1 Define an ophthalmologic “emergency” and give two common examples

An ophthalmologic emergency is any injury that may lead to incremental vision loss without early recognition and prompt initiation of treatment. Two common examples are chemical burn and globe rupture. Both of these presentations warrant emergent (same-day) ophthalmologic consult after beginning initial treatment/stabilization.

2 What is the initial treatment/stabilization for globe rupture?

Stop the examination, place a rigid eye shield, and keep the patient calm to avoid increased pressure to the globe, which may cause further extrusion of vitreous or aqueous humor. Administer pain medications, tetanus, and IV antibiotic prophylaxis, if possible. Order an imaging study if a retained foreign body is suspected.

3 List the important aspects of the history in all patients with eye injuries

4 What is included in the routine physical examination for all pediatric patients with eye injuries (except when temporarily deferred in absolute emergencies)?

5 What are the common pitfalls in evaluating children with eye injuries?

Levin AV: Eye trauma. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Baltimore, Lippincott Williams & Wilkins, 2006, pp 1485–1496.

6 How do you test visual acuity in infants?

Check for pupillary reaction to light and fixation reflex. Infants should be able to fix on a high-contrast object held in their central vision, such as the caretaker’s or examiner’s face or a bright toy. By 2–3 months of age, they should be able to fix on and start to follow an object or light, and by about 6 months to fix and follow to all visual fields. Central, steady, maintained fixation is estimated to be equivalent to 20/40 vision, unsteady fixation equivalent to 20/100, and eccentric wandering gaze to < 20/400.

7 How do you test visual acuity in preschool and school-aged children?

8 What pearls should be kept in mind for visual acuity testing in children?

9 For patients without their glasses or contact lenses, how can you differentiate between decreased acuity and baseline refractive error?

Pinhole testing—with a premade device, a card with a hole punched with an 18-gauge needle, or multiple pinholes in a rigid eye shield—corrects refractive errors to about 20/30.

10 How do you record decreased acuity in patients unable to visualize a chart?

11 What are the causes of an irregularly shaped pupil?

12 What are the causes and expected course of subconjunctival hemorrhage?

Subconjunctival hemorrhage, the localized rupture of small subconjunctival vessels, may be spontaneous or may be due to direct trauma or increased intrathoracic pressure (e.g., coughing, noseblowing, vomiting). It usually is benign and resolves in 2–3 weeks without treatment or sequelae. Very large hemorrhages or those that fully encircle the iris raise concern for an underlying injury, such as globe perforation, or a bleeding diathesis.

13 What is the most common pediatric eye injury?

Corneal or conjunctival abrasion.

14 Which eye injuries are possible when a child is a restrained passenger in the front seat and is involved in a car crash with air bag deployment?

Airbags have reportedly caused monocular and binocular injuries. Some injuries to the eyes are “mechanical,” caused by the force of the airbag hitting the child’s face. These injuries include eyelid trauma, corneal injury, orbital fracture, lens dislocation, corneoscleral laceration, and hyphema. Chemical injury to the eyes is also possible, and alkaline burns have been reported. An alkaline substance that triggers the airbag inflation has occasionally caused burns to the eyes. Wearing glasses at the time of the crash protects against the chemical injury but may increase the risk of penetrating trauma to the eyes.

Lee WB, O’Halloran HS, Pearson A, et al: Airbags and bilateral eye injury: Five case reports and a review of the literature. J Emerg Med 20:129–134, 2001.

15 How does a child with corneal abrasion typically present?

The common presentation is a red eye with epiphora (tearing), intense pain, resistance to eye opening, and, less frequently, lid swelling or photophobia. The child often does not know what caused the injury.

16 How is a corneal abrasion diagnosed?

Larger abrasions often can be visualized with tangential light as an irregularity or dry-appearing area of the eye surface. Fluorescein staining and cobalt blue light (or Woods lamp) best delineate abrasions of any size. Use of a topical anesthetic facilitates the examination and aids in the diagnosis. If topical anesthesia fully alleviates the pain, an ocular surface problem, such as a superficial foreign body, abrasion, or superficial ulcer, is suggested. Persistent pain after use of a topical anesthetic suggests pathology of deeper structures. Be sure to check thoroughly for a retained foreign body when evaluating corneal or conjunctival abrasions. Any concern for a corneal or scleral laceration or an imbedded foreign body should prompt an ophthalmology consultation.

