globe, raising intraocular pressure and leading to rupture.
Although severe intraocular disruption may occur, the globe has a remarkable
ability to maintain its integrity. Upon injury, the iris or choroid may move and
plug the wound. Blue, brown, or black material on the surface of the sclera may
be visible as the iris or choroid forms a plug ( Fig. 114.5 ). With small lacerations
that are plugged by iris or choroid, the globe may maintain a remarkably normal
external appearance. Alternatively, with the movement of the iris or choroid in
more significant cases, the pupil often takes on a teardrop appearance, with the
narrowest segment pointing toward the opening ( Fig. 114.5 ). A teardrop pupil is
a worrisome indicator that an open-globe injury likely occurred. In addition, if
there is 360-degree subconjunctival hemorrhage, one may be unable to see if a
scleral laceration is present. Patients who present following trauma with severe
360-degree conjunctival swelling should be treated as if they have an open-globe
injury and should be referred immediately to an ophthalmologist. Hemorrhage
within the anterior chamber (hyphema) may accompany a corneal or anterior
scleral laceration ( Fig. 114.4 ).
FIGURE 114.3 Open globe with teardrop pupil.
