Pediatric emergency medicine trisk 921
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FIGURE 114.8 Lateral canthotomy and cantholysis: A: Lateral canthotomy. B: Grasp the
lateral lower eyelid with toothed forceps. C: Pull the eyelid anteriorly. Point the scissors toward
the patient’s nose, strum the lateral canthal tendon, and cut. (Reprinted with permission from
Gerstenblith AT, Rabinowitz MP. The Wills Eye Manual: Office and Emergency Room
Diagnosis and Treatment of Eye Disease. Philadelphia, PA: Wolters Kluwer/Lippincott
Williams & Wilkins; 2012.)
Triage Considerations
Children with high-risk lacerations, as detailed above, should be triaged rapidly
and ophthalmology consultation initiated promptly.
TABLE 114.3
EYELID LACERATIONS
Consult ophthalmology if laceration is associated with:
Full-thickness perforation of lid
Ptosis
Orbital fat prolapse
Involvement of lid margin
Possible damage to tear drainage system
Tissue avulsion
Globe injury
FIGURE 114.9 Lower eyelid laceration involving tear drainage system. Thick arrow indicates
lower eyelid punctum, which has been displaced laterally. Thin arrow indicates normal course
of canaliculus, which drains tears from the puncta to the lacrimal sac located medially.
Management
Lacerations of the periorbital skin and superficial eyelid may be managed by
standard skin closure techniques. Tissue adhesives are widely used to close
superficial, nongaping facial lacerations with good cosmetic outcomes. It is
important that sutures not grasp deep tissue within the eyelid because this may
result in cicatricial eversion of the eyelid margins. Table 114.3 summarizes those
findings that, when associated with eyelid lacerations, should prompt
ophthalmology consultation for wound closure. CT scan should be considered in
all cases of full-thickness perforation of the upper lid because of the possibility of
intracranial involvement or occult foreign bodies within the orbital space.
Pneumocephalus should prompt neurosurgical evaluation. A perforating
implement can reach the orbital apex and optic nerve. Thus, evaluation of visual
acuity, relative afferent pupillary defects, and confrontation visual fields can
detect signs associated with optic nerve injury in relatively innocuous appearing
lacerations.
CORNEAL AND CONJUNCTIVAL INJURY
CLINICAL PEARLS AND PITFALLS
Topical anesthetics will only improve pain if the pathology is corneal or
conjunctival, and therefore are diagnostically useful.
If fluorescein staining shows one or more vertical linear abrasions,
consider the presence of a foreign body.
An ophthalmologist should evaluate larger corneal abrasions and those
involving the pupillary axis within 24 hours of injury.
If a teardrop or irregular pupil is seen, the abrasion may represent
penetration into the deeper corneal tissues (open-globe injury) and
emergent ophthalmology consultation is indicated.
Corneal abrasions should heal within 48 hours; nonhealing and/or
persistently painful abrasions should prompt ophthalmology
consultation.
Current Evidence
Literature has established that the use of a patch with simple corneal abrasions
does not improve healing or pain control and is therefore generally not
recommended. Topical antibiotic ointments are frequently prescribed although
there is limited data that this practice improves outcome.
Goals of Treatment
The goals of ED treatment of corneal and conjunctival abrasions are as follows:
(1) Rule out the presence of more severe ocular injury, (2) control pain, and (3)
facilitate corneal and conjunctival healing.
Clinical Considerations
Clinical Recognition
Corneal or conjunctival abrasions may occur even from mild surface trauma,
including accidental self-inflicted injuries. Corneal abrasion can be painful and
accompanied by dramatic photophobia and resistance to opening of the eyes.
Patients may complain of a foreign-body sensation even though no foreign body
is present. In the absence of clinical findings associated with other more severe
injuries and in association with a mechanism of injury that may lead to a
scratching of the cornea, abrasion should be suspected in a painful, red eye. In
newborns who have unexplained fussiness, corneal abrasion is common, as young
infants do not yet have sufficient motor control to avoid scratching the eye
surface.
Triage Considerations
Patients with severe eye pain and redness should be promptly triaged and
assessed. Pain control is a primary concern. Analgesics should be initiated in all
cases.
Management
Literature suggests that patching corneal abrasions does not accelerate healing or
decrease pain. Many physicians suggest applying a lubricating antibiotic ointment
(e.g., bacitracin, erythromycin, Polysporin) three times daily for 3 to 5 days to the
ocular surface without a patch. Topical nonsteroidal anti-inflammatory agents are
used for pain control in adults, but are rarely used for children. There is a
theoretical risk of corneal melting with these agents. For patients who are
relatively asymptomatic with corneal or conjunctival abrasions that are small and
do not involve the pupillary axis (i.e., not involving the central cornea over the
pupil), management with antibiotic or artificial tears alone may be sufficient. The
use of mydriatic drops such as cyclopentolate 1% can be instilled to relieve
ciliary spasm, though this is uncommon. Ointments containing steroids or
neomycin should not be used. If the patient is asymptomatic within 48 hours, no
follow-up is required. Larger corneal abrasions and those involving the pupillary
axis should be seen on the day following the injury by an ophthalmologist. For
any size corneal abrasion, if pain or foreign-body sensation continues for more
than 2 days, or if there is increasing pain and redness, the patient should be
instructed to seek ophthalmologic care.