Pediatric pearl: Consider application of a topical anesthetic before your first examination attempt in suspected corneal or conjunctival abrasions. In young children, this is most easily accomplished by letting the child keep the eye shut, having the child lie in a supine position, and pooling several drops of the topical anesthetic medially at the corner of the eye. Gentle traction caudally on the cheek will crack apart the lids, and the drops will run onto the eye surface. Let the child sit up, and in a few seconds he or she will usually spontaneously open the eye and your examination can proceed without a fight!

17 Describe the management of a corneal or conjunctival abrasion

Most abrasions heal quickly without sequelae. Antibiotic ophthalmic ointment or artificial tears provide lubrication and some pain relief. Small lesions do not need to be patched and, if asymptomatic in 24 hours, do not require follow-up. Large abrasions and those involving the visual axis are treated with antibiotic ointment, consider soft eye patching, and daily follow-up until they have healed. Patients should be instructed to return or see an ophthalmologist for pain or foreign-body sensation that persists for more than 2 or 3 days, or if pain and redness worsen at any time. Instruct those who wear contact lenses to discontinue their use until the patient is seen by an ophthalmologist.

LeSage N, Verreault R, Rochette L: Efficacy of eye patching for traumatic corneal abrasions: A controlled clinical trial. Ann Emerg Med 28:129–134, 2001.

18 Describe the management of the child with “something in my eye.”

Most patients with an external foreign body (conjunctival or superficial corneal) report just that. If there is no suspicion of a perforated globe or deep corneal laceration, a topical anesthetic allows thorough examination of the bulbar conjunctival surface, cornea, palpebral conjunctivae, and superior and inferior fornices. Evert the upper lid to examine its inner aspect; outward traction on the lower lid with upward gaze provides good visualization of the lower bulbar and palpebral conjunctivae.

The foreign body usually can be loosened and removed with saline irrigation. A moistened sterile swab or gauze also can be used. If the foreign body is still adherent, consider removal under slit-lamp magnification or ophthalmologic referral. Be sure to complete a full eye examination after removal of the foreign body; look for and treat associated corneal abrasions if necessary.

19 What is a hyphema?

A hyphema is bleeding into the chamber between the cornea and iris or lens after blunt or sharp trauma. It may range from microscopic bleeding to a full-chamber or “eight-ball” hyphema.

20 How are hyphemas diagnosed and treated?

A hyphema (Fig. 55-1) should be suspected in any child with a tearing, painful eye and injected bulbar conjunctiva immediately after blunt eye trauma. It is often diagnosed by careful physical examination—many are visible without microscopic slit-lamp examination. Smaller hyphemas may require microscopic slit-lamp examination. All hyphemas require urgent ophthalmologic consultation for management, although in 66–97% of isolated hyphemas the hemorrhage resorbs without complication.

Figure 55-1 Hyphema.

Children with large hyphemas are sometimes managed as inpatients, particularly if they are young or if inadequate follow-up is a concern. Some ophthalmologists prefer home management. The patients are treated with cycloplegics, topical or systemic steroids, and bedrest (with sedation, if needed). Some ophthalmologists recommend the use of an antifibrinolytic agent, such as aminocaproic acid (Amicar). Children with hyphema should be cared for in consultation with an ophthalmologist.

Hertle RW, Bacal D: Traumatic hyphema: Evaluation and management. Contemp Pediatr 14:51–68, 1997.

Recchia FM, Saluja RK, Hammel K, et al: Outpatient management of traumatic microhyphema. Ophthalmology 109:1465–1470, 2002.

21 What is the major potential vision-threatening sequela of hyphemas? Who is at risk?

Rebleeding with development of acute glaucoma or corneal staining. Rebleeding is most likely within 3–5 days of the initial injury. Patients with sickle cell disease are at particularly high risk of ocular complications; a screening test or hemoglobin electrophoresis is recommended for patients at risk for an undiagnosed hemoglobinopathy.

22 When and how does traumatic iritis present?

Traumatic iritis (Fig. 55-2), which may accompany other ocular injury or be the sole manifestation of blunt eye trauma, usually presents later than microscopic hyphema (24–72 hours after injury). Physical examination reveals a painful, red eye (typically perilimbal conjunctival injection), tearing, and pain with pupillary constriction (on accommodation or concentric constriction to light). The affected eye also may have slight miosis and a decreased or sluggish pupillary response. The pain is secondary to inflammation in the anterior chamber. Slit-lamp evaluation is diagnostic when it reveals white cells and a protein “flare” in the aqueous humor.

Figure 55-2 Iritis.

23 How is traumatic iritis treated?

In children, an ophthalmology consultation should be requested for definitive diagnosis and initial management, which includes mydriatics for pain control, topical steroids, and close follow-up.

24 What is an orbital “blow-out” fracture?

An orbital blow-out fracture involves one of the bony orbital walls and is usually caused by blunt trauma to the face. The presentation may include periorbital ecchymosis, facial asymmetry, lid swelling or ptosis, proptosis or enophthalmos, ophthalmoplegia, localized anesthesia of the face, and, in rare cases, orbital emphysema. The patient may have entrapment or restriction of the extraocular muscle adjacent to the fracture site and restriction of extraocular movement may be evident on examination. In particular, the patient may be unable to look up with the affected eye. The most common fracture sites are the inferior and medial walls (rarely lateral). Superior wall fractures have the potential to communicate with the intracranial space. Plain radiographs and computed tomography or magnetic resonance imaging may help to delineate the fracture. A full ocular examination is needed to rule out other eye injuries, including retinal trauma.

25 What is the major pitfall when diagnosing an orbital wall fracture?

Failure to consider and appropriately rule out other eye injuries. The incidence of concomitant globe injury with orbital fractures has been reported at 5–10%.

26 What physical examination findings are consistent with a ruptured or perforated globe?

Note: When a globe rupture or perforation is suspected, stop your examination, place a rigid eye shield, avoid patient agitation, keep the patient in bed with the head elevated, and request an emergent ophthalmologic consultation (see Question 2).

Levin AV: Eye trauma. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Baltimore, Lippincott Williams & Wilkins, 2006, pp 1485–1496.

27 What aspects of the history or physical examination place patients at high risk for globe perforation or rupture?

Note: It is sometimes difficult to see a globe rupture, especially if the etiology was a rapidly penetrating foreign body (from hammering). The more difficult it is to examine the patient after trauma (because of pain, edema, hyphema, or vitreous hemorrhage), the greater the likelihood of globe rupture.

Handler JA, Ghezzi KT: General ophthalmologic examinations. Emerg Med Clin North Am 13:521–537, 1995.

28 What are the important considerations for evaluating lacerations of the eyelids?

It is important to consider the potential for a full-thickness laceration and underlying orbital injury. Even if the laceration is superficial in appearance, be sure to check the inner (conjunctival) surface. In upper lid lacerations, always assess the integrity of the levator muscle (both lids raise equally with upward gaze). Full-thickness lacerations, lacerations through the lid margin or tarsal plate, and lacerations potentially involving lacrimal canaliculi (any laceration of the medial canthal angle) require ophthalmologic consultation for multilayer repair. Consider consultation for lacerations with ptosis or significant avulsions or if you are unable to rule out other ocular injury. Adipose tissue exposed in an upper lid laceration indicates full-thickness lid laceration (this is exposed orbital fat).

29 Describe the emergency initial management of chemical burns to the eye

Blende MS: Irrigation of conjunctivae. In Henretig FM, King C (eds): Textbook of Pediatric Emergency Procedures. Baltimore, Williams & Wilkins, 1997, pp 605–608.

30 Which are more severe—alkali or acid burns?

Alkali burns are potentially more severe. Alkali substances penetrate more deeply than acids, which coagulate with surface proteins. Common alkaline agents include lye, lime, ammonia, and aluminum- or magnesium hydroxide–containing fireworks (flares and sparklers).

31 An emergency physician attempts to repair a forehead laceration of a young child using cyanoacrylate glue. Some of the glue drips down the child’s face and the child’s eyelashes are noted to be stuck together. The child’s parent is quite concerned. Which eye injuries are likely?

Usually none. The eyelashes may be stuck together by the glue, but the eye is very rarely injured in this scenario. Parents may be concerned, as the child cannot open his/her eye. Avoid forceful attempts to pry open the eye lids. Instead, place petroleum jelly on the eyelashes and wait patiently or massage with a cotton swab until the glue dissolves.